- Welcome to Healthy Minds.

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

Today on Healthy Minds...

Welcome to Healthy Minds.

I'm Dr. Jeff Borenstein.

Today, I continue my conversation with suicide prevention expert, Dr. Christine Moutier.

Funding for this program was provided in part by the American Psychiatric Association Foundation.

Additional funding was provided by the John and Polly Sparks Foundation.

I think your advocacy as a professional, as a researcher, and as a person who shares their own experience is so important and so powerful and makes such a big difference.

- Well, thank you so much.

- I want to ask you about contagion and you spoke a little bit about that in the medical school situation and just in general.

Tell us what contagion means and what do we do about it?

- Sure.

So we're talking about suicide contagion, and I would just think about the fact that we are social creatures in so many deep-seated ways, you know, the way that our brains are wired so that we're not, this is not even a conscious level behavior.

We're in a constant state of sort of imitation.

The mirror neurons in the brain and the way that we interact with one another on so many levels of human to human interaction and across societies.

So when it comes to suicide risk, however, it's not the case that the whole population, that their risk is elevated when a person in the community or a celebrity, for example, dies by suicide.

But for those who already have some intersecting risk factors, so that sort of bed of risk has already been woven together in a way, and so they might already be struggling in some way.

They might be aware of it or may not be aware of it, but that peer dies by suicide or even attempts suicide, and that exposure to someone else's suicide is actually considered a risk factor for suicide.

And so, you know, when you think about that in a school setting, in a workplace setting, or at the community population level when a well-known figure dies by suicide, those are all very concerning moments in time where suicide contagion could occur.

And that would mean that those who are already vulnerable are drawn closer to their impulse for suicide or their sense of not only hopelessness, but that that act has been modeled as a real path and a real solution in somebody else's life that then draws them closer to their own risk.

And there are known ways we believe to mitigate suicide contagion and that risk of contagion.

And those steps are really what we call postvention.

And those are the steps of, really, it's a crisis intervention moment after somebody has died by suicide, especially in, let's say, a school, a workplace, or a faith community setting where the leadership or some group comes together and really in a very daily way, over a period of usually several weeks at least, meets and thoughtfully considers the ways to communicate out to the community, the ways to present all of the resources that hopefully they're bringing to bare, ways to debrief.

So, it's actually the, I would say that postvention is too pronged.

The reason for it is to decrease the risk of contagion as well as to actually facilitate healthy grieving so that there's a framework, there is an expressed narrative that is honest but not engaging those who are vulnerable in increased risk.

And so that is tricky business and not something that thankful any of us have to do every day.

And so at AFSP, we have put together what we call postvention guides.

They're called after a suicide toolkits for schools, for medical schools.

We've customized them for veterinary medicine settings.

And even now the construction industry is working with us to have those toolkits customized for their settings.

And they are really quite granular.

They contain templates for what to say, how to support the family, how to abide by the family's wishes if they're not ready for it to be called a suicide death yet in the immediate aftermath.

And so there are strategies for all of those scenarios.

- I want to pick up on what you're saying about families where the worst tragedy happens and they lose a loved one to suicide.

Tell us about the support for them.

What can they do?

What should they do when such a terrible thing happens?

- Yes, thank you for raising the loss part of all of this.

So, suicide loss or suicide bereavement is actually much more common than people may realize.

And it is a very obviously complicated, traumatizing potentially form of grief and loss.

And so what we know in the world of suicide loss and healing as well as suicide prevention, and at AFSP, we're fortunate to have all of that integrated into community efforts.

We know that connecting with other loss survivors is oftentimes step one, the sort of opening the door to being able to process that experience of traumatizing, oftentimes blindsiding loss.

And we view, just like grief and bereavement in general is viewed as a journey and a process.

It doesn't have an end point.

You don't get over the experience of suicide loss.

But what we do believe is that there's an integration that can occur over time.

And oftentimes, this is months to years where the suicide loss and the loved one who has been lost becomes integrated into the person's life in a way that they can still be engaging in their life quite fully, you know, very fully.

And so, it is important to realize there are some complications to any loss that might be a bit more commonplace after suicide loss.

Things like having a depressive episode, you know, sort of reactivated or things like complicated grief, now called prolonged grief disorder, where there's can be almost a stuckness to the grieving where the intensity of loss and yearning is so overwhelming that it keeps the person from being able to engage in other aspects of, you know, basic life functioning and relationships in their life.

And those are things that I think to the person who is grieving might feel like the way that they're holding on and actually kind of honoring their loved one.

And I think oftentimes it's other loss survivors who will reassure them that by having that addressed and moving through that, they will be able to honor their loved one even more.

You know, from that more integrated healthy place with where healing is occurring.

- I want to ask you about the future and where we as a society, we as professionals, and just the general public, where are we going in terms of really reducing suicide?

- During these last several decades, so many findings have been sort of confirmed.

Much of what we've learned in through the science of suicide risk and prevention has not yet been implemented into community or clinical practice yet.

And so, I would say that we're at a stage of hopeful transition where we're becoming ready as a society, and this means a national investment, not only in the research that needs to be commensurate with the morbidity and mortality of the issue.

We aren't quite at that funding level yet but it's getting closer.

But not only the funding, but then the implementation, again, into clinical health systems but also into, you know, community-based structures like schools, workplaces, families, faith organizations.

- The tremendous hope in potentially where we're going, one of the more recent changes is having the 988 hotline, so that people don't have to memorize a long phone number but 988 is the new 911 for a mental health emergency including suicide risk that people could just dial that and get help right away.

And that's a step in the right direction.

- Yes, it certainly is.

And that, the way I look at suicide prevention from a public health framework standpoint is that you have upstream universal interventions and programs that would be like education that starts at a very early age and education for parents and just that embedding into every setting of some basic set of knowledge and tools, age appropriate of course in terms of school curriculum based.

So that's the upstream part of suicide prevention.

And then the midstream is when you realize that a certain population does carry increased risk then there are specific strategies, and of course clinical treatment is a big part of that, but also recovery and peer support, all of that.

And then there's the downstream moment which is that acute moment of risk when people are really at that moment of risk of acting on suicidal thoughts.

And that's where 988, I would say, is mostly for that downstream moment, but, of course, anyone is actually invited to call for any level of mental health or substance-use related distress at any time.

But when I look at the application of suicide prevention at the national level, there are are several countries that have been quite serious about their national suicide prevention plan.

I would say the United States is starting to get more serious about it.

We've had one since 1999.

We just haven't known how to implement it.

And look, we're a complicated country compared to some of the, let's say, Scandinavian countries where they implement certain policies and they go nationwide, you know, and they have a way to keep that effort going because suicide prevention, another thing that we've learned is when you get something started, it has to be sustained and thoughtful and strategic over years.

And when the funding dries up or the effort wanes, suicide rates, that may have gone down because of those efforts, tend to go back up.

So it actually needs a continuous investment.

So those countries that have applied their suicide prevention plans at full scale have seen reductions in suicide mortality and that gives us hope.

One of the things they all have in common is a robust crisis response system.

And that's really the significance of 988 for the United States.

In addition to the fact that it will hopefully give us a whole new infrastructure and funding stream to develop all of the resources that most communities don't have, like a mobile crisis team where mental health clinicians show up instead of just law enforcement, where peer supporters are part of that response in the community, and where it's not just take them to the emergency room or nothing, but where there is a multi-leveled, sort of, person-centered approach that can be, you know, crisis respite in the community and not only relying on the clinical system.

- When somebody's in a crisis, both individuals and the broader society need to embrace them and help them through the crisis.

- That is so right.

And we're seeing attitudes change.

It's so, so exciting that we do have Harris Poll every couple of years with some partners and it is showing that the American public wants to help, that, you know, it's 96% of American adults say they would do something if they knew that someone in their life were struggling or suicidal, but they also point out that they don't always know what to do.

They also sometimes feel frustrated at the lack of resources for mental health, you know, distress or suicidal crisis.

And so, you know, it has just sort of confirmed our sense of that the needle is moving on attitudes and culture, but our ability in a way to keep up from a policy standpoint and from an access to care standpoint is actually kind of fallen behind.

I mean it's, you know, obviously there are tremendous efforts to rectify those problems as well, but they are complicated ones obviously.

- Christine, we referred to safety planning and I'd like you to speak, what does that mean?

- Sure.

Safety planning is a relatively new.

We can call it a very brief intervention that was developed by Barbara Stanley and Greg Brown as they were conducting research with the involvement of suicidal adolescence.

And they actually came up with something very practical to sort of try to ensure and augment safety during the process of research.

But lo and behold, it turned out to be a very practical tool so that it now has become, you know, its own intervention that has been studied and sort of honed in for decreasing the likelihood of suicidal behavior for somebody who's found to be at risk.

So it, and it's been applied not only in clinical settings but like even school-based counselors and other settings are using the safety plan.

And so, it's a very practical tool that I would say if you're a clinician, you know about the term contracting for safety from the past which is now considered not good practice.

It's a very sort of old school way of really reassuring the clinician more so than being patient-centered where, you know, clinicians would basically try to ask for the patient's promise to not act on suicidal thoughts, you know, and again probably was addressing our own anxiety more so than truly being helpful.

And it's been sort of debunked.

So safety planning is actually patient-centered and what it does is it empowers the person who knows their patterns best.

And of course, with the help of a clinician, they can kind of tease things apart to first identify what are the triggers for becoming suicidal or just even a little backup in time before they even become suicidal but where the downward spiral begins to start.

And so, the person might identify that it's certain interactions, it's fights that I have with this person, or it's this type of setting or stressors when it's more likely to happen.

So identifying triggers and making a plan around mitigating those.

And then once the person is actually feeling distressed or suicidal, then there are a series of steps that they can take in order to really keep safe is the main goal here.

But, of course, much more than that, it's helping them to live through these moments to find better meaning and purpose and stability overall.

But the steps include, again, very practical things like making a list of what are the things I can do in that moment when those thoughts first start and I'm beginning to feel that sense of needing to escape pain or however they define it and it feels to them.

That they know best if it's taking a walk, listening to music, drawing, you know, it's activities, mental or physical, but that the person does themselves.

That's sort of the step one.

And they make a plan for themselves and the idea is on the app or in their written safety plan, they actually learn to pull it out and use it.

And, of course, that's the hard part for some people.

Beyond that, there are a series of other steps they can take if they're not finding that first self-contained method to be useful.

And that could be, who are the people in your life who are sources of...

They don't even have to be mental health savvy people.

They're like people who are kind of distractions, if you will, that help the person to just come out of that mode and be living in a different mode of, you know, of their thought life and their feeling experience.

So, and ideally they actually engage with these people in advance so that they know that they're part of a person's safety plan.

So when they call, hopefully they're a little more attuned to like, oh, this might not just be a, you know, a regular garden variety called.

This might be that the person is actually reaching out at a time when they need some help and some distraction from those thoughts, thoughts and feelings really.

And then beyond that, there are external sources of who are you going to call that can be, you know, your mental health professional, your clinician, a mentor, or other crisis line type of resources.

And the last step, which is a really important one as I've alluded to already, is how do I keep myself physically safe right now in the environment?

And so that might be getting some help to, again, get lethal means out of sight and out of mind.

And ideally, that's something that's already been done but oftentimes, we are living in homes that have medications, cleaning fluids, and supplies.

Some, you know, 35-40% of households have firearms in them and not all are being stored securely and safely.

So those are all examples of ways to ideally get the lethal means out of the home for a period of time.

And so the person would be engaging with a, well, they could do it on their own of course but they could also engage with a trusted family member, friend or clinician to be kind of walking that through with them.

And so I think, you know, this brings up another point for family members as well as for clinicians that I think we've been assuming a lot of wrong things about what would come across as offensive to a person or even, and I'm thinking of the lethal means conversation specifically, but offensive or also assuming that they wouldn't want to engage in making their environment safe.

And just because somebody is suicidal, remember they have ambivalence.

There's a part of them that wants to live and wants to survive, and there's like an internal war going on.

So be that person who comes alongside them and says, "Let me help you make the environment safe.

Can we do that together?"

So it does not have to be an adversarial dynamic there.

- In many ways, it's a mindset that plans ahead for what may happen so that you're safe and takes actions.

I remember when nobody wore seat belts, and now we all wear seat belts.

It's a natural thing.

And this kind of safety planning could become a natural thing like seat belts.

- I think you're so right.

It is like those things that we learn to do sort of automatically now.

In, you know, when we're on an airplane, we know the steps of take care of yourself first.

And like you said, seat belts.

Simple practical things.

And I will say that the suicide safety plan, I think is it actually kind of got out the gate even before there was a lot of research, showing its efficacy but we have that data now that really does show that it reduces the likelihood of subsequent suicidal behavior.

And I will just add that as a psychiatrist but also as a human being with, you know, the 360 experience that I have for myself, my family members, friends, patients, community members that there's a way to apply this very proactive approach to mental health more broadly than even just to the suicide risk very specifically.

And that, of course, is my life's work is focused on that.

But when I think about how we are learning in our field of psychiatry, that prevention can be possible in certain ways and, of course, we need more science to inform that.

You know, we need much more in terms of clinical resources but individuals are learning how they tick as well and how to optimize our own mental health and reduce the likelihood of mental health exacerbations of let's say a recurrent depression, PTSD, addiction.

We learn ways to keep ourselves, you know, more likely to remain stable than to have that relapse.

- I want to ask you as we wrap up, if somebody's watching right now and they're having thoughts of suicide, what do you say to them?

- Well, I would say that you are not alone.

That you are part of a human race where many of us have experienced that and that there is hope.

Those reasons that you hold on even when you are in this much despair or distress are real and there's a way to reconnect with those people and sense of purpose and meaning in your life that is potentially right around the corner.

Just give yourself a moment.

And please, please take the step.

Take the risk it might feel like to reach out and talk to someone in your life, someone that's indicated that they are potentially supportive and safe.

And if you can't think of anyone, then call 988 because they are there for you with a caring, compassionate, and trained response.

- Christine, I want to thank you so much for joining me and thank you for the work that you've done over the years and the work that you're continuing to do.

Thank you.

- Well, thank you so much, Jeff.

It's a real honor.

Your work is a legacy itself and it's just really a privilege to join you on Healthy Minds.

So thank you.

(soft music) - [Dr. Jeff] Do not suffer in silence.

With help, there is hope.

Funding for this program was provided in part by the American Psychiatric Association Foundation.

Additional funding was provided by the John and Polly Sparks Foundation.

Remember with help, there is hope.

(soft music)