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!

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