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!