Spreading a Different Courage

courageThink back to this time last year. A little story was lurking somewhere behind Kim Kardashian breaking the internet. We simply weren’t paying it much attention.

In fact, the “little story” was only the largest Ebola epidemic in human history, affecting multiple countries in West Africa. More than 25,000 individuals were diagnosed with the disease, and more than 10,000 succumbed to the scourge, including many healthcare workers.

Despite this, the disease wasn’t much on the minds of most Americans. But that all changed on September 30, 2014 when the CDC announced that a 45-year old from Liberia, Thomas Eric Duncan, had been diagnosed…not thousands of miles away in West Africa, but while visiting family on US soil…in Dallas, Texas. He was treated at Texas Health Presbyterian Hospital in Dallas, and within two weeks, two nurses who had treated Duncan also contracted the infection.

Our response? Naturally, we panicked, imagining a full-scale zombie-like invasion and the total breakdown of civilized society. And those fears of contagion spread faster than lightning. For example:

  • The Boston Globe reported that half of Americans were concerned that there would be a large Ebola outbreak and more than one-third feared a family member would get sick.
  • A teacher from Maine who had recently attended a conference in Dallas was placed on 21-day leave, as demanded by worried parents.
  • A young female healthcare worker who returned from Sierra Leone was hounded by the press and encouraged to quarantine herself.

However, Ebola did not hold exclusive claim to fear of contagion in 2014.

After the death of beloved actor Robin Williams last August, The New York Times reported, “suicide contagion is real,” and suggested there was science to prove it. This idea argues that vulnerable people exposed to repetitive or promotional coverage about suicide, including using the word “suicide” in the headlines, talking about the means of suicide, and/or presenting death as an escape, will lead to an increase in suicides.

In fact, the Academy of Motion Picture Arts & Sciences received much heat over their tweet, “Genie, you’re free.”

I don’t doubt this tweet comforted many grieving the death of someone they felt they knew, but also prompted The Washington Post to express concerns regarding the dangers of infecting others with thoughts of suicide through social media and the news. It would be better, many think, to not talk of it at all.

Think youth sex education. Many believe if we talk about birth control, we will give young people an idea they didn’t already have. But that’s not the way it works, and Columbia researcher Dr. Madelyn Gould has disproven the myth that the idea of suicide will infect someone who doesn’t have it.

Fear of contagion, whether it be of disease or increased suicides, is not always based upon facts. What seems to get lost in all the media hoopla is the actual risk of contagion.

Disease researchers use a basic metric to estimate how many people on average each sick person will infect. According to Wikipedia, “The basic reproductive rate (R0 or R nought)] is calculated by estimating the chances of exposure, number of susceptible persons, length of contagious period, how the disease spreads, and how much time passes between exposure and becoming contagious.”

Using this scale, one of the most infectious diseases we know of is measles. Measles is an airborne disease and leads to infection on average of 12 to 18 people for every one person infected. The 2014 measles epidemic in Disneyland started with one person, and from that, 117 people became infected (mostly those who were not vaccinated).

HIV/AIDS typically spreads to 2 – 5 other persons thru sexual contact. The 2003 outbreak of SARS had a similar R0.

By contrast, Ebola, which is communicated only through bodily fluids and only while a person is showing symptoms, is much more difficult to spread, with an estimated infection rate of 1 to 2 persons on average.

The goal of public health is to drive R0 for any disease to < 1, which is the difference between it dying out or it becoming more widespread.

Ebola is no less serious than SARS, measles, or influenza, it just doesn’t spread as easily. In fact, it is the least communicable of all well-known infectious diseases, and THIS is the simple fact most Americans missed.

In comparison, suicide simply does not have an R0. It is NOT communicable in the same way infectious diseases are.

And yet, researchers struggle with how best to describe the increase in deaths that can occur after a high-profile (and widely reported) death by suicide, or the apparent clusters of suicides that sometimes happen in small communities.

Herald.ie featured a story of a cluster of four young girls who died by suicide within a very close time frame in small communities just outside Dublin, Ireland. The three large dots in their map represent three girls who were just 13 and 14 and died within three weeks. A 17-year-old girl had died before Christmas. The girls all knew each other and had common friends.

Hence, the question: If suicide is not contagious, then why does someone take their life only days after a fellow student, close friend, or revered media figure has?

Perhaps the answer lies in my experience with The Spartan Race, a mudrunner event I participated in a few years ago. For the uninitiated, this race is like boot camp, Survivor, and a 10K, all rolled into one.

Before this, I had never contemplated quitting a road race, but as I stood looking up at the unscalable wooden wall in front of me, I assumed this would be the one. My first attempt at clearing the wall failed miserably. Head down and in despair, I began looking for the exit when, out of my peripheral vision, I spied a middle-aged woman racing past me toward the wall. Undaunted, she threw her foot into the wall, catapulting her high enough for her fingers to grip the top. In the next instant, she flung a leg up and caught the edge with her toe, pulled herself up, and flopped over the wall. Gone. I’m a foot taller and have a runner’s build, yet she cleared the wall.

Did I observe her technique? Yes. In fact, I replicated it exactly. But the most powerful motivator was not tactical; it was the sudden belief that I could now do something that only seconds earlier was unattainable. Prior to that moment, I desperately wanted to clear the wall, but knew I could not. Watching her do it, though, was like flipping a switch. My mindset changed and I cleared it easily on my very next attempt.

People want to die when their deep anguish and belief that their life has no value intersects with an abiding loneliness that aches in the soul. The desire to die by suicide isn’t catching; it’s a response to intolerable emotional pain. The overwhelming majority of these individuals already stand in front of the wall, head down, wanting desperately to get over the wall, but they assume it is impossible.

Surely, skills are observable and techniques can be learned quickly, but what is truly contagious is courage: believing it can be done because you witnessed it. “If they made it over, perhaps I can, too.”

This is what frightens those in the suicide prevention field and what leads us to advocate for more thoughtful and careful media coverage after a reported suicide. When people die by suicide, others around them, also struggling with unbelievable pain, are suddenly at greater risk, because the “courage” that is most often shared in the media has to do withending one’s life.

But what if the stories people heard were about those who lived… about those who found a way to hold on a little longer… until the pain subsided.

We should be investing our time and effort on media stories about individuals who have survived suicide attempts, rather than negative messages (or worse yet, trying to control the uncontrollable media after a high-profile suicide).

Help us get the news out. Give a voice to those with lived experience facing down unbearable pain and surviving.

Perhaps if those three young teenage girls outside Dublin had heard someone like Dese’Rae Stage (Livethroughthis.org) talk about how she found a way to cope, they would have held on long enough to live.

It’s time to flip the metaphor. To not talk about people being “set free,” but people surviving.

It’s time to end the silence. To share messages of hope and encouragement from suicide attempt survivors.

It’s time to embrace that we are better together. To create an epidemic of survival.

*Note: Also, see my YouTube TED-style TALK at the 2015 National Council for Behavioral Health Conference in Orlando, FL, “Ebola Versus Suicide (Facts and Fiction).”

America Shrugs: A Glimpse into the Future of Suicide

army tankIn order to catch a glimpse of the future of suicide prevention, perhaps it would be helpful to visit the past, a time when our nation was first complacent, then went to war.

So many deaths of people in the prime of life… and yet “America simply shrugs.” This was last week’s hard-hitting USA Today article on suicide, but it sounds a lot like something that could have been written about cancer…back in 1943. This was an era when the New York Times refused to “publish the word breast or the word cancer in its pages.” It was a time when children with Leukemia were diagnosed and hospitalized, but because there was no treatment available,  they were sent home to die (an approach referred to as “compassionate care”). In short, it was a time when the nation lamented “Why waste effort on an incurable disease?”

Siddhartha Mukherjee’s book tracing the history of cancer and its treatment evolution, “The Emperor of All Maladies,” won a Pulitzer Prize for its vivid recounting of the heroic work by Sidney Farber and Mary Lasker who “would stop at nothing to drag even a reluctant nation toward an unshakable, fixed vision of a cure.” But when Lasker first turned her laser focus to cancer, the nation’s view of cancer was as fatalistic as its view of suicide today. She was very disheartened following her first visit to the underfunded American Society for the Control of Cancer (ASCC) in April 1943, describing it as “self-contained and moribund, an ossifying… social club.”

Two extraordinary dynamics converged in the few years following that galvanized the cancer treatment movement and set the stage for the gripping story of advancements we continue to see today. First, Mary Lasker began to apply her marketing savvy and political activism to create a federal “War on Cancer.” The metaphor was timely, as the nation had been shaken from its singular slumber and was now involved in the second world war.

“Subtly, although discernibly, the tone of the society changes as well. The ASCC had spent its energies drafting insufferably detailed memorandums on standards of cancer care for medical practitioners. (Since there was little treatment to offer, these memoranda were not particularly useful)” (Page 112). A marketing blitz created a social movement. Funding exploded to $12 million annually within three years. A prioritized agenda for research was developed. Action became the banner cry.

Yet, unless and until there were real and effective medical interventions that worked, Lasker knew the movement could not succeed. Then in 1947, in a dark basement lab not much bigger than a closet, a pediatric pathologist named Sidney Farber was struck by the lightning that would eventually evolve into chemotherapy and open the pathway for radiation therapy.

It took nearly 30 years before childhood leukemia was no longer considered an incurable disease, but the teamwork of Lasker and Farber changed the world of cancer treatment forever. During the ensuing decades, they faced strong opposition from within the field. One quote from the New England Journal of Medicine said this about the cure for cancer: “I am not opposed to optimism, but I am fearful of the kind that comes from self-delusion.” By contrast, Farber wrote to Lasker in September 1965, “The iron is hot and this is the time to pound without cessation.”

What are the parallels between cancer and suicide? I think when a future book about suicide prevention is written, it may well find a similar convergence happened in 2014.

The National Action Alliance for Suicide Prevention and the Zero Suicide and Way Forward initiatives have borrowed heavily from the Lasker toolkit. We have seen impressive advances and expanded utilization of suicide risk assessment (from the National Suicide Prevention Lifeline’s Suicide Risk Assessment Standards to the Columbia Suicide Severity Risk Assessment).

Yet, despite the movement, it feels a lot like 1945 did for cancer. The momentum is beginning to build, but we are awaiting Sidney Farber’s innovations in treatment (as it were). Three central drivers are poised to shape similar striking progress as Mukherjee chronicled in cancer treatment.

Future Trend #1 – Systems Accountability and Integration

When three Americans were diagnosed with the fearful Ebola virus, the Obama administration appointed a “czar” to assume overall responsibility for integrating the response efforts of various government agencies and ensure decisions get made. If there’s a suicide czar right now, one might well look to Julie Goldstein Grumet, who leads the Zero Suicide in Healthcare collaborative that includes a number of US state mental health authorities and leading community mental health providers, including the nation’s largest in Centerstone America.

Inspired by the outcomes reported by the US Air Force, the Henry Ford Health System and Magellan Health of Arizona, the National Action Alliance for Suicide Prevention produced the Suicide Care in Systems Framework. These programs were developed largely outside the formal suicide prevention field with leaders of these systems starting the goal from the other end. Instead of incremental improvement, the CEO and top leadership aspired for zero and reported their progress publicly. And, they used a quality improvement and customer-focused approach, including individuals with lived experience in the design and/or leadership.

The trend for systems accountability and integration is not limited to healthcare organizations. The Mates in Construction program was developed by and for construction industry workers in Australia. Similar programs in law enforcement and fire are emerging. These systems approaches are creating a learning environment and offer rapid acceleration of learning in what works.

Future Trend #2 – Direct Treatment for Suicide

Washington State’s recent Supreme Court ruling that psychiatric boarding in emergency departments is illegal may break the cycle. Take a typical scenario for someone with suicidality: they wait days in an ED, because we may understand their suicide risk, but we do not know what to do for them. Once transferred to an inpatient or crisis stabilization unit, they may receive medication, but no treatment for their suicidality. By the time they return to outpatient behavioral healthcare, they realize how futile it is to mention thoughts of suicide. And if they do? The result is often more assessment including a return to the ED. Lather, rinse, and repeat.

Last month, I had the opportunity to spend some time with David Jobes, who was in Phoenix to keynote at the Arizona Suicide Prevention Coalition Hope conference. He shared with me an advanced view of the results of his partnership with Denise Pazur, and I could not help seeing the parallels with Lasker and Farber.

He said it’s not the lack of clinical interventions for suicide. Rather, it’s a lack of training. More than 90% of the million people in the US behavioral healthcare workforce — a $40B industry —  have not received any training in suicide care (beyond basic guidance on suicide risk assessment). For the few who report having received training, almost all cite a “gatekeeper” model, which was developed to assess and refer, not treat.  It’s not even accurate to say we have dabbled in suicide prevention in behavioral healthcare settings —  neither our master’s preparation programs, accrediting bodies, licensure boards, state and health plan oversight, or healthcare agencies have trained staff in treatment.

The state of Oklahoma may be the first to operationalize the Zero Suicide initiative with a full-scale inclusion of the Collaborative Assessment and Management of Suicide (CAMS) approach. While the list is short, there are other clinical frameworks to treat suicide directly. Keep your eye on Kate Andreasson Aamund’s important research, which she will present at IASP 2015 in Montreal, regarding her comparison of the results between CAMS and Dialetical Behavior Therapy (DBT). There is also Cognitive Behavioral Therapy for Suicide and a series of brief interventions (including frameworks from Sweden’s Konrad Michel and Columbia University’s Barbara Stanley).

Slow change. As the research mounts on the effectiveness of these direct clinical interventions for suicide, the challenge will be innovation diffusion. The fundamental models for training in behavioral health and suicide today depend upon a network of master trainers and thousands of certified trainers that deliver lengthy face-to-face sessions. These predominantly one-day and two-day trainings can be an expensive investment and seem extremely inefficient in today’s world.

Future Trend #3 – Suicide Care Training Goes Online

In 2013, I attended a national meeting in which a federal leader in suicide prevention expressed frustration with the current models and encouraged innovative solutions to be explored. One of the industry leaders who represents a face-to-face training product responded that it is not possible to replicate the results and experience with an online product. There was a long silence of nodding assent in the room… and then two federal leaders challenged whether there was a single research article backing up this belief.

Denise Pazur leads Empathos, a company committed to delivering suicide treatment training online, in ways that fit into a professional’s daily workflow, at the point where decisions are made that can affect persons at risk. Her view is that training must be online, customized, and asynchronous. If the field is going to truly scale interventions that save lives, staff must be able to obtain dynamic training in ways that fit their schedules, where they can start and stop, repeat, incorporate, and learn.

David Jobes gave me an advance glimpse into the three hour online CAMS training co-created with Denise, and I felt that perhaps I was seeing the future. I believe 2015 will be a breakthrough year. Marsha Linehan will keynote at the AAS conference in Atlanta talking about her own incredible journey to develop DBT. And CAMS will be available and accessible online through Empathos.

Imagine a world without the merry-go-round of EDs, assessments, inpatient/crisis and outpatient, where lather, rinse and repeat is the norm. Instead, imagine one in which we not only have a society gatekeeper trained to identify risk, and professionals trained in assessment, but also behavioral healthcare professionals confident and prepared to deliver competent care directly.

A cure for cancer seemed a pipe dream in 1943, and doing anything effective with suicide seems impossible to most people today. But real change is brewing. I am inspired by these three trends. Online CAMS training is coming in January 2015. Also next year, the National Council for Behavioral Health and Suicide Prevention Resource Center will partner for a Breakthrough Series on Zero Suicide with six states participating. I cannot wait to see what happens next!

Everything We Knew About Suicide… Is Wrong

dragon in battleIn “How to Train Your Dragon,” the citizens of Berk had observed, measured, categorized and chronicled dragons for decades. They thought they knew most everything there was to know about these violent beasts. But when Hiccup, a small, anything-but-Norse-like-warrior boy comes into contact with one of the most feared and misunderstood dragons, his eyes are opened wide. Putting aside his preconceived notion of dragons, he develops a loving friendship with “Toothless,” admitting, “Everything we know about you guys…is wrong.” Hiccup then sets his mind on changing those misconceptions still held by his fellow citizens.

Italian researcher Dr. Maurizio Pompili offered a similar challenge during his brilliant plenary on the first day of the European Symposium on Suicide and Suicidal Behavior (#ESSSB14), held in Tallinn, Estonia (which was so beautiful, I would not have been surprised to see an actual dragon flying above the 13th century medieval Old City).  Dr. Pompili asked us whether we truly understood what it is like to be suicidal. Like Hiccup, he challenged the suicide prevention and behavioral health community about our steadfast conclusions when we lacked first-person knowledge to confirm our beliefs.

Some researches may have bristles when presented with such a challenge. Perhaps they questioned whether the rest of Dr. Pompili’s presentation would be grounded in firm science, or simply be the voice of sympathy. Then Dr. Pompili talked about the significant differences in observing people in love (and measuring, categorizing, and chronicling what is observed), and actually feeling the experience firsthand. He listed some of the descriptions of suicidality proposed by various leaders over the decades and they seemed to fall flat, like a second-hand description of love by someone who has never felt it…the adrenaline rush, giddy nervousness, shortness of breath, the crushing in the chest caused by absence, and, as time goes by, deep contentedness, connection and…well…love.

“Love, like most first person experiences, is not discussed at suicidology conferences,” he added. But could we researchers and clinicians possibly “imagine how much these patients suffer” without our own firsthand experience? I thought back to how we have used “psychiatric distress” to describe the suicidal experience. By contrast, individuals who have experienced it first-hand sound like… well… like they have actually been there.

William Styron’s book “A Darkness Visible,” which he wrote about his own debilitating suicidal depression, is titled after John Milton’s description of Hell in “Paradise Lost”:

No light; but rather darkness visible
Served only to discover sights of woe,
Regions of sorrow, doleful shades, where peace
And rest can never dwell, hope never comes
That comes to all, but torture without end
Still urges, and a fiery deluge, fed
With ever-burning sulphur unconsumed.

Psychic ache vs. torture without end. The gulf between third person observations and the anguish of first person experience is profound. However, over the last decade, many of us have begun to chip away at this gulf, learning from leaders who have personally struggled and survived, their lived experience giving them the expertise we lack. Such interactions have led me to question the near religious belief our society holds about suicide as a choice. Rather, it seems individuals succumb when all their strength, supports, resources, and hope completely fails in the face of unimaginable pain. I also no longer subscribe to the idea that suicide is unpreventable for many (those supposedly “truly intent”). Zero Suicide is something I believe in and aspire to.

perestroikaI’ve been told by experts over the years that getting suicide survivors together in a room would lead to trouble, but in fact, the opposite has happened. We’ve witnessed true creative innovation and energy with an incredible focus on recovery, hope, and…love. Dr. Pompili is on to something big.Preach on, Hiccup. Everything I knew seems to be wrong.

Danuta Wasserman, President of the European Psychiatric Association, launched the ESSSB conference by revisiting Estonian independence and the Perestroika movement, engineered by Michael Gorbachev in the late 1980s. It’s time for a social openness and political restructuring in Suicidology, too. The “old guard” of researchers, policy makers, family members, and practitioners must now welcome suicide attempt survivors.

These survivors are like Hiccup’s dragons, unique and individual and far-too-often misunderstood. Athletes we worship. Marines who defend our country. Researchers, clinicians, and healthcare leaders who pour their own lives into their work. The come from every background and represent every profession. They are activists. They are storytellers. They are pioneers. Some of them have struggled with serious mental illness.

Mostly, though, they are just like us. Human. Fragile. Worthy. Silouan Green reminds us “We can all get broken.” And Craig Miller tells us we can discover who we truly are and find recovery, whatever challenges we face.

19 suicide leaders in 2014How to train your suicide prevention leader. In 2005, I began as Vice-Chair of the National Suicide Prevention Lifeline Steering Committee, and first met Eduardo Vega. Over the next decade, he and a host of others would help me realize I had misunderstood many fundamental concepts about suicide. These are the leaders who have impacted me most (pictured from left to right, starting with the top row):

 

  1. Dese’Rae Stage: Live Through This chronicles in photographs nearly 50 suicide attempt survivor stories and has been featured in the New York Times.
  2. Eric Hipple: Former NFL Quarterback was a keynote speaker at AAS 2014 in Los Angeles and author of Real Men Do Cry.
  3. Heidi Bryan: Long-time survivor leader and founder of Feeling Blue Suicide Prevention Council after losing her brother to suicide.
  4. Dequincy Lezine: First researcher to “come out” in the suicide prevention field about his own attempt some 20 years ago (Eight Stories Up), and first director of newly formed AAS Attempt Survivor Division.
  5. Kevin Hines: Internationally-known speaker on anti-bullying, wellness in the workplace, drugs and alcohol prevention. His book Cracked, Not Broken tells his story of surviving a suicide attempt by jumping off the Golden Gate Bridge (also interviewed in The Bridge documentary).
  6. Craig Miller: Author of This is How it Feels: A Memoir – Attempting Suicide and Finding Life, and speaker in break-through panel by survivors at AAS 2014 in Los Angeles.
  7. Kita Curry: CEO of Didi Hersch Mental Health Services, board member of the National Council for Behavioral Health and keynote speaker at AAS 2014 in Los Angeles about her own suicide attempt.
  8. Cheryl Sharp: National Council for Behavioral Health leader in trauma-informed careand suicide attempt survivor in panel presentation “Personal Stories of Recovery,” at NC 2013 in Las Vegas.
  9. Cara Anna: Talking About Suicide chronicles in interviews nearly 80 suicide attempt survivor stories and has been featured on National Public Radio.
  10. Silouan Green: Former top Marine, activist, survivor, and “voice for the lost and broken (the many among us with depression, suicide, PTSD, trauma” (Live Freewebsite).
  11. William Styron: American novelist famous for The Confessions of Nat Turner andSophie’s Choice. In 1985, he experienced a suicidal depression, which he later chronicled in a memoir, A Darkness Visible.
  12. Terry Wise: Former Boston trial attorney and national speaker whose suicide attempt following the death of her husband from Lou Gehrig’s Disease (ALS) is chronicled inWaking Up and an award winning video.
  13. Sabrina Strong: Suicide prevention leader in New Mexico and founder of the Waking Up Alive peer crisis respite program in Albuquerque
  14. Tom Kelly: Former consumer affairs leader for the Arizona Health Department, Magellan Health, and Centene, Tom has personally known 20 individuals who died by suicide and wrote about his own attempts in the 2012 National Council Magazine, Not Another Life to Lose.
  15. CW Tillman: Along with Stephanie Weber, Kate Comtois, and Jason Padgett, CW presented in a watershed plenary panel at AAS 2011 in Portland, Silent Journey: Helping Suicide Attempters and their Families.
  16. Leah Harris: A blogger (Speaking Truth to Power), dynamic story-teller, survivor and activist, Zero Suicide faculty member, director of the National Coalition for Mental Health Recovery, consultant to the National Empowerment Center (Dan Fisher).
  17. Katie Ayotte: My partner in the Magellan Health Zero Suicide initiative from 2009 – 2013, Katie was featured in Behavioral Healthcare Magazine in 2011 (New Perspectives) and her story “Journey to Hope” was in the 2012 National Council Magazine, Not Another Life to Lose.
  18. Ursula Whiteside: Clinical psychologist, researcher (Now Matters Now) and fierce advocate, Zero Suicide faculty member, Group Health clinical leader and innovator with Forefront (also YouTube interview: Better Informed, Better Care)
  19. Marsha Linehan: world-renowned psychologist, author and developer of Dialectical Behavior Therapy (DBT), came out about her own suicide attempts in 2011 NY Times article, Expert on Mental Illness Reveals Her Own Fight.
  20. Eduardo Vega: Principle-investigator for The Center for Dignity, Recovery & Empowerment and co-lead National Action Allince Suicide Attempt Survivor Task Force and its Way Forward Report (also YouTube Interview: Power of Peers and Suicide Care).

There are many new voices emerging in this community, including Samantha Nadler, Misha Kessler, and others. It’s time they take an equal seat at the table. We need to hear their voices and learn and share. (And, this list is exclusively from my experiences with those in the United States – who are the leading voices in other countries?)

Here there be dragons. Like in “How to Train Your Dragon’s” fictional Berk, this phrase has been used throughout the millennia to warn of danger. And, we, too, have kept our distance from suicide attempt survivors. But, the phrase has also meant an unknown place, one to be explored. The above individuals are all fierce leaders, creative thinkers, socially aware and connected, and many strong friends, and we are simply better together.

Can Clinical Match the Power of Peer Supports?

hands reaching outGenerally, people ask the opposite question looking to researchers to examine the outcomes of peer supports and comparing them with established clinical best practices. Consider, though, the school shooting that was averted due to the actions of a peer. How would we clinicians have done in her shoes?

August 24 marks the one-year anniversary of a school tragedy that didn’t happen, thanks to an Atlanta bookkeeper named Antoinette Tuff. On that day in 2013, she was confronted by a young man with an AK-47 and nearly 500 rounds of ammunition at a Decatur, Georgia elementary school. We know how she interacted with the young man because of a 24 minute 9-1-1 call, during which he leaves twice to go to the front of the school to fire off his weapon towards police.

The call is terrifying and hard to listen to. There are long periods of silence. Once, Antoinette considers fleeing, but realizes the consequences could be dire. At the end of the ordeal, the woman who has seemed so calm throughout the crisis breaks down in tears to the 9-1-1 dispatcher as the young man is taken into custody.

CNN and others rightly hailed Antoinette a hero, but her heroism was in sharing and connecting with the young man as a peer. I doubt the young man would have felt that she “met him where he was at.”  She didn’t come down to his level; rather, she shared. She talked about her painful divorce and her subsequent suicide attempt, describing how she’d recently been where he was, and she connected with him. She fearlessly engaged and maintained no walls between herself and the young man who was threatening both the school and law enforcement.

After Tuff persuaded the young man to surrender, and shortly before the police secured the scene, she told him she loved him. “It’s gonna be alright sweetie,” she said. “I just want you to know that I love you, though, OK? And I’m proud of you. That’s a good thing. You’ve just given up. Don’t worry about it.”

I recently joined Recovery Innovations as Deputy CEO. Their mission statement is “to create opportunities and environments for people to recover, to succeed in accomplishing their goals, and to reconnect to themselves, others, and meaning and purpose in life.” This is facilitated through a focus on hope, empowerment, choice, recovery environments and language, and spirituality, and is founded on the belief that everyone can recover and that peers are key to making this happen. Everyone can remember who they are, and use their strengths to become their best. It starts with hope and empowerment.

In 2005, researchers from Columbia and Rutgers interviewed crisis center supervisors and silently listened in to thousands of crisis telephone calls. They monitored the outcomes both during the call and with two-week follow-ups, and they used factor analysis to determine what worked. The crisis center supervisors reported in interviews that their teams did not engage in self-disclosure. However, despite policies at various call centers to the contrary, the researchers actually observed that self-disclosure was a common occurrence. Furthermore, they were surprised to see a correlation between self-disclosure and the strongest outcomes of any activity on the calls. Genuine personal connections made a difference.

Nearly thirty years ago, I visited a nutrition “doctor” who used a simple muscle test to determine my health. Of course, at the time, I had no idea how this parlor trick worked. He had me extend my right arm and applied a gentle pressure to my wrist while checking for various issues. If my arm stayed up, I was healthy. If the arm fell, it indicated I had an infection, poor health, or food sensitivities (which could be alleviated with a month-long prescription of supplements that I could purchase on the spot). The first time indicated health, but the second time the “doctor” pressed on my right arm, it fell. Naturally, I was suspicious of his “diagnosis.”

I’ve since learned the secret behind this trick, the principle of which is actually taught in the New Employee Celebration curriculum at Recovery Innovations: it’s the power of language. Include a positive statement — “David, you’re looking strong today!” — and your arm will stay strong and resist the gentle pressure. But include the slightest negative statement — “David, you look tired today.” — and your arm is likely to weaken and fall.

The 1990s were called the decade of recovery, and yet we continue to look on peer supports and recovery somewhat like I looked on the nutrition “doctor” some thirty years ago…skeptical that it’s real, or that it works. But walking into an agency where 60% of the staff are peers, where people talk about their own “lived experience,” where those experiences are considered expertise, and where people believe everyone can recover, this is the equivalent of positive statements embraced by your subconscious that makes your arm strong.

In contrast are services where peer staff are non-existent or limited to administrative or janitorial tasks, where recovery is considered rare for those with Severe Mental Illness, or where only clinical professionals engage. It’s the equivalent of a negative message; your subconscious believes you’re weak, so your arm falls.

Professionals can be torn. Their gut instincts may tell them a peer approach won’t work. Hope and empowerment and recovery isn’t really possible, is it? I think it is. Everyone can use their strengths to find recovery and maximize their best selves, and we in behavioral healthcare have a powerful role in lifting people up or holding them back. Such risks and vulnerabilities might make us nervous. We might consider such approaches well outside our comfort zone.

But we might ask ourselves: would the outcome have been different if one of us counselors, social workers, nurses, or psychiatrists had been sitting in that bookkeeper’s chair last August? I have confidence we would have mustered all the empathy within us, but this isn’t the same as actual lived experience. I can guess what it feels like to feel depressed and suicidal, but only someone who’s actually lived it will know what someone else is feeling and be able to connect to him and give hope in a way a professional simply cannot.

Would the situation have ended peacefully? I honestly don’t know, but listening to the full recording is a great insight into the power of human connection and the hope and strength that can be shared. Someone else has been in desperate pain, has survived… and cares. Perhaps on the anniversary of a tragedy that didn’t happen, we should reflect on the power of one person connecting with another.

Note: I would like to acknowledge the team at Recovery Innovations, including Gene Johnson, Lori Ashcraft, Chris Martin, and Gloriana Hunter, for the inspiration and stories in this blog. This organization and its amazing leaders have been sharing recovery around the world since Gene was inspired by Dan Fisher’s message of hope nearly 15 years ago (www.recoveryinnovations.org). 

Robin Williams & #Standupfor Cancer

robin williamsAs national leaders in suicide prevention, we can say with all urgency that our field can learn a lot from the fight against cancer.

A bittersweet irony of Robin Williams’ death by suicide was the support he gave to the fight against cancer, which, like suicide, takes millions of lives. He was a strong backer of St. Jude’s Research Center and Stand Up to Cancer, and he visited patients and brought joy into lives that would be cut short as unfairly as his was.

We once whispered about cancer, but the movement tofight it has become enormously effective in getting the public involved in support, fundraising and advocacy. Now many people, whether or not they’ve been directly affected, stand shoulder to shoulder with people who are fighting for their lives.

How did this transformation happen? The cancer prevention movement advanced science and relentlessly promoted stories of hope and recovery.

The suicide prevention field indeed, all of us who despair at deaths by suicide can do this, too. And we are starting to see signs of an emerging social movement to make it happen.

This year alone, much has been achieved to embrace the full circle of people living with the experience of suicide and suicidal thinking, from those who have lost loved ones to a growing number of suicide attempt survivors who are “coming out” through projects like Livethroughthis.org and saying that going on to live a full, meaningful life is entirely possible.

We have several challenges ahead.

Consider the way we talk about suicide. We don’t say someone “committed cancer” or shrug and say cancer is a choice. We don’t demonize people with cancer.

Consider the treatment of suicidal thinking. With any health issue, we expect that our medical teams will have state-of-the-art skills in detection and treatment. That’s not true with suicide.

Only two states, Kentucky and Washington, require that mental health professionals be trained in working with suicidal people. A patient’s death by suicide is one of many professionals’ greatest fears, and yet the majority are underprepared to assess and manage suicide risk, let alone give support in recovery.

Cancer doctors don’t make their patients sign a contract not to die, and yet some mental health professionals still use “no-suicide contracts” instead of working together on plans for support and safety. Other professionals fear that working with suicidal clients will end up in a lawsuit, so they “pass the hot potato,” and suicidal people feel rejected within a system that otherwise urges them to ask for help.

Consider our response to suicidal thinking. When someone discloses they have cancer, the response is usually an outpouring of support. When someone discloses they survived a suicide attempt, the response is often discrimination and avoidance.

The irony is that our world, and especially the mental health world, is full of gifted professionals who’ve been suicidal and don’t dare say so. Imagine if their talent and influence could be applied to this health issue to offer role models of recovery and perseverance.

As the compassionate but challenging therapist in the movie “Good Will Hunting,” Robin Williams counsels Matt Damon on life, love and grief before telling him, “Your move, chief.”

Now it’s our move. Let’s honor Williams’ memory, and that of everyone who has struggled with suicidal thinking, by fanning the flames of a new movement.

Here is what has happened this year alone:

  • The country’s oldest suicide prevention organization, the American Association of Suicidology, this year founded a division for people who’ve been suicidal. Suicide attempt survivors spoke at four separate keynote conference sessions and received multiple standing ovations.
  • The National Action Alliance for Suicide Prevention’s attempt survivor task force last month published the federally funded, unprecedented report “The Way Forward,” a sweeping call for change in the way suicidal people are treated.
  • The Center for Dignity, Recovery and Empowerment, directed by an attempt survivor, has emerged as a national leader in innovative programs for people who’ve been suicidal, with a major goal of eliminating prejudice.
  • Finally, the Action Alliance’s new “Zero Suicide” national health care initiative dares us to imagine a world free from the tragedy of suicide and to behave as if we cannot lose one more life in isolation and despair.

How can each of us become part of this movement?

  • Reach out and ask others, “Are you okay? What can I do to support you?” Let them know they are not alone and that you can help them connect to targeted resources like ManTherapy.org.
  • Promote the National Suicide Prevention Lifeline (800-273-8255). Contact your local crisis call center to see how you can help with fundraising, volunteering and advocating.
  • Participate in suicide prevention work like community walks, town hall meetings, crisis line support and more. Make sure to engage people who know what suicidal thinking feels like.
  • Donate to suicide prevention organizations and encourage others to do so.
  • Learn the facts about suicide and the strategies that have been shown to prevent it.
  • Bring others into the circle: your employer, educators, faith leaders and so on. Make suicide prevention a priority.
  • Speak to your elected officials and demand resources to support dignified treatment and eliminate discrimination against people who are asking for help.
  • Ask your mental health service provider about their training in suicide prevention. Ask your behavioral health system if they know about “Zero Suicide” and “The Way Forward.”

As a society, we’ve stood up for so many other important health issues. It’s time for us to stand up to suicide. The silence simply isn’t working.

#standup2suicide #zerosuicide #wayforward

By members of the National Action Alliance for Suicide Prevention:

  • David Covington, LPC, MBA, co-chair, National Action Alliance for Suicide Prevention Zero Suicide Advisory Group
  • Dr. John Draper, co-chair, National Action Alliance for Suicide Prevention Attempt Survivor Task Force
  • Dr. Mike Hogan, co-chair, National Action Alliance for Suicide Prevention Zero Suicide Advisory Group
  • Dr. Sally Spencer-Thomas, co-chair, National Action Alliance for Suicide Prevention Suicide Loss Survivors Task Force
  • Eduardo Vega, co-chair, National Action Alliance for Suicide Prevention Attempt Survivor Task Force

Note: Special acknowledgement to Cara Anna (talkingaboutsuicide.com) who provided invaluable guidance and support in developing the final version above.

The Oxford Declaration: No One Should Die Alone and in Despair

oxford“We are at the beginning of this journey and we start out from the core value that no one of our patients should die alone and in despair by suicide.” This challenge, issued by Dutch psychiatrist Jan Mokkenstorm, became the shared declaration for the first international gathering of organizations committed to Zero Suicide in Health Care, who met along with others at the International Initiative for Mental Health Leadership (IIMHL) conference in Oxford UK on June 9-10.

Those who travelled to the UK explicitly for Zero Suicide included:

  • Jan Mokkenstorm and the team from 113Online Foundation: Marijke JosephusJitta, Barbara Stringer, Wendela Termeulen, and Hetty Vromen (Netherlands)
  • CEO Elsbeth de Ruijter from the parent company of 113Online, GGZinGeest
  • Fergus Cumiskey, Managing Director, from Contact Northern Ireland, and Barry McGale, Suicide Prevention Liaison, Western Health & Social Care Trust (United Kingdom)
  • Steve Duffy, Clinical Director, from Canterbury District Health Board in Christchurch (New Zealand)
  • Becky Stoll and Jennifer Lockman from Centerstone America
  • Jerry Reed from the National Action Alliance for Suicide Prevention and Suicide Prevention Resource Center (SPRC) (United States)

While the number of attendees promoting Zero Suicide was seemingly small, the organizations they represent employ thousands around the world. Centerstone, where Becky Stoll has led the development of a Zero Suicide protocol for several years, is the largest Community Mental Health Center in the US with nearly 3,000 employees across four states. GGZinGeest has 1,600 employees and a significant online presence in addition to its full continuum of behavioral health direct care, and has trained its staff in engagement and “good contact” to support those at risk for several years as well. Steve Duffy has traveled to see the Henry Ford Health System in Detroit, Michigan, Magellan Health in Phoenix, Arizona, and Nav Kapur’s team in Manchester, United Kingdom, as his team has been evaluating a Zero Suicide design for Hillmorton Hospital and its array of mental health programs.

Zero Suicide advocates joined a group of 25 other participants hailing from the UK, Australia, Canada, Ireland, New Zealand, and Sweden, led by Julie Kerry and Aarti Chapman from NHS England and Professor Keith Hawton, internationally renowned suicide prevention leader from the University of Oxford. The IIMHL program included presentations on a variety of suicide prevention topics, from means restriction to post-vention approaches, and ample time and open spaces provided opportunities for participants to network, share, and collaborate.

all harm is preventableThe summit opened with controversy as colleagues questioned the language of “Zero” Suicide. For some, it seemed to evoke other problematic initiatives that utilize “zero tolerance” approaches. We explained what we aspire to in our health care settings regarding Zero Suicide. I showed a photograph that Jerry Reed and I had taken the day prior while on a bus tour of London: a sign at a construction site that read, “All harm is preventable: Target Zero.”

In fact, the quality management language of frame-breaking change seemed to be ubiquitous during our trip overseas. It was the first time I had seen Unicef’s Zero campaign for child mortality, and others referenced language used by European leaders to render suicide a “never event.” Like Henry Ford Health System’s “Perfect Depression Care” initiative, these different programs all borrow from the language and principles of robust performance improvement, and all aspire to innovative solutions that will change paradigms and dramatically improve results.

At the end of the first day, though, those who had traveled to Oxford for Zero Suicide and those who had not discovered we had more in common than we realized. We all shared a passion and optimism to change the upward trends too many nations are experiencing, as well as our focus on systems-level improvement and top leadership commitment (despite what we labeled our individual approaches). In fact, leaders from the UK described their “Suicide Safer Care” initiative for Brighton, an approach inspired by a partnership between two members of the Clinical Care and Intervention Task Force that birthed Zero Suicide, Jenna Heise from Texas and Heather Stokes from Living Works.

After breaking into four smaller groups, the Zero Suicide network was frantically taking notes as the UK’s Jo Smith shared amazing advice for Zero Suicide’s advancement, based on lessons from her work with innovation diffusion around early psychosis treatment. “Antagonism and resistance are your friends in mobilizing a movement.” She shared the original declaration they had developed years ago, which begins “imagine a world where….” She confessed they lifted the format almost directly from innovators creating similarly “impossible” goals around diabetes care years earlier.

Jo instructed us on the stages of similar movements:

  1. A “burning platform” that intensifies dissent
  2. Main stream adoption
  3. A national program and stronger investment, with research and validation running parallel as the model is refined and perfected
  4. Documented outcomes

“People change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings,” she said, and it resonated with us. As if to prove her point, Barry McGale shared with the larger group his initial resistance to the idea of Zero Suicide and later “being converted,” and others said they’d become “infected;” their initial resistance gave way to curiosity and then enthusiasm. Jo said Zero Suicide is a social movement and we should fan the flame with adherents working together to innovate solutions.

The social movement must also include those with lived experience, which was a major thread woven throughout the two days in Oxford. Eduardo Vega, Executive Director for the Center for Dignity, Recovery and Empowerment, joined us on the second day and related the outcomes of the prior day’s Peer Support and User Festival in London and how inclusion of peers qualitatively changes the discussion (as compared with meetings in which he has been the only self-disclosed peer/consumer).

Bringing this lived expertise to bear in strategizing change and improving services represents a  crucial next step to make Zero Suicide real, as reflected in the work of the Action Alliance task force on Suicide Attempt Survivors and the historic summit that occurred between those peer leaders and Zero Suicide.  In his presentation to the larger group, Barry McGale referenced this as well,  asking  “Why did it take us so long [to include peer leaders]?!”

Zero Suicide advocates came away feeling that we have so much to learn from one another, and we also met new friends and potential partners in Zero Suicide. Just one example included a very exciting conversation with Jennifer Vornbrock from the Mental Health Commission of Canada about how we might support one another’s efforts in 2015. In fact, before I left Europe, I had dinner with Fran Silvestri (CEO of IIMHL) and Ella Arensman (President of IASP), whose organizations will host international conferences in 2015 inVancouver and Montreal, respectively. One team. One dream.

mind the gapA week later, at the Dublin Dialogues in Ireland, I joined other leaders as we envisioned the future of mental health. Paddy McGowan concluded the presentations on the second day by delivering a powerful story about his wife’s suicide, playing the song “What’s Going On?”

“25 years and my life is still… Trying to get up that great big hill of hope…”

There was much social chatter about his message and it’s impact, but I found it strangely ironic that nowhere in the chatter did the word “suicide” come up. It’s a gap that must not be overlooked.

Zero Suicide advocates remain positive in our commitment to usher in a new era of suicide care. We must “mind the gap” and support one another in this effort, partner with individuals with lived experience, and begin providing the kind of supports and services that will make the Oxford declaration a reality.

Link to gallery of Oxford IIMHL pictures.

*Note: Special thanks to Fran Silvestri and Janet Peters for IIMHL’s leadership in matchmaking and creating the space for learning and unique partnerships to occur, and to Jerry Reed for supporting the organization of this first international meeting of Zero Suicide. Also would like to acknowledge Zero Suicide champions who were not able to join us in Mike Hogan and Julie Goldstein Grumet with whom we will be hosting the first Zero Suicide Implementation Academy June 26 – 27 in Washington, DC.

Why “Jumpers” is the Wrong Word

jumpersI just returned from a whistle-stop speaking tour in New Zealand and Australia. While it was only a brief week-long trip, I brought back so many amazing memories of the people and places. The most indelible by far was Gap Park, just five miles outside Sydney. The park sits atop cliffs that outline the coast for miles on the city’s eastern side.

Just a couple hours earlier I presented on Zero Suicide and traced the history of the Golden Gate Bridge and the half-measures taken to stop individuals from climbing over its short rails. Afterward, a woman approached me to explain that her daughter had died at the Gap, and I knew I had to see it.

When I arrived, I took in the many signs and warnings about the dangers of the area, signs the woman’s daughter would have passed on her way to the edge. One sign read, “For your own safety do not climb over the fence.” Another warned of fines for doing so, and scattered about the area are twenty-two closed-circuit cameras to monitor activity and act as a “deterrent,” as well as provide quick emergency response when necessary. Recently, the Woollahra Municipal Council installed new, inwardly sloped fencing that is “difficult to scale from the pedestrian side.”

we careThere are also many signs offering support. One sign at the park entrance reads, “Are you thinking of suicide?” An Emergency Phone reads, “You are not alone. Talk to someone you trust or call Lifeline,” and one push of a large round button elicits the immediate support of a counselor. A bright orange sign proclaims, “Hold onto HOPE. There is always HELP.”

However, there are also areas with little or no barrier to the cliffs, no signs for support. About 400 feet north of the main park site, I easily straddled an aged, two-foot fence. When I approached the edge of the cliffs, some 260 feet above the ocean, it occurred to me that jumping is not required. One can simply fall over the edge and disappear.

A year ago, I participated in Fear Factor, a game show in which participants attempt to beat their competitors by facing their fears. My first challenge was to hang from an upside-down Y-shaped bar 40 feet above the ground. When the floor dropped from below, I found myself struggling to hold on. My hands were sweaty, slipping on the bar. My muscles began to hurt, intense pain that became stronger and stronger as the seconds passed. I closed my eyes, relaxed my breathing, and repeated to myself, “One more second, one more second.” I wanted to hang on. That was my choice. Yet gravity and fatigue worked against me and I fell, forced to succumb to the pain — but even then, falling was not what I chose to do. I fell a split second after another competitor; he was eliminated, I was not. I had hung on long enough.

I spoke in a previous post about how people who die by suicide don’t choose to do it; rather, they succumb to the intense psychological anguish and desperation they are experiencing when all their supports and solutions fail. When individuals die by suicide at locations such as this, we call them “jumpers,” but I’m not sure this label is accurate because it reinforces the myth that their death was primarily a conscious choice. Such a label distances us from our responsibility and capability to prevent these deaths.

gap parkIt may be that for some individuals who make the lonely trek up the steps to the park, the tunnel vision of repeated pain and darkness blocks out what their peripheral vision might have picked up — help and hope. Instead, their emotions are so constricted, they can only see what is right in front of them — steps leading up to the cliff’s edge — and they walk towards it, stand at the edge, and fall off.

In some cases, another person may be able to help someone see what exists in their periphery. Until 2012 when he died, Australian Don Richie came between those cliffs and hundreds of individuals who sought an end to their pain, often by inviting them into his home for a cup of tea. For a brief moment, he helped them see more than the tunnel of darkness ahead of them, and it was enough to change their fate.

We can also help individuals see past the darkness by blocking it, giving them no alternative but to focus on something else. In early 2011, work was completed on the construction of an eight-foot barrier on the George Washington Memorial Bridge (formerly Aurora Bridge) in Seattle, which effectively ended the structure’s status as one of the most frequent US sites for suicide.

While there are a number of helpful initiatives that undoubtedly save lives, I left Gap Park and its contiguous cliffs with the same thought I had following a visit to the Golden Gate Bridge. Individuals in enormous pain can find their way to the edge with relative ease.

One of the arguments over the decades has been that individuals intent on suicide will find another way if their access to high places is blocked. However, many other methods provide more opportunity for the mind’s security system to kick-in, for ambivalence to prompt a contact to emergency medical personnel. Not so here on these cliffs.

waters edgeClinical professionals frequently use the term “psychic distress” to describe what someone considering suicide is going through. My visit to Gap Park left me thinking that this phrase is much too antiseptic. It does not fully capture the pain, anguish, desperation, and isolation these individuals must feel as they stand at the edge. I thought again about the mother whose daughter died there. Perhaps her daughter didn’t “jump” so much as she fell.

Don Richie apparently thought that every suicide could be prevented, even up to the last moment. His belief led him to engage those at risk and he saved many lives. Washington State’s action to install a higher fence on the Aurora bridge has reduced deaths by suicide there to nearly zero. These inspiring examples are now influencing other fields, fromAustralian construction to American healthcare. People struggling with intense pain need the support to hold on, to not let go. Sometimes, one more second is all it takes.

Historic Summit Celebrating Lived Experience (San Francisco)

prideIn “Silver Linings Playbook,” Pat Solitano talks about his friend Tiffany with his psychiatrist. He questions whether he, like Tiffany, can like “that [‘shameful’] part” of himself along with all the other parts.

“Can you?” Dr. Jones asks.

“You’re really asking me that question? What, with all my crazy sad[ness]… Are you [completely] nuts?” Pat says.

And yet, Dr. Jones was spot-on. Pat was developing a beautiful and positive philosophy that originated from his prior lived experiences with bipolar disorder. Whether we can like all the parts of ourselves is a question we typically have trouble relating to, and yet our experiences make us who we are.

Last week in San Francisco felt very much like that scene from the movie. Gathered together at the “Lighting the Way Forward National Summit on Lived Experience in Suicide” were individuals with prior suicide attempts sharing their expertise and experiences with more than 20 policy makers, researchers, crisis workers, and family members engaged in suicide prevention. The Mental Health Association of San Francisco sought out national peer leaders who have attempted suicide — individuals who know intimately the issues, agony, and decision-making behind being actively suicidal. The landmark event held on March 6, 2014 was the product of two task forces of the National Action Alliance for Suicide Prevention: the Zero Suicide in Health Care Task Force and the Suicide Attempt Survivors Task Force.

Instead of token representation and a “seat at the table,” these individuals with prior suicide attempts owned the table. Fifty percent of the participants shared prior lived experiences with people such as SAMHSA’s suicide branch chief Dr. Richard McKeon and EDC’s Suicide and Prevention Resource Center Director Dr. Jerry Reed. The conversation, facilitated by National Suicide Prevention Lifeline’s Executive Director John Draper and Mental Health America of San Francisco’s Executive Director Eduardo Vega, produced a tone and spirit unlike any we have encountered before. Suffering and courage were major themes and were described as essential elements that unite and strengthen us.

Lighting the Way Forward Lived Experience National Summit 2014We also celebrated the milestones that had brought us to this point. Dequincy Lezine shared his experience of “coming out” as a researcher and person with lived experience of suicide twenty years ago, and the feeling of being that lonely voice. Many group members participated in the first-ever OASIS National Conference for Survivors of Suicide Attempts, Health Care Professionals, and Clergy and Laity in Memphis in October 2005 or in the National Suicide Prevention Lifeline’s Consumer/Survivor Subcommittee. Heidi Bryan, CW Tillman, and Jason Padgett talked about their watershed plenary session on Suicide Attempt Survivors at the American Association of Suicidology conference in 2011. Later that year, Cara Anna launched her prolific Talking About Suicide blog, where she interviews individuals about their own suicide attempt stories.

DeQuincy Lezine summarized for the Action Alliance the recommendations of an upcoming paper by the Suicide Attempt Survivors Task Force, “The Way Forward: Pathways to hope, recovery, and wellness with insights from lived expertise.” The draft builds from eight core values:

  • Inspire hope, meaning, and purpose
  • Preserve dignity; counter stigma, stereotypes, and discrimination
  • Connect people to peer supports
  • Promote community connectedness
  • Engage and support family and friends
  • Respect and support cultural and spiritual beliefs and traditions
  • Promote choice and collaboration
  • Provide timely access to care and support

The group also reviewed the core recommendations from the Zero Suicide in Healthcare task force (whose members include David Covington, John Draper, Richard McKeon, Jerry Reed, and Becky Stoll, VP for Crisis and Disaster Mgmt, Centerstone America), looking for synergies between the two. The core recommendations are:

  • Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care
  • Systematically identify and assess suicide risk levels
  • Ensure every person has a timely and adequate pathway to care and supports
  • Develop a competent, confident, and caring workforce
  • Use effective, evidence-based care, including collaborative safety planning, restriction of lethal means, and effective treatment of suicidality
  • Continue contact and support, especially after acute care
  • Apply a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk

Zero Suicide believes that suicide is preventable…always, even up to the last minute. This idea resonated with many peers in the group, who turned the discussion to improving the clinical relationship. Richard McKeon said that coercion represents a system treatment failure, and Leah Harris of the National Empowerment Center agreed, saying “treatment should never feel like punishment.” There was much discussion about shifting the focus of systems from safety to collaborative care. John Draper talked about the fear that underlies these approaches, saying that 50% of behavioral health staff self-report that they lack the training, skills and/or supports to be effective and to really help.

Summit participants then broke into three small groups to identify core messages and strategies for communicating them, and Tom Kelly set the tone: “Transformation is not doing things better, it’s doing things differently.” Leah Harris summarized the discussions of her small group, which called for recovery principles to be infused into systems of care, saying “We need to focus on what is strong, not what is wrong.” Sally Spencer-Thomas of the Carson J. Spencer Foundation reflected on stronger continuity of care as “really about not giving up on someone.” The overall consensus was that we should use the word “safety” less and use the word “recovery” more, which reflects greater efforts at positive engagement and increased optimism. Staff need training, and there was a moment where we all felt “we can do better.”

Celebrating Lived Expertise, I am not a lost causeThe Summit was unlike any previous national meeting about suicide prevention that any of us have ever participated in. Carmen Lee of Stamp Out Stigma told the group, “I’ve always been considered a client. This is the first [time] I haven’t felt that way.” An often-repeated message throughout the day came from Sabrina Strong of Waking Up Alive who said, “I’m a person. I’m not a lost cause.” Feeling Blue’s Heidi Bryan teared up discussing the “magnitude of this moment” and the “respect and dignity that is being given to all of us attempt survivors.” There was a shared commitment to celebrate survival and the expertise that comes with experience. It was truly a momentous day.

After the San Francisco summit, it was impossible not to reflect on the stunning change in social views and legal standing of individuals in the LGBT community over the last 50 years. As a recent article stated, “Progress came about largely due to the individual choices of countless gays and lesbians to come out of the closet and get engaged.”

In a similar way, the early activists and courageous suicide attempt survivors who joined us at the summit are paving the way towards a whole new social view of suicide and its prevention, giving a voice to countless individuals. We look forward to the day when the views and beliefs about suicide that many of us hold today seem archaic and outdated because of the individuals who will have come “out” by sharing their personal experiences with suffering, courage, and survival, and giving us strength. This summit, although only one day, has been a very important step in that journey.

*Note: Special thanks to Eduardo Vega without whose tenacity and leadership this event would never have taken place and SAMHSA and the SPRC for their support. Also would like to acknowledge the participants whose tweets created a real-time documentary of this historic moment, including @drlezine, @sspencerthomas, @AboutSuicide, @eduardomhasf, @leahida, @NMSPC, @cdubs703, @melodeeee and others.

Us & Them: Our Brothers in Law Enforcement

policeWe had just exited the Urgent Psychiatric Center (UPC) when the radio announced an armed robbery in process at a convenience store just over a mile away. Nick and I jumped into his police cruiser and took off. My body slammed back into the seat from Nick’s swift acceleration and I barely noticed the scenery as my peripheral vision dropped away, my brain focused intently on the narrow view straight ahead of us. It was a pure adrenaline rush, my heart racing as Nick flipped on the lights and siren, his police car screaming down the street.  This was definitely not what I expected when I agreed to spend the evening with Phoenix Police Officer Nick Margiotta.

I was brand new in my role with Magellan Health Services overseeing the clinical system of care and wanted to see how the system worked first-hand. Was it safe, effective, and person-centered? Was it accessible? I met Nick through our community governance board, and he brought a wealth of experience and passion from his work as the city’s Crisis Intervention Coordinator. He suggested we spend a night on the street, with him dressed as a regular police officer and me in plain clothes as a ride-along without announcing our positions to anyone. Think “Undercover Boss,” and it seemed like a great idea.

As we rolled onto the scene of the armed robbery, we saw that another patrol car, which had arrived before us, was blocking the car that held the two armed men. We stopped in the street about 40 yards away and Nick and I got out and stood behind our doors. (Well, I stood behind the door after Nick yelled at me to get out of the line of fire!) It was dark, there was a lot of yelling, lights, a bunch of guns, and I was struck by what felt like chaos in the situation. Fortunately, the two men were safely taken into custody; the whole event did not take more than five minutes.

As Nick turned back towards the patrol car, he noticed a middle-aged Native American male, intoxicated, sitting with his legs in the street. We walked over and Nick began engaging him about his interest in getting some support that evening. The man was initially quite belligerent. What I didn’t realize as we engaged with this person was Nick was working to transition himself, too. He had felt what I felt during the attempted robbery. Cops are human, after all, and just moments earlier there had been real danger which had internal, physiological impacts on him just like me. With a new found respect for the skills of CIT-trained law enforcement, we transported the individual, connecting him with the local Community Bridges center, which has a detoxification unit.

Over the course of that shift, we interfaced with more than 15 individuals who were experiencing mental health and addictions issues. Less than 30 minutes earlier we were at a local apartment complex visiting a friend of Nick’s who has Schizophrenia, but was in recovery and had been clean from Heroin for more than two years. While we were there, we received a “pick-up order” for another individual in that same location who was on court-ordered treatment and needed to be transported to the UPC. After a brief discussion with that person, she agreed and we took her to 2nd Street and East Roosevelt.

I was struck by the near-instant transitions Nick was able to effectively navigate, from command and control of armed robbers to engagement and collaboration with those in behavioral health crisis. Crisis Intervention Team (CIT) does not turn law enforcement into social workers; they will always be cops first and foremost. However, more than 2,000 jurisdictions have adopted CIT and put it to use in developing more integrated and responsive community systems. It equips law enforcement with knowledge regarding the signs and symptoms of mental health and addiction, tools for effectively engaging individuals, and the resources to divert them from being sent to jail.

Five Key Pillars Crisis Intervention Team (CIT)

Officer Training The most visible component, the 40 hour, week-long training is most effective when officers have volunteered. In addition to a primer for behavioral health, generally two days are devoted to crisis de-escalation.
Community Collaboration A partnership of local advocates, law enforcement, and behavioral health providers formed the Memphis model. This community bridge has been one of the strongest elements of the program over time.
Robust Crisis System An integrated system that is focused and responsive to the needs of law enforcement is mandatory. Unless access to care is quick and responsive and hand-offs are smooth, the program will not result in decreased incarcerations.
Behavioral Health Staff Training Building positive working relationships between law enforcement and behavioral health means also training the mental health and addiction community of providers. Riding along with law enforcement can be a big eye-opener.
Advocate Training The local NAMI provided the energy and moral leadership that made the Memphis model so successful, and including peers, family members, and advocates is critical to embed a program in the community.

Ten years ago, 17 of us from the greater Atlanta area, including law enforcement, behavioral health providers, and NAMI leaders, traveled to Memphis, the “CIT Mecca,” to learn how to implement a statewide program in Georgia. The original founders of the program, Major Sam Cochran and Dr. Randy Dupont, were heavily involved and inspirational leaders. Naturally, as a part of the training, I did a ride-along with a local cop, Officer James.

James described his evening shifts as making trips into Mogadishu and recounted several harrowing stories of shoot-outs in which he had been involved. He added that working with individuals with mental health and addictions issues was easy; as he received excellent training through CIT and he proudly wore the unique badge that identifies these specially trained officers. I asked him about the most challenging situations faced by law enforcement.

James mentioned two scenarios, both of which occurred on our shift. In the first, we were called to the scene of a break-in, and we didn’t know if the perpetrators were still there. I remember being extremely anxious as he went inside and I stayed in the vehicle. It was palpable.

However, the worst situation happened later that evening. Two officers on the southwestern side of the city were shot through a door as they served a warrant. I remember hearing almost the entire play-by-play over the radio as cops from all over the city raced at break-neck speed to the scene.

I’ve been on two police ride-alongs with CIT trained officers, and they were both wild rides! Yet, I saw both of these officers demonstrate compassion and finesse while working with individuals and families who were struggling with behavioral health crises. And, in both cases, I saw responsive behavioral health systems that focused on quick accessibility and humane, transitional hand-offs that helped avoid unnecessary trips to jail.

It’s easy for behavioral health professionals to disregard our brothers and sisters in law enforcement, but working together we are creating better community support systems (see December 2013 article from Spokane). How do you start making a difference in your own area? I would suggest starting with an evening or night shift in a patrol car observing the challenges and opportunities first hand.

*Note: David Covington co-authored this blog with Nick Margiotta. Nick is a member of the board of directors for CIT International and chair of its public awareness committee.

How to Avoid Tragedies and Near Misses

At the end of Novewatch towermber in 2013, Virginia State Senator Creigh Deeds told CNN that he was alive for just one reason: to work for change in mental health. Just a week earlier, his son “Gus” stabbed him 10 times and then ended his own life by suicide. This happened only hours after a mental health evaluation determined that Guss needed more intensive services, but unfortunately, he had to be released from custody before the appropriate services could be found.

Sadly, it is common for individuals in mental health crisis to initially receive support and then later “fall through the cracks.” The cracks occur because of interminable delays for services that professional assessments have determined individuals clearly need. They walk out of an Emergency Department “Against Medical Advice” and disappear from view until the next crisis occurs.

Far too many individuals like Gus are falling through the cracks. While they sometimes hurt themselves, it is infrequent that they harm others. When it does occur, it’s rarer still that the person is a public figure. However, every time there is a Columbine, Tucson, or Sandy Hook, we grieve… and we wring our hands and consider whether there is a better way.

Nearly 40,000 Americans die by suicide every year… and we assume nothing can be done. I contend it is time to raise the bar in crisis services and innovate with solutions that will drive a different set of results.

Learning from Air Traffic Control Safety

In 2006, the movie “Flight 93” chronicled the heroic efforts of passengers aboard a hijacked United Airlines plane. It also gave us an up-close and personal view of the way air traffic control works to ensure the safety of nearly 30,000 US commercial flights per day! When three individuals died in an Asiana crash in San Francisco in July 2013, it marked the end of a 12-year time span in the US without a passenger death on a large commercial airliner. Today, it is remarkably safe to fly.

The keys to advancements in aviation safety are simple. There are two vitally important objectives that, without them, make it impossible to avoid tragedy:

  • Objective #1: always know where the aircraft is – in time and space – and never lose contact;
  • Objective #2; verify the hand-off has occurred and the airplane is safely in the hands of another controller.

In the Air Traffic Control example, technology systems and clear protocols ensure that there is absolute accountability at all times, without fail. It was surprising to see in the movie the air traffic controllers using wooden blocks to represent each plane, given all the high-tech tools at their disposal. But when an air traffic controller has the block, they have responsibility for that plane… unless and until they physically give that block to someone else, who then assumes the same care and attention. They simply do not allow an airplane to be unsupported and left on its own.

These objectives easily translate to behavioral health. Always know where the individual in crisis is and verify that the hand-off has occurred, yet these objectives are missing from most of the US public sector behavioral health and crisis systems. Individuals and families attempting to navigate the behavioral health system, typically in the midst of a mental health or addiction crisis, should have the same diligent standard of care that air controllers provide.

Gregg GrahamIn 2006, I was part of the team that launched the Georgia Crisis & Access Line. Our goal was to have an “air traffic controller’s view” of individuals currently navigating the crisis system. We accomplished this goal through state-of-the-art technology, including an integrated software infrastructure that tracks individuals at a statewide level, with built-in insurance of consistent triage, level of care protocols, and warm hand-offs to the appropriate crisis service teams across the state. This is very different from traditional systems and can reduce the number the failures facing current systems across the country.

Making the Case for a Close and Fully Integrated Crisis Services Collaboration

In 2010, the Milbank Memorial Fund published the landmark “Evolving Models of Behavioral Health Integration in Primary Care,” which included a continuum from “minimal” to “close fully integrated” that would establish the gold standard for effective planned care models and change the views of acceptable community partnership and collaboration. Prior to this, coordination among behavioral health and primary care providers had frequently been minimal or non-existent and it would have been easy to accept any improvement as praiseworthy.

In fact, the Milbank report portrayed close agency-to-agency collaboration (evidenced by personal relationships of leaders, MOUs, shared protocols, etc.) at the lowest levels of the continuum and insufficient. They described these community partnerships and their coordination as minimal or basic, citing only sporadic or periodic communication and inconsistent strategies for care management and coordination. They called for frame-breaking change to the existing systems of care, and their report continues to reverberate throughout the implementation of integrated care.

Required Elements of a Statewide Crisis Services “Air Traffic Control System”

Crisis Access Holdings, LLC has modified the Milbank collaboration continuum (original citation Doherty, 1995) for the purposes of evaluating crisis system community coordination and collaboration (see table below).

Milbank Memorial Fund, Close and Fully Integrated

In our model, the highest level requires shared protocols for coordination and care management that are “baked into” electronic processes, not simply add-ons.

For a crisis service system to provide Level 5 “Close and Fully Integrated” care, it must implement an integrated suite of software applications that employ online, real-time, and 24/7:

Key Elements Level 5 Crisis System (Air Traffic Control Approach)

Status Disposition for Intensive Referrals There must be shared tracking of the status and disposition of linkage/referrals for individuals needing intensive service levels, including requirements for service approval and transport, shared protocols for Medical Clearance algorithms, and data on speed of accessibility (Average Minutes Till Disposition).
24/7 Outpatient Scheduling Crisis staff should be able to schedule intake and outpatient appointments for individuals in crisis with providers across the state, while providing data on speed of accessibility (Average Business Days Till Appointment).
Shared Bed Inventory Tracking Intensive services bed census is required, showing the availability of beds in crisis stabilization programs and 23-hour observation beds, as well as private psychiatric hospitals, with interactive two-way exchange (individual referral editor, inventory/through-put status board).
High-tech, GPS-enabled Mobile Crisis Dispatch Mobile crisis teams should use GPS-enabled tablets or smart phones to quickly and efficiently determine the closest available teams, track response times, and ensure clinician safety (time at site, real-time communication, safe driving, etc.).
Real-time Performance Outcomes Dashboards These are outwardly facing performance reports measuring a variety of metrics such as call volume, number of referrals, time-to-answer, abandonment rates and service accessibility performance. When implemented in real-time, the public transparency provides an extra layer of urgency and accountability.

In addition, the system should provide electronic interconnectedness in the form of secure HIPAA-compliant, and easy-to-navigate web-based interfaces and community partner portals to support communication between support agencies (including emergency departments, social service agencies, and community mental health providers) with intensive service providers (such as acute care psychiatric inpatient, community-based crisis stabilization, inpatient detoxification, and mobile crisis response services).

Interfaces should also include web-based submission forms for use by community partners to support mobile crisis dispatch, electronically scheduled referrals by hospitals as a part of discharge planning, and managed care and/or authorization requirements.

I currently lead a joint venture, Crisis Access, LLC, and the five call centers across our companies have received over ten million crisis calls over the last twenty years from individuals, their families, and the social service agencies that work with them. We utilize sophisticated software to help the crisis professional assess and engage those at risk and track individuals throughout the process, including where they are, how long they have been waiting, and what specifically is needed to advance them to service linkage. Their names display on a pending linkage status board, highlighted in green, white, yellow, or red depending on how long they have been waiting.

Average Minutes Till DispositionWhen a person contacts one of our call centers, they have metaphorically put their hand out and our crisis teams have taken it. We continue holding their hand until we have confirmation that someone else has taken hold. We verify that we have successfully connected them with another agency/entity that will have clinical responsibility. If there is a referral to mobile crisis, law enforcement, or an emergency department, we ensure they were connected with care. These approaches also apply for those with routine needs met by our mobile teams or crisis call center staff because we follow up with everyone, 100%. As a result, despite increasing numbers of referrals flowing through the system, individual are being accepted into care faster and faster (AMTD, Average Minutes Till Disposition).

Going Beyond Agency-to-Agency Relationships

“Knowing your neighbor agency” is just not good enough, as evidenced by the Deeds tragedy. Even organizations with numerous close relationships can be extremely inefficient and ineffective when their protocol relies on telephonic coordination of care (voice mails, phone tag, etc.) This seemed to be the principal challenge with the Virginia tragedy, and when the time period for hold lapsed, there was no tracking or follow-up.

There have been several national discussions as of late about current system failures and the frequency by which individuals fall through the cracks. Crisis systems must take seriously the need to avoid both near misses and tragedies, and I believe statewide community collaboration for Level 5 crisis systems are needed. The approaches described above are not notional; they have been employed on a statewide basis for nearly eight years in Georgia. New Mexico and Idaho added statewide crisis and access lines in 2013; Colorado is launching its statewide system in 2014, and Arizona is currently soliciting feedback considering a similar model.

If the National Transportation Safety Board settled for a 99.9% success rate on commercial flights, there would be 300 unsafe take-offs and/or landings per day!  Air controllers only settle for 100% success, and so should we.

To see the Georgia system in action, click on the PowerPoint or YouTube.

*Note: I would like to extend special acknowledgments to partners at the Georgia Department of Behavioral Health and Developmental Disabilities, The National Council for Behavioral Health and Qualifacts (the latter of whom sponsored the 2014 Impact Award for Health Information Technology). Also, thanks to Mark Livingston, BHL’s Chief Innovation Officer, and the entire team involved with advancing the “air traffic control” integrated system.

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