Optometry's Role in Suicide Prevention with Dr. Emily Aslakson & Mr. Philip Himebaugh

In this important episode, Dr. Emily Aslakson and Mr. Philip Himebaugh discuss how optometrists and vision therapists can play a crucial role in suicide prevention. Learn how to recognize suicide risk factors, initiate life-saving conversations, and connect patients to the help they need.

What You'll Learn:

• How optometrists can identify suicide risk in patients
• Real-life examples of suicide risk in vision care
• Tools for asking difficult but vital questions
• The importance of triage and timely referral
• Resources for suicide prevention training

Resources Mentioned:

• National Suicide prevention Lifeline 1-800-273-TALK(8255
• QPR Training: Question-Persuade-Refer Training. Three steps anyone can learn to help prevent suicide:  https://qprinstitute.com/
• Psychology today to search for local mental health providers. https://www.psychologytoday.com/us
• ISPATHWARM acronym: ideation, substance abuse, purposelessness, anxiety, trapped, hopelessness, withdrawal, anger, recklessness, mood changes.
• Crisis Text Line: Text HOME to 741741

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Transcript

 Denise: Hello and welcome to the Healing Our Sight podcast where we discuss vision from the patient perspective. May is both Mental Health Awareness Month and Healthy Vision Month, and today's conversation brings those two worlds together in a way that's rarely talked about. We're exploring how eye care providers can provide a quiet but powerful role in recognizing suicide risk and supporting patients who may be struggling. Joining me are the creators and co teachers of the course suicide assessment optometry's role, which they presented on May 14 through OEPF, the optometric extension Program foundation and Beyond Being professional collaborators, they also happen to be a married couple whose shared dedication to education, compassion and whole person care is deeply inspiring. 

Let me introduce them. Dr. Emily Alexson is a professor at the Michigan College of Optometry. She graduated Summa *** Laude from Alma College in 2007 with dual Bachelor of Arts degrees in Psychology and Theater. She earned her doctorate in Optometry from Indiana University in 2015, graduating with honors and received the Andrea Lowther Scholarship Award for Service and Humanitarianism. She completed a residency in Pediatrics and Binocular Vision at MCO in 2016 and went on to earn her Master of Arts in Education from Ferris State University in 2022. Her clinical and academic passions include neuro, optometric rehabilitation, vision therapy, binocular vision, optometric education, and communication skills. 

Her husband and co presenter, Mr. Philip A. Heimbaugh, is an Assistant professor and academic advisor at the School of Education at Ferris State University. He is also a licensed professional counselor in the State of Michigan. Before entering academia, Philip worked in both public and private clinical mental health settings. He holds both a Master of Science and an Education Specialist degree from Indiana University's Wendell W. Wright School of Education, focusing on counseling, counselor education, mental health counseling, and human development. Together, they're helping optometrists and vision therapists develop the awareness and tools needed to recognize when a patient might be silently struggling and how to respond with care.

 Let's jump right in. When did you realize that optometrists needed to know about suicide and how to recognize the signs?

Dr. Emily: Yeah, so I'll talk a little bit about that from my perspective as an optometrist. I had a little bit of a non-conventional way into optometry. I actually started out in social work, so I did have a little bit of this training. I didn't end up obviously choosing that career path. But while I was in school, my husband Philip, who was joining me, I said, I don't know that this is the right field for me, but I think you'd be really good at it. So, he ended up pursuing his advanced degree in mental health therapy. But anyways, so I had already had, you know, some of this training, so I felt comfortable doing this work. And I approached Philip about developing this training after an incident in clinic where another doctor came to me and she knew my background, and she said, I just had a patient tell me that they're going to go home and kill themselves. What do I do? I mean, the patient was just that forthright about it and said, I'm going to go home, and I just want to OD on heroin. And the. The doctor was just kind of beside herself. She had no idea what to do. So that was the moment where I was kind of like, yeah, we really do need this training because we work with patients. We are primary care providers; we're primary eye care providers. We might be the ones hearing this or recognizing this in a patient, and we need to be prepared and know what to do if that situation arises. So that's what kind of sparked the development of this training. So, I worked closely with Philip for his expertise, because he certainly has a lot more experience and expertise in this area than I do. But so, yeah, that's how we kind of developed this talk.

Denise: And was that a recent development or tell our listeners how long you've been doing this.

Dr. Emily: Yeah, so we did this first talk. Gosh. I want to say it was maybe for the faculty at the institution that I work at. It was maybe 2018 or 2019. So, we've done it for the faculty, and then we've done it for. For the students just before they go out on their fourth-year rotations for about four or five years now.

Denise: The optometry students, correct?

Dr. Emily: Yes. Yeah. Yep. Our optometry students in our program.

Denise: Okay, so this was before COVID Yes.

Dr. Emily: Yep.

Denise: You're finding it's more necessary now than it was before that.

Dr. Emily: Ooh, I don't know if I'd say. I mean, certainly always necessary. And Philip can probably comment a little bit more on some of the, you know, trends that we're seeing in mental health post Covid. But I mean, as far as what I'm seeing in optometry in my patients, I don't know that I've more frequently had to do this for your post.

Philip: I think the one thing, you know, if there's a silver lining to the COVID pandemic, it's the destigmatization of mental health was kind of accelerating during that time. I mean, it was already starting to take place a little bit where people were feeling more comfortable accessing services and things. And then once we had the pandemic and the host of issues that. That brought forward, with everybody in isolation and fear and anxiety and all those sorts of things, I think that was probably the biggest role that the pandemic played, is that now the students say, okay, not only does it make sense why I need this training, but it makes sense to me that I might be using this training every day. And so that's something that I tell them at the beginning of every talk, is, look, I'm not the smartest person in the room. I probably never will be. I'm not going to allow you with my research acumen. But what I really hope you take away from this today is, hey, one or two tools that when you're doing an eye exam and you hear something you're not expecting to hear from a patient, that you've got something you can fall back on. And I think, you know, the feedback we've gotten from the students has been.

Dr. Emily: Overwhelmingly positive, very positive.  I do agree. I think now in more recent years, the students do see the value in it, maybe more than they did what we did pre pandemic.

Philip: Yeah. And each. Each class is a little different, but even the class this year, my favorite part is when we get to the end and all the hands shoot up, you know, when there's lots and lots of questions at the end, that means, you know, it went well, and it went well this year. So that was great.

Denise: That's awesome. Yeah. And you're getting ready to teach this class this evening to a group of optometrists that are already in practice rather than just students, Right?

Dr. Emily: Yes.

Denise: Yeah, that's going to be an important one as well. I thought this topic was really interesting, and I wanted to attend that class, actually. And here I am in China going, okay, time zones and all that good stuff.

Philip: Yeah, right. Yeah, yeah.

Denise: But I've been talking to my own students about mental health because it's Mental Health Awareness Month. And when I think about mental health or suicide prevention and optometry, I don't put those in the same sentence at all. Right. So is it because it's a primary care thing or is there something with maybe the kinds of patients you might see in your practice, that there might be more of a chance of them feeling this way?

Dr. Emily: I mean, the big one to think about when you think about risk factors of suicide are changes in health status, loss of independence. And as optometrists, those certainly might be things that we are going to be very involved in potentially diagnosing, managing, being the first ones to talk to our patients about. So those are some kind of situations where you might hear this. But I mean the incident with my colleague, for example, that was a 15 year old girl in for a routine. So you know, you never know what a patient's going to tell you. And I very strongly believe that. And everyone should have some idea on how to manage this. But certainly people who are in healthcare.

Philip: Well, there's the trend too. I can't speak for optometry, not being an optometrist, but I think the mental health field, we're a little bit ahead of the game in terms of treating people holistically. I tell my clients all the time, look, I'm not a physician, but I'm not going to deny that it's important that you take care of yourself, mentally, physically, spiritually, emotionally, I can try to help you do all those things. And one of the things we're trying, I think to, to impart these optometrists and then hopefully, you know, healthcare at large if this kind of catches on is that I think every healthcare provider should be approaching their patients that way. You know, just because I come in, because I have the sniffles doesn't mean that I'm not dealing with a big emotional problem too. And it's all part of the human condition and it's all part of treating people as, as holistic beings, I think.

Denise: Yeah, yeah, I definitely agree with that. So, if we're talking from the patient perspective and we come in to get our vision checked, what are you going to notice as a provider about me as a patient that is going to show you there might be some things to be concerned about.

Philip: It's your chance to show off our curriculum here, hon.

Dr. Emily: Well, so I mean, if you're a patient that I know that I've seen a few times and I know you and there's been a change, there's been a shift kind of in your behavior, in your mood and your effect, I'm going to pick up on that. If you're normally someone who's, you know, very chatty or upbeat or always has something to say or some funny story, and then you come in this time and it's different, I'm going to pick up on that and probably ask questions about, hey, you seem a little different today, what's going on and using those open ended questions to try and get the patient to open up. 

Now if you're a patient that I don't know, I'm seeing you maybe for the first time and I don't really know your normal personality. I'm just going to listen for things. I mean, I've had several patients where, you know, they just tangentially, as they're talking about, you know, their vision, they'll launch into all these other, you know, maybe health issues that they're dealing with, and then maybe they bring up something within their family or, you know, something about their job. And that is a cue for me to say it sounds like you're. You're really dealing with a lot right now and trying to kind of maybe get them to open up to me a little bit and seeing if I can hear any, anything that might suggest that they are having, you know, suicidal thoughts, ideation. And if I hear anything about that, then of course, you just come right out and ask the question, are you thinking about killing yourself or hurting yourself?

Philip: And I think one of the really important things, too, Denise, just to kind of tack onto that is we make it abundantly clear when we give this talk, especially to optometrist, is the last thing we're asking these kids to do is to start practicing outside their scope. Right. I mean, they're new doctors. I don't want them to get the impression that, okay, not only now am I responsible for this person's ocular health, but now I have to play armchair therapist too. Right. I wasn't expecting this layer to kind of be there. We say no, it's. That's. That's not what we're asking you to do. In your position, right. As a health care provider, you don't have to play investigator. Right. Those red flags are going to pop right out and hit you in the face. Right. And if that's not happening, you probably don't need to intervene because that is not your primary role. Right. 

So, one of the things we teach is a really handy acronym. It's fairly well used in the mental health world is, is path, warmth. So, kind of a long acronym, but I, S, P, A, T H, W A, R, M. And these are just things we teach. Hey, don't ignore the flags. These are all the flags. You. It is path form. So, I is ideation. Right. They said anything about, you know, even what we call thoughts of death in the mental health world, someone says something like, oh, my gosh, you know, I went to bed last night and thought if I didn't wake up tomorrow, that'd be okay with me. Right? That's not a person that maybe is at imminent risk, but that is a red flag to say, oh, okay. That's an interesting thing to say. Right. So ideation. Right. S is for substance use. Right. Is this person now using a substance they weren't before? Have they increased their use? The P stands for purposelessness. I won't go through all of them, but there are all these really great red flags that you can just kind of have those antennae out for. And if you hear any of these things, kind of put a little tally mark in the. Okay. This falls under the questions I might want to come back to later. But wanting these kids to. I say kids, young optometrists, new optometrist, or practicing ones to really understand, hey, this isn't something we're trying to make into something you're not. It's simply we're adding tools to the tool belt.

Denise: I relate to that because I was feeling some of those things right after I lost my husband, you know, and, and I, I said some things to my children that of course were red flags for them. And they're like, you need to do something different, you know?

Dr. Emily: Yeah. So.

Philip: And it's really common. Denise, you know, we talk a lot in the presentation about there's this myth out there that if you talk about suicide or self-harm, that it's somehow going to encourage somebody to do it or it's going to plant that seed that they'd never considered it before, but now that now they are, and nothing could be further from the truth. In fact, statistically, I really wish I was prepared with the number here. I told you, I'm not the smartest person in the room. I don't have my numbers ready. But the statistics point out that most folks who are having suicidal aviation, they'll walk around and anecdotally say, yeah, I walked around for two, three weeks just waiting for somebody to say, hey, are you okay? Like, or hey, are you. Is something going on with you? Are you having thoughts of death? Are you having suicidal ideation? And one thing I really encourage students is use the language and get comfortable with the language. You know, one of the things our modern culture has done, I point out in these TikTok videos, you have people saying things like unalive yourself or I was unalived, or I can't think of another example right now. 

But we're swapping out all these words because we want the algorithm to tag things and get our videos taken down. And I really think that's harmful in a lot of ways. I think we really need to become comfortable with the language of suicide. Self-harm, suicidal ideation. So that we don't feel, we don't trip over our words, you know, super-duper important topic. We want to make sure that we can use the appropriate language as well. A bit tangential, I know. There's just so much that goes into this that I think is important for folks who haven't been introduced to it to, to know.

Denise: Yeah, well, and, and I'm not saying that I was using the same things that were all of. On your acronym, but that first one where I was like, oh, I would be okay if I could just be with my husband, you know, like, of course, absolutely, yes. Which I wouldn't consider necessarily. I'm considering harming myself, but it just, you know, very distressed. Of course, so.

Philip: So of course, yeah.

Denise: So if the optometrist picks up on those cues, or anybody that's listening, really, that's paying attention to. Okay, these are the things that we are going to watch out for. What do you recommend that they do as far as help for that person that they're worried about?

Dr. Emily: Yeah, I mean, like Philip said, being comfortable using the language and asking the question directly. Not dancing around the issue of, yeah, it smells like there's me. Are, are you okay? What's going on? Are you. And kind of dancing around that topic and being very direct with, I hear you saying this and this and this, and you've got ***** going on. Are you having thoughts of hurting or killing yourselves? And depending on what they say, if they, if they disclose that they are, and I think Philip can probably elaborate on this more, if you ask the question, most patients are going to be pretty honest with you.

Philip: In fact, a lot of times the question will take them by surprise. And that's a great, a great tool at your disposal because when you get someone off guard, they are a lot more likely to be honest with you. Right. Are you having thoughts of suicide or harming yourself? If they're not, they'll come in, oh my gosh, no, no, no. You know, they don't want to go down that road. Right. They know what might happen. The calls that have to be made, the processes that have to be followed, they'll tell you, no, no, no, that's not the case. But if they are, hey, it is very likely they've just been waiting for somebody to ask, to say, you know what, I am really concerned about myself. And in that case, you know, again, I'll defer to Dr. Aslakson’s expertise here. But as the healthcare provider, we always say, look, if this person's an imminent danger to themselves or others. You can't leave them alone. That's number one. Not even to run out and grab somebody else. If you have to use the outdoor voice inside to say, hey, can I get somebody to come assist me in this room right now, we don't want to draw a ton of attention to the situation, but do what needs to be done. And if that person says no, they're not at risk, then maybe you just have a different conversation at that point. I think I've lost my train of thought a little bit here, but I think that's, that's the perfect next steps. And we, we try to really drive that point home, too, is that, you know, this, this can all be pretty simple and not too much further outside the bounds of what you're doing every day in terms of, you know, documenting an eye turn. You're. Well, you're going to document. Let's do this out of ideation as well.

Dr. Emily: Yeah. So I mean, once you've kind of, once you've asked the question, and from there a lot of it is your, your clinical judgment, they say, oh, my gosh, no, no, no, no, I'm not thinking about that. That's not what I'm doing. You believe them, then, okay, maybe you follow up and say, do you have anybody you can talk to? Do you have a support system? I do have a list of mental health providers in our area already printed out and I've given that to patients. I've even offered to make the call with the patient to get scheduled to see someone.

Philip: If you're listening, write that down and put a big star next to it. Like, get a list of your local providers. It will save your bacon in a lot of situations. So, when somebody says, who can I talk to? And you've got three names right there ready to go. Whew. That's a much better feeling than scrambling trying to figure it out. Also, psychologytoday.com is your friend. You can search by zip code. Sorry, Dr. Aslakson, to interrupt, but I. Yes, that's a great point.

Dr. Emily: And I also have them broken down for those of us in the States, which providers take which insurances, which are cash pay, which take Medicaid, Medicare. Just so I'm not giving, you know, my patient on Medicaid all these cash pay only therapists that aren't going to be an option for them. So, I do have it noted who takes what insurance and everything.

Denise: When you're talking to them, it sounds like you're getting the clues from the dialogue you have with them. But I was curious if there was something in the way someone's eyes are looking or responding that's going to give you clues about what their mental health state is.

Dr. Emily: I mean, you know, certainly just general behavioral cues, I'd say. So, if someone's, you know, maybe, you know, eyes down, not really looking you in the eye, that can give you a clue that they're not really, you know, wanting to engage or interact. Obviously, if they're, you know, hearing or anything like that, that can give you a clue. I mean, I've walked into exam rooms and had patients just sitting there holding back tears, and it's like, what's. What's going on? And then they just, you know, will let loose, you know, as far as, you know, physiologically looking at things like pupil responses, you know, I wouldn't say there's anything reliable there that I would use to base, you know, clinical decisions off of. It's more, you know, kind of that behavior. I say.

Philip: So, we get into a little more of the subjective, right? The eyes are the window to the soul. And, you know, we talk with clients all the time in therapy about so much of the work that we do here is an art form, not a science. And that's a really, really difficult thing. You know, Trust your intuition, right? If you're looking at somebody and you see sadness in their eyes. And again, that sounds like. How on earth am I supposed to tell that, Philip? Well, just trust your intuition. I think there's something to be said for that as well. Even a line as simple as, I see a lot of emotion on your face right now. Right. We don't even ask a question. Just make an observation. You'd be surprised at what that can unlock. And if you're wrong, they might just say, oh, no, it's allergy to, oh, no, I'm fine. Oh, I'm just thinking about work or what. Oh, hey, great. That's no problem. Right? Crisis averted. But really simple observational statements. Just like you might say to a friend, really, really easy.

Dr. Emily: Yeah.

Denise: So, these are things that people could say to their friends, too. Since some of our listeners are not doctors necessarily. That's something that would be helpful for them in that kind of stuff.

Philip: Yeah. I mean, we all have this, you know, emotional intelligence, right? All of us, just as human beings. You don't have to have any training. You don't have to be a therapist or a psychologist. We all have that. That innate emotional connection to other people. And so that's why I say a lot of the time, if you be like, gosh, you know, this person is giving me a vibe of just not being quite right, hey, I say go for it. I say ask the question. I'm a little more bold than some because I'm more comfortable with those types of questions. But trust that intuition. It's not always a bad thing.

Dr. Emily: I mean, yeah, it's that gut check. You know, as a doctor, I can kind of feel whether it's, you know, this patient, they're not doing well, or gosh, this patient has something going on and I just don't really know what to do.

Philip: Yeah, I remember when I was working in mental health, home based mental health in few counties south of here. I really struggled with doing child protective services referrals. I mean that can just be a devastating experience for a family. It's not a fun process for anybody. And I remember just saying, gosh, I feel like I should, but I don't want to and what do I do? And. And it was just as simple as my supervisor saying, PH. She called me PH. She said, “PH, you gotta trust your gut. You know, if you're going home at night and you're not falling asleep cause you're thinking about this kiddo, that means you probably should have done something”. And it was at that point, Denise, I said, you know, I. From now on in my career, I would rather be the guy that did more than he should have than the guy who didn't do enough. And that served me pretty well, you know, got me into a few situations. So like, okay, maybe I overreacted just a touch. But hey, in these types of situations, I'm a big proponent of better safe than sorry. But they're important decisions. You know, even trying to intervene and having the best intentions can really, can really impact somebody's life.

Denise: Definitely.

Dr. Emily: Yeah, I, I've kind of adopted that motto since Philip told me about that day and at his work. I've kind of adopted that motto myself. And I mean I, I have one patient that I talk about in the lecture where it just, it didn't feel right. And I ended up calling the police to do a safety check on him. And I, I've never seen that patient back again.

Philip: Yeah, it's a, it's an example we give. I'm sorry, I'm interrupting you constantly here. An example we given the curriculum. And yeah, the patient was none too pleased. But you know, I feel like Emily really did the right thing. I'm going to stop interrupting you, I promise.

Denise: I don't know that it's an interruption necessarily as much as an addition. Right. So I would love to hear more of this, the examples that you're giving in your class.

Dr. Emily: Yeah.

Philip: So, the great one that I really like that you do, if I can put you on the spot for a little bit, is the tattoo artist the degree. I mean, to me, this is a perfect encapsulation of why we give this training and how the vision loss in the patient can lead to much, much bigger problems. I think it's a. It's a perfect case study for what we talk about.

Dr. Emily: Yeah. So, this was a patient I saw, gosh, probably four years ago now, and I was seeing him with students. So, the students came back and they're like, we don't. We don't really know what to do because they were only in the exam with him for about 10 minutes. And they came back and I'm like; are you guys ready for me already? They're like, we don't really know what to do. He's. He's just. He's really depressed. Like, oh, okay. And this was a new patient. We had no history on him. We didn't know what to expect. He was a younger patient. I want to say he was in his late 20s, early 30s. So, we were kind of like, okay, new, new youngish patient, or. He had had an optic neuritis in one eye several years ago and was left functionally blind and then had an optic neuritis a few years later in the fellow eye and was now legally blind. And his job, he was a tattoo artist before all of this. So, you know, they're like, he just keeps talking about how he can't work, and he can't see his daughter. So, we. I went in and, you know, kind of just opened up and was like, hey, you know, what's going on? Tell me what's going on? And he. He disclosed all this. He said, I just, I. I don't know what I'm doing with my life. I just. I can't work. I was a tattoo artist. That's what I really love to do. I can't do that anymore. I feel like a failure because I can't even see my daughter grow up. 

So, you know, there's some huge red flags that I'm hearing a person say that. So, I launched right in with that's gotta be really, really hard to cope with. Are you having any thoughts of hurting or killing yourself? And. And he said, yeah, I think about it. What would happen? And fortunately, that relationship with his daughter was very protective for him. He didn't want to do anything that would hurt himself or end his life because he had that relationship with his daughter. He did have a relationship with a therapist already. So, I did ask, you know, is it okay if I just reach out and let your therapist know that, you know, you mentioned this to me just so that your therapist is aware? And he's like, no, it's fine. Absolutely. In the end, you know, after talking with this gentleman, I deemed that he was safe to go home. So I. I let him home. I. I called his therapist and let him know, hey, I. I saw so and so. And of course, therapists are. I cannot confirm or deny that I know this person.

Philip: Okay, well, we don't do that because we like to. Yeah, that's not something we do. It's fine.

Dr. Emily: I'm just letting you know. I saw this person. They told me that you were their therapist, and this is what was disclosed to me.

Philip: So. And at that point, and Dr. Aslakson you can agree or disagree, but to me, again, not being an optometrist, in that moment, your responsibility flips. I mean, the eye exam, to me, again, my opinion becomes secondary at that point. I mean, if you'd have a person in your room, I mean, just think about that. I think about myself. If I were to lose my vision, how devastated I would be, and my reasons would be almost completely personal. Right. I can't watch my favorite shows. I can't play golf. I can't play with my son. Those are all devastating things. But you put on top of that how you make your living, and then you put on top of that that you make your living at an extremely difficult field to get into, in an artistic field where you've been blessed with this gift to be able. And now that's taken away from you. 

Oh, my goodness. How else are you going to feel other than, well, what am I doing here? Right. I mean, it just at that point. Yeah. I mean, the way you handled that situation. I love talking about this case because it's a perfect encapsulation of how that exam can just get flipped right on its head. Dr. Aslakson heard every red flag that there was. This person said they were having ideation. But then the really cool thing about this case, at the end of the day, Dr. Aslakson's clinical judgment told her that he was okay to go home because she followed the procedure and said, hey, we don't have to make this into something bigger than what it is. It just is what it is. And we listen to the patient, and we come to the right conclusion. So, I just. I really love that case.

Dr. Emily: Yeah. And to your point, Denise, actually, when I. When I was a student, it wasn't necessarily a suicidal patient, but I had a. I had a patient was one of my first patient encounters as a student. And this man. His daughter had passed away, like, a month ago. And we were just in the middle of the exam. I went out to get the preceptor. We came in, and this man is just sobbing in the chair. And at that moment, our exam was done. And I spoke to my preceptor afterwards, and he said the exact same thing, that this patient doesn't need an eye exam right now. This exam is done. The purpose of the exam is to make sure this patient is okay. And that was something I learned as a student.

Denise: Even so, at that point, you don't really finish the exam. You just make sure they're okay and send them on their way if they are. Is that what I'm hearing?

Dr. Emily: Yeah.

Philip: Yeah. I mean, that's why I would love to be able to bring similar training like this to, you know, physicians and dentists and massage therapists and anybody who's. Who's interacting with the public. You know, there's a line I love to. I give a presentation, a little training about motivational interviewing. And one of the things that motivational interviewing says is that client outcomes are more important than clinician egos. And I love using that line with medical professionals. Not because I think they have big egos, but I think sometimes they get stuck in this mode of, well, I'm a doctor, and the only thing that matters is me doing Dr. Y things. Right. You came in here because you're sick. I have to help you feel better. That's my job. Where sometimes we need to take a step back and say, well, actually, no, right now it's okay just to be a person and just to listen and, you know, you don't have to fill that cavity today. It might be more important today to get your patient some help.

Denise: Well, it sounds like the kind of help that person needed was what you provided because you couldn't necessarily have done something for his vision.

Dr. Emily: No. And, I mean, we did end up referring him to our low vision service, our vision rehab service. And he did go to that appointment. But, yeah, in that moment. And he knew. I mean, it had. He'd had. He'd had the optic neuritis. He'd been legally blind for several months, almost a year at this point. And he knew. But yeah.

Denise: So for patients that might worry about privacy and that kind of thing, do you want to just go into a little bit about how that part of it is handled in the office?

Dr. Emily: Yeah. So, yeah, patient privacy is something that you obviously have to take very seriously. But again, this is where your clinical judgment comes into play. And the privacy laws, if the clinician believes that the patient is imminent harm to themselves or others, those privacy laws kind of go out the window. Because at that point, the more important thing is protecting that person or protecting, you know, another person if you believe that they're, you know, potentially going to harm another person. So, most of the case law that I looked through, you know, as long as the clinician did their due diligence, they documented what was said, what they were told, use their clinical judgment, then the physician's not going to be, you know, held liable for breach of privacy.

Philip: And it's really important to Denise, I mean, to just be super-duper upfront with folks about this. Yeah, you know, something I said all the time in therapy is like, hey, now that you've disclosed this, here's what's going to happen. I have to tell a person, B person, c person, and that's non-negotiable. And that can be a really difficult conversation to have sometimes as well. But I find most people, like Dr. Aslakson alluded to, if you explain, hey, this is the law, and if I don't do this, I'm at risk of losing my license, losing my job, getting in trouble. Sometimes they care, sometimes they don't. That's okay. But clarity is going to be exceptionally important too, because you can tell them. Look, yes, I do have to tell the following people, but here's a whole list of people I don't have to tell. You know, I don't have to tell your spouse this happened. I don't have to tell your best friend. I don't have to tell your parents. Right, but we do have to tell, right, the police. We do have to tell your therapist. 

So, I think as long as you know who you have to tell who you don't, and you can be exceptionally forthright with that patient because the very worst thing in the world is you say no one's going to find out. And then the patient comes to learn that, well, half the doctors in the office know. Well, why is that? Right? If you're going to tell another doctor, if you're going to consult about that case, tell the patient that. Right. Even have them sign a release for that. Hey, this is so that I can chat with my colleagues to help you in the best way possible. I get permission for that, whether you think you need it or not. Just to add that extra level of transparency for patients who are concerned about their privacy.

Dr. Emily: And I know, Philip, you like to cite a case in our lecture where, I believe it was more mental health, but where the therapist was told something and it was a really.

Philip: Yeah, really, really famous case. Anybody who's been through, you know, counseling school, Tarasoft versus the Board of Regents of the University of California. You know, a case back in the 1970s where, yeah, a therapist was essentially told by a client that they're going to harm another person, and that therapist chose not to disclose that the other person ended up being murdered and that therapist was held liable. So, I say, yes, please, please, please look at that case. When you go to school, you read that case and you learn it inside out, outside, forward, backwards and upside down so that you do understand what your responsibilities are, even if you're not a mental health practitioner.

Denise: Okay. Wow, this is heavy stuff today. So, it's important.

Philip: I'm glad you said that too, Denise, because we. That's another thing too, that's really important. When we give this talk to our students, we say, this is not easy to talk about. You know, we're in there at, what, 8 o' clock in the morning. We're saying, hey, you know, good morning. Let's talk about death, dying and suicide. And so, we always do give that little disclaimer, too. If you feel uncomfortable, if you need to leave, if you need to come talk to us afterwards, please feel free to do that. And we've had a number of students who've taken us up on that. It's just such an important topic. We got to treat it the right way. So, I'm really glad you said that. It is heavy, but it's important.

Denise: Yeah, well, I was a little concerned with one of my students because of an essay that was submitted to me. You know, and I told him, I. This makes me really sad. You know, it was kind of a lifelong thing that he had struggled. So, when I gave this class this past week, and he sits by himself, which is not the norm, in a classroom of Chinese students, that probably isn't in any classroom, but it's. It's definitely not the norm in my classrooms. And there's maybe one or two people in every room that will do that, but, you know, it's not what people usually do. And I went through my list of here's some things you can do to help regulate yourself, get in a better emotional state and all those kinds of things. And he looked at that and he said, I've tried all of that. None of that works for me. Which made me concerned. You know, it's like, well, what kind of help can this person actually receive at this point? You know, because I don't think that he's going to necessarily go to a mental health provider and ask for any kind of help that way.

Philip: It's a great question. One of the most difficult things about being in the mental health space is having to come to the realization that you can only help the people who want it and the people who are ready to receive it. And with the young person that you're talking about, what's really tragic about that is it sounds like this is a person who wants it and is ready to receive it. But that first step is really hard. Right? That first step toward asking. Or maybe it's an accessibility issue. But, yeah, that's where just talking and being open and using the language can be super important.

Denise: Well, good. I, it still has to be, I think, something that we have to feel prompted to do in that moment when you, you know, you can see that it's absolutely to do at that, at that time. Because I, I, you know, you know, we. Again, you have to go back to what you said about trusting your gut. Right.

Philip: Yeah. And being open to what the answers are that the other person is going to give you. Right. If you just, hey, is everything okay? You seem really. They say, oh, yeah, everything's great. Sometimes, even if we don't really believe it, we have to sit with that for a little while. Okay. And maybe we just make a little note that we're going to, that we're going to check back later. But yeah, continue asking, continue checking in on those people because eventually, if something is wrong, they will want to talk about it.

Denise: So I know that you're continuing to teach this class every year, and now you're opening it up to larger groups and different groups. Really. What do you see for the future of this course that you teach and what kinds of things do you hope will happen as a result?

Dr. Emily: I mean, I would love for as many people to hear the talk as possible because, yeah, I think at first glance, a lot of people see optometry and suicide assessment and are like, no, I, no, but, you know, we are, we're healthcare providers and we work with people and you never know what a person's gonna say. You never know what's going on in a person's life. And if you can be someone who knows what to listen for and knows how to follow up appropriately, I mean, you could potentially save a person's life. I've had patients where I've asked these questions, and. And they will say exactly what Philip said. I have been just wanting someone to ask me about this. I feel like I want to talk about this, and no one's asking me. So just listening to the patient, I think, can go a really, really long way. I would love to have as many people hear this talk as possible.

Philip: Yeah. I think to piggyback on. Emily said, I definitely would love to continue to do this year after year at Michigan College of Optometry. I think it's been a really helpful lecture for those students. I would love to get it in front of, you know, more health professions in colleges, whether it's at Ferris State University, where we both are employed, or at other institutions. You know, we've had a chance to give a talk at a conference. What Was that in 2018 or 19?

Dr. Emily: That was our faculty development.

Philip: That was the faculty development. Okay. So really, just as Emily indicated, you know, bringing this to optometry, bringing this to really anywhere that wants to have it, because it really is that important. And one of the things Emily said is people see optometry and suicide and think, okay, this is one of those things we have to do, or this is something that doesn't really apply to me. And it's so cliche to say, but it really is true that you never know what could happen in your own life. And we don't have to get into it right now. But I went through my own scare with vision loss when Emily was actually in optometry school and felt some of these feelings firsthand. And so, you know, we're all just a minute away, a second away, a moment away from having something really profoundly to change our lives. And so I think it's really important to know how to react when those things happen, how to react to the reaction, maybe more importantly.

Dr. Emily: Yes. Yeah.

Denise: Are there some resources that we can put in the show, notes for people who are wanting, maybe a checklist or some other ways of evaluating things?

Philip: Yeah, absolutely. The IS Path WARM acronym. It's a pretty ubiquitously used acronym for suicide assessment. The really great thing about it is, even though it is long, if you can't remember the whole thing, chances are you can remember one or two. So you at least have a few there. Right. That you can use. So the IS PATHWARM acronym, the National Suicide Hotlines Right. They can be a little bit impersonal, but if you have somebody who is in a crisis, crisis situation and you just need something, I don't have that number right here in front of me, but you can really easily look that up on the search engine choice. I suppose.

Dr. Emily: I would also say link to Psychology Today.

Philip: Yep, yes.

Dr. Emily: People to search by zip code available mental health providers and Psychology Today will actually kind of break it down. They'll also show you maybe what insurances that office takes if they're accepting new patients or not. Because our mental health providers are all very full and there are some who are not even accepting new patients. So that is something you'll want to check and update fairly regularly. Another so this is the additional training I've had since I've been out practicing optometry is the qpr, which is question, persuade, refer training. It's very simple. It's really good for healthcare providers because it's ask the question, persuading them to open up and then making that appropriate referral. Whether that is, I'm going to, you know, call this person that you've told me is a support system for you and maybe let them know what's going on. I'm going to call this person and say, hey, I'm really concerned about so and so can you just be sure to check in on them? Maybe that's calling the police to do a safety check. Maybe that's calling the emergency room to get this person in right now. So kind of knowing where you need to refer. Yeah.

Philip: And of course there's the, the humanitarian piece of that and doing the right thing and making the proper referral. We tell students too. I mean, look this, these are also skills that if you, if you have to look at it a different way, could be really good for business. Right. I mean, this is the type of skill that differentiates a great optometrist from a good one. Right. We're both going to give you the same prescription. We're both going to let you pick out your glasses. We're both going to be nice. 

But gosh, if there's an optometrist in there know really cares about you as a holistic person and when you've had a bad day, that person can identify and say, “Hey, Denise, are, are you all right? You know, you seem a little down today.” Whether you like that interaction or not, you'll probably appreciate it. Right? And so, if the whole mental health, we call them the woo woos in counseling school, if the woo woos aren't for you, the touchy feelies. Hey, think about this as a business investment. If you know how to do these things, if you know how to. To treat your patients holistically, then you're going to be a better optometrist.

Denise: Yeah, well, I was concerned when I went in for my checkup that my vision would be worse and I would need a stronger prescription potentially. And that, in my view, is also another reason to not do it if the person's not in a great space, you know, maybe, yeah, I could affect whether it's really an effective prescription for them or not. I don't know. That's kind of get. Gets off into the weeds, maybe of a different topic. But I was disgraceful when I went in that my prescription hadn't changed, even though I had gone through this traumatic life event.

Dr. Emily: And so I actually designed a breaking bad news workshop for our students to give. I. I hire trained actors, Philip is one of them, to portray patients who have lost their vision. And the students have to have that conversation with the patient. But I appreciate you bringing that up about your prescription is. I talk about, you know, bad news is in the eye of the beholder. So, to the optometrist, we may think, so what, Your prescription's stronger. We'll just write you a new pair of glasses. But to the patient, that might be something very distressing for them and kind of being aware of that and being sensitive and empathetic to that, that, you know, maybe to us, we're thinking, like, what is the big deal? Why are you so upset that your prescription changed? But, you know, to some patients, that might be something that probably means more to them than you having the history you have. That probably means more to you than someone who doesn't have that history.

Denise: Yeah, well, I've been working on natural vision improvement for years, too. So, my goal is always to have my prescription decrease. And it didn't decrease, but it didn't increase either.

Dr. Emily: Right.

Denise: Well, do you want to give any last piece of advice for my listeners in general? I don't know how many of them are doctors per se, but people who are obviously concerned about our overall health and working on our vision all the time.

Dr. Emily: Sure. I mean, I would say kind of. The main takeaway points are get comfortable asking the questions clearly to people, recognizing the red flags, know who to refer to. And if you say you're going to do something, do it. If you say you're gonna call the patient later to check up on them, do it. If you tell your friend that you're concerned about. Hey, I'm gonna give you a call tonight. Do it.

Philip: Yep. Don't. Definitely don't leave your patients hanging. I think that that's the big one, as Dr. Alexson said, you know, and kind of backtracking a little bit. Denise, I really think it's important, too, like Emily said, that the bad news is in the eye of the beholder. You never know what, you know, the proverbial straw that broke the camel's back. You know, what else is this person dealing with? And, you know, like I said, we're all just one moment, one second, one minute away from hearing a piece of news we never thought we'd hear before. And, you know, that's been a big part of the bad news workshop, too. It's part of what makes my job so easy as an actor is one of the cases we do is actually my case. And, you know, the having the emotional memory of what it was like to hear that news and how I was treated in that moment has really had a big impact on how we've developed this course and how we encourage optometrists to take the content and implement it.

Denise: Awesome. Well, thank you for the work you're doing. It's awesome.

Philip: Oh, of course. We enjoy it. Well, I do. I won't speak for you, but I enjoy it. Yeah.

Denise: That's awesome. Yeah. Would you like to go ahead and share your. Your story that you act out in this scenario so that.

Philip: Yeah. Yeah.

Denise: One isn't hanging and wondering what you went through that was so impactful.

Philip: It was, you know, one of the. The life events that kind of brought this whole thing to life for us or at least made me start thinking about. It was. It was 20, what, 13. We were in Bloomington, Indiana. Emily was going to optometry school at iu, and I was there with her, of course. And I started noticing over the period of a month or so, like, gosh, you know, I'm watching TV and things are just blurry, right. So maybe there's a little ticker running at the bottom of the screen. I can't read it. Or, you know, maybe there's. Gosh, I can't see this person's face clearly on the tv, and I'm sitting the normal distance away. What's going on? So, I think, well, you know, I've worn glasses for the majority of my adult life. I probably just need a new prescription. It's no big deal. 

And thankfully, my wife is a student at the optometry college, so I go down there, I get my eye exam, and they do the test and they say, oh, your prescription hasn't changed at all. Okay, well, that's a little odd. And so that follow up appointment, follow up appointment, follow up appointment, test after test after test. And what they finally say is, we think you have a. A small strabismus. So microstrabismus, that's just causing your binocular vision just to be that much off that it's causing you a little bit of blur. And so that was kind of the working theory for a while, and it just wasn't getting better. And in fact, it started to get worse. Golly, this is. Something is going on and I'm not sure what. So we finally go in and they say, we need to do an MRI. We need to get some imaging done. And Denise, I was the stereotypical patient. I fought it. I said, oh, come on, don't make me do this. I mean, at the time, this is pre–Affordable Care Act. We were not Medicaid eligible. We did not have the student insurance. And so, I was like, I am not paying $5,000 out of pocket for an MRI I don't need. 

Yeah, well, thankfully, the optometrist was quite insistent, and I went, I got the MRI and I went back to my follow up appointment and heard the words I never, ever, ever thought I'd hear. You have a 37-centimeter mass in the center of your brain. It's wrapped around your pituitary gland. We have no idea what it is. That's what's causing the vision loss. It's constricted your optic nerve, so you're going blind in that left eye and that damage is probably irreparable. Okay, great. So, I went from, hey, I might need new glasses, to one of your eyes is pretty much shot and you have a brain tumor and we're not sure what it is. So, like I say, it's just that fast that life changes. And then in that moment, here I am as a master's in counseling student, trying to help calm myself down and getting a great opportunity to use all these coping skills I've been learning about. But for us, it was an exceptionally challenging time. And part of what we learned is how the doctors around us behaved. And some of them did exceptionally well, and some of them missed the mark a little bit in terms of how they dealt with this really difficult situation. 

I was never asked specifically if I was having suicidal thoughts. Suicidal ideation, self-harm ideation. The truth of the matter, Denise, is that I was. Now for me, a lot of it was kind of circumstantial and dependent, which I think for a lot of people it would be like, hey, if this gets really bad and I go blind. Yeah. I could see myself wanting to not be alive anymore. Right. But thankfully, I had an amazing care team, and the tumor was shrunk down with medication. I still have some pretty profound vision loss here in the left eye but corrected. I do okay. So, you know, just kind of my own personal foray into the world that I'm hoping to teach these young optometrists how to navigate. Because as tough as it is for the patient, I can only imagine it's equally as tough and as shocking for the doctors because, you know, those MRI results aren't going to be the big tumor every time. Most of the time, I think for the doctors, it's going to be okay. There's nothing going on. So, you know, it's a big deal for them, too. But that's my story. I'm still undergoing treatment for it to this day, and it's made me a pretty passionate, passionate advocate for mental health and in optometric spaces, so.

Denise: And also, for getting diagnosed.

Philip: Yeah, absolutely. And for being an advocate for yourself. You know, there were a lot of great doctors who were doing the best that they could, but I'm not an optometrist, but I knew something wasn't right. So, a really good lesson, too, in self-advocacy and also to have an amazing partner here who as a student was willing to step in and say, hey, I have a partner to play this as well. So, she played a big role in that diagnosis as well. So, I'm very, very, very grateful for that.

Dr. Emily: Insisting you go to follow up after.

Philip: Insisting that I go. Denise, you got to understand, I'm one of those people, like, why on earth do I need a follow up appointment? I had my gallbladder out a week ago, and it's time for the follow. I don't need a follow up. I'm fine. They just want to bill me for more. No, you really do need to go to your follow up. Don't. Don't be like me. Yep. Emily's a saint sometimes in that regard.

Denise: That's an awesome story. I can see why you feel strongly about what you're doing.

Philip: It's.

Denise: It's very important work.

Philip: Yeah. And to hear that you have this podcast that you have, you know, about this topic is. Is amazing. You know, I'm so glad that there are other folks out there doing the advocacy work and talking about it. So, for people in the situation, it can feel very isolating. Like, who on earth is going through something this specific, like me. Well, there, there are a lot of folks out there who are so, so very, very cool.

Dr. Emily: There are.

Denise: And I, I feel frustrated often that the people who really need to hear about vision therapy, about options for improvement are the very people who don't know where to find it. And they're on these support groups and not always getting really great support, not really getting the information that they need. And that's why I go on there and that's why I do the podcast. Thank you for, yeah, awesome what you're teaching. It's going to be great for my listeners.

Dr. Emily: Thank you. Thank you for having us.

Philip: Yeah, Denise, thank you so much. This was so much fun. I really appreciate it and I hope it does well for you.

Denise: Thank you so much for joining us for this important conversation. If today's episode stirred something in you, whether you're a patient, a provider, or someone in between, please know that you are not alone. Mental health is part of whole person care, and that includes vision care, too. A special thank you to Dr. Emily Alexson and Mr. Philip Heimboff for the work they're doing to bring suicide awareness into the world of optometry and for showing us what's possible when we look beyond the surface. If you or someone you know is struggling, please reach out to a mental health professional or contact a crisis line in your area. Help is available. You can learn more about their course through the Optometric Extension Program foundation or by contacting them. If you found this conversation meaningful, I'd love if you share it with a friend, leave a review or send me a message. You can also join the Healing Our Sight Facebook page. Thanks for listening.