Promoting Hope, Preventing Suicide

Behavioral health vs. mental health: Battle Conformity

Elana Premack Sandler, L.C.S.W., M.P.H. — Tue, 17 Nov 2009 19:22:35 +0000

When I posted a couple of weeks ago about the concept of "behavioral health," I received a number of very thoughtful and interesting responses. A couple of commenters addressed the idea that behavioral health connotes conforming to society's expectations for behavior, which is different from mental health. I'd definitely agree, and I think that's pat of why I struggle with the term. When I was training as a social worker, I was struck by how much of the work is about getting people to fit a mold - perhaps a mold that does not fit them.

I've included excerpts that I found particularly thought-provoking below:

Mandy Harris wrote: "If a guy walked into an ER, bleeding profusely from a bullet wound in his leg, we would not diagnose him as having a ‘bleeding disorder.'

The behaviors associated with mental illness are symptoms of something else. Nowhere in medicinal vernacular should we advocate naming an illness for its symptoms rather than for the origin of the illness."

Mandy went on to say: "Behavioral health sounds like crazy people running amok because they don't know how to behave. Stick them in a straight jacket or dope them up so that they do not behave badly then they would stop being behaviorally ill, yet would remain mentally ill.

Stick with mental health and encourage the public to see the brain as they do their hearts or pancreas: as something that can occasionally not work optimally and as an organ that requires good care."

Marik Bromine wrote: "Behavioral health conjures images of dog training or potty training, a rather Pavlovian approach to this confounding notion of how we are to exist.

Really, I think what you seek is a term that might describe the guidance, knowledge, practices, and tools required for one to derive the greatest benefits from life while minimizing the harm and dangers (to self and others) that might result from living recklessly, carelessly or unhealthily."

In the work of suicide prevention, the ultimate behavior change is eliminating, or at least decreasing, behaviors that result in suicide. But, thinking of all that lies beneath suicidal behavior, I have to think that mental health (or perceptual health, or life health, or emotional health) is a more suitable term.

Is humor ever not funny?

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 11 Nov 2009 16:22:00 +0000

"The Office" has gotten a lot of attention over the past week or so for its Halloween episode, which showed boss Michael Scott in a noose, sharing a particularly poorly worded suicide prevention message. I was struck by how a similar image, also in the public sphere this past week, generated a different kind of response. Ireland's "Sunday World" newspaper published an image of a man in a noose as a way of drawing public attention to police delay in removing the man's body.

I wonder if because "The Office" is a comedy, we are prepared to laugh at whatever comes across the screen. But, in the case of the photo published in the newspaper in Ireland, the image of a man hanging was not at all humorous. Similar image, very different contexts.

What's different?

1. The death of the man in Ireland really happened. He was someone's real family member, someone's real colleague, someone's real friend.
2. The newspaper felt it had a duty to cover the "story" of because the body was not taken down immediately after having been discovered.

Michael Scott, love him or hate him, is not a real person. There is humor that possibly results from showing a hanging man sharing a suicide prevention message - there must have been a reason that I laughed along with everyone else. But, to those who have defended "The Office" in its choice to include this scene because the show is intended for adults and airs during the evening, I want to point out that actual children were involved in the filming of the scene. Real people watching this scene have lost loved ones to suicide by hanging. Vulnerable individuals watch funny TV too, and I have no doubt that some were watching this episode, laughing along with their families, co-workers, and friends. What message was sent to those people - those children, survivors, vulnerable people - about suicide? That it's something to mock? Laugh off? Not take seriously?

The response to the "Sunday World" photo was swift - people felt that, even with a duty to report the news, the newspaper did not have to publish a photo of the man. Publication of such a photo was triggering to those who have lost someone to suicide and, in general, voyeuristic.

The response to "The Office" episode was very interesting to observe. I've included some of the comments posted on the "Entertainment Weekly" website below:

"Let me say, I'm a huge Office fan and would usually ridicule the PC police with everyone else. Unfortunately one of my 19 year old son's best friends had killed himself with a shotgun just a week earlier. After this scene he left the room very shaken and didn't return. It just brought all the pain back, especially since it was played for laughs. So I guess it all depends on your circumstances, experiences and timing. One person's joke is another person's nightmare..."

"No, it wasn't in poor taste, but it wasn't particular[l]y funny either. They could have come up with something better."

"I[t] didn't offend me, but I didn't find it funny. Some of you just don't, or can't understand. Suicide is one of those things you never really appreciate until you've lost someone important to you. My sister took her life this past May. It's not something to joke about, sorry. I'm not thin skinned at all, I just think the lack of compassion for others is pathetic."

"The Office" does not have a duty to include information about suicide, or any means of death, in its show as a public service. If anything, it has a responsibility, if it chooses to include this kind of information, to do so thoughtfully and safely. Humor can be an opening for a real conversation about a difficult issue, so I'm not suggesting that the office avoid tough topics. Many have said that Michael Scott's is offensive in an equal-opportunity kind of way - no one and no group is off limits, and that this isn't the first time the show has touched on suicide ("Safety Training" episode). So, talk about - or even make jokes about - suicide. Don't demonstrate suicide on the show.

What rates in different nations might tell us about suicide

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 04 Nov 2009 17:42:25 +0000

What do you think - is homicide more common than suicide? Turns out, it depends on where you live. I received multiple e-mails about the tidbit in the New York Times "Freakonomics" blog last week on homicide and suicide rates worldwide.

Japan, for example, has a very low homicide rate, but a very high suicide rate. Jamaica has a very high homicide rate and a very low suicide rate. Outliers, as the blog points out, are some states of the Former Soviet Union, which have high homicide and suicide rates.

In the U.S., people are more likely to die by suicide than by homicide, a fact that, I think, if considered more thoughtfully, would perhaps differently direct sources of funding for suicide prevention.

What's interesting for me to consider is the potential protective factors that exist in places like Jamaica that keep suicide rates low. What is it about the environment, the culture, or the psychology of the people that keeps them from dying by suicide? Along the same lines, what are the risk factors that exist in places like Japan - or the U.S. - that make suicide more common? Most importantly, what can we do to increase protective factors and decrease risk factors?

Discussions I've been involved in recently have made it clear how important it is to be specific about risk and protective factors. For example, religious community involvement is considered a protective factor. But, what is it about being involved in a religious community that is protective? Are there instances where being involved in a religious community is not protective? From a public health perspective, figuring out what risk factors are modifiable and which protective factors should be promoted is done on a large scale. Rather than considering what, in each individual, adds to risk or protection, public health looks at the big picture of environments that increase risk or protection. In the U.S., access to firearms increases risk, and certainly contributes to this country's high suicide rates.

How can we build protective factors and decrease risk factors across levels - from individual, to family, to community, to institutions, and to society - to impact suicide rates?

Behavioral health versus mental health

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 28 Oct 2009 14:07:01 +0000

The terms "behavioral health" and "mental health" are often used interchangeably. But, do they really mean the same thing? I've made two short lists below as I've tried to work out what's good, and not so good, about the term "behavioral health," and am very curious to hear what you think.

Three things I like about the term behavioral health:

-It's a way of being inclusive. Behavioral health includes not only ways of promoting well-being by preventing or intervening in mental illness such as depression or anxiety, but also has as an aim preventing or intervening in substance abuse or other addictions.

-Perhaps the term "behavioral health" is less stigmatized than "mental health," so a kinder, gentler name opens doors that might otherwise remain closed for folks.

-Behavior is an aspect of identity that can be changed, so "behavioral health" might be a more hopeful concept for those who experience mental illness or addiction and who may have felt that these diseases were permanent parts of their lives.

Three things I don't like about the term behavioral health:

-The frame of behavioral health places the onus on the individual to change, rather than examining and working to change external, environmental factors that influence an individual's well-being., such as poverty, discrimination, or abuse.

- In a related vein, behavioral health doesn't seem to imply that there are root causes for what we see as behavior. Within the field of suicide prevention, for example, we don't just want to prevent the behaviors that lead to suicide, but the underlying causes of those behaviors.

-Finally, "behavioral health" seems like a concept that was created by someone who works for an insurance company, rather than someone who has struggled with mental health issues.

I'd love to hear what you think. Do you find the term behavioral health to fit the work you're doing, either as a provider/practitioner or a patient/consumer/client? Do you think it helps or hurts the field? My friend and colleague suggested we might use a term like "perceptual health," as sometimes errors in the way we perceive a situation (or ourselves) lead to actions that do not help us. What term would you prefer? If you could, what would you rename "mental health"?

America’s Big Secret

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 21 Oct 2009 15:43:29 +0000

What's your secret?

That's the question Frank Warren is asking when he encourages people to contribute to PostSecret, an ongoing community art project in which, according to the blog for the project, people mail in their secrets anonymously on one side of a postcard.

Last week, I went to hear him speak because I, like many, am fascinated by people's secrets and intrigued by the idea of people sharing them with the "world's most trusted man." I also knew that Warren is a staunch suicide prevention advocate.

Warren's talk is about the kinds of secrets he gets to see and his responses to these secrets. He shows his audience secrets that have, for various reasons, been "banned" from inclusion in any one of the five published PostSecret books. Warren is often asked what he does when people write in with secrets about wanting to hurt or kill someone else. He said that he doesn't really get those secrets, but that he does get a lot of secrets about suicide.

"Suicide is America's secret," said Warren.

Whether an artifact of the suicide prevention theme running through his talk, or a reflection of the realities of those in attendance, it became clear by the end of the evening that suicide and suicide prevention were on the minds - and in the secrets - of those who attended. As a conclusion to his presentation, Warren invites members of the audience to share their secrets with the group, at microphones stationed at different spots in the room. Several of the brave young people who shared their secrets shared that they had thought about or attempted suicide.

I'm used to thinking and talking about suicide and suicide prevention all day, but when I was listening to those who shared their secrets, I experienced the same chills, the same tears, and the same awe that struck everyone else in the room.

"When we think we're keeping a secret," Warren said, "Sometimes that secret is really keeping us."

Hearing all of these secrets related to suicide made me think that a PostSecret book with just suicide-related PostSecrets would be a way to illustrate that suicide is America's secret. How many people are "kept" by their secret about suicide?

What Are The Suicide Warning Signs to Remember?

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 14 Oct 2009 16:21:31 +0000

Several years ago, the American Association of Suicidology developed a mnemonic to aid in remembering the warning signs for suicide. It's quite a list, so a quick way of recalling the most important warning signs can be very beneficial. The mnemonic developed, IS PATH WARM? appears below, along with further detail about each warning sign.

I Ideation
S Substance Abuse

P Purposelessness
A Anxiety
T Trapped
H Hopelessness

W Withdrawal
A Anger
R Recklessness
M Mood changes

The warning signs of acute risk are related to suicide ideation and require immediate action:
-Threatening to hurt or kill himself or herself, or talking of wanting to hurt or kill himself or herself; and/or,
-Looking for ways to kill himself or herself by seeking access to means; and/or,
-Talking or writing about death, dying, or suicide, when these actions are out of the ordinary.

Additional Warning Signs
Increased substance use
No reason for living; no sense of purpose in life
Anxiety, agitation, unable to sleep or sleeping all the time
Feeling trapped - like there's no way out
Hopelessness
Withdrawal from friends, family, and society
Rage, uncontrolled anger, seeking revenge
Acting reckless or engaging in risky activities, seemingly without thinking
Dramatic mood changes

Some details to keep in mind: this list is not a ranking of warning signs based on prevalence, nor is it a list of risk factors, which are related to the potential, rather than imminent, risk of suicide. There has been some recent debate in the suicidology and suicide prevention communities regarding the usefulness of this mnemonic to remember the warning signs. What do you think? What devices have you used to remember other signs or symptoms?

How France Télécom has turned the world’s attention to suicide prevention

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 07 Oct 2009 14:43:43 +0000

Twenty-four suicides. An article this week in the New York Times covering the suicide deaths of 24 France Télécom employees that occurred over the last year and a half stated that the number is not "extraordinary" for a company employing over 100,000 people in France.

But, 24 suicides still means 24 deaths, 24 individual lives lost. In addition, the New York Times article reported that there have been at least a dozen suicide attempts that were not completed.

These suicide attempts and deaths have reverberated internationally, impacting not only the company, but putting a focus on the workplace as contributing to suicide risk.

For France Télécom, crucial factors seem to be transitioning employees to the pressures of the global economy, as the company competes with other private companies providing similar services, and a lack of a supportive environment for employees experiencing work-related stress.

The descriptions of some of the deaths indicate that employees wanted to make sure the company knew that their deaths were connected to their experiences at work. Several employees attempted or completed suicide at the office, and many specified in notes to their families that the work atmosphere was to blame for their deaths.

I wanted to point to some resources that have been developed specifically for suicide prevention in the workplace.

First, the Air Force, which created an evidence-based program for workplace suicide prevention, has an online Leader's Guide to Managing Personnel in Distress, which can be adapted to individual workplace needs.

Value Options, a managed care company, references the Air Force program and walks through the process of creating a comprehensive workplace suicide prevention plan.

Finally, the Suicide Prevention Resource Center, with which I work, has developed two customized information web pages for workplace suicide prevention, one for co-workers and one for employers.

If nothing else, the deaths of France Télécom employees have turned our attention to the importance of seeing employees as people, complex beings with complex needs, rather than cogs in the wheel of progress, industry, and finance.

Thanks to my friend Rabbi Joel Alter for bringing my attention to coverage of the France Télécom story.

Is suicide by train changing how we think about prevention?

Elana Premack Sandler, L.C.S.W., M.P.H. — Tue, 29 Sep 2009 16:14:03 +0000

My beloved Washington, D.C. Metro has been in the news lately, and it's not for being the cleanest and most organized public transportation system in the country.

Unfortunately, it's for being the means by which a number of Washington-area residents are choosing to end their lives.

But, Metro is taking steps to curb the suicides occurring on its tracks, partnering with area suicide prevention organizations to develop training for Metro employees and reach out to individuals at risk for suicide through signs placed in Metro stations.

Metro is not the only transit agency to take on suicide prevention.

The Boston-area T, run by the Massachusetts Bay Transportation Authority (MBTA) has partnered with Samaritans to place signs with hotline information at T stops. Toronto is planning an automatic train control system which will allow trains to operate without drivers, stopping in exactly the same place every time. Because the train will stop at a predictable location, a glass wall preventing access to the tracks can be installed.

What's interesting to me about how suicidologists are approaching prevention in this particular realm is the combination of studying individual characteristics of those who died by suicide on the tracks and an examination of the physical site at which they died.

According to an article by the American Public Transportation Association, the American Association of Suicidology (AAS) is looking at the motivation and background of people who have died by suicide on both freight and passenger rails systems.

At the same time, researchers are looking at "what structures exist - or don't - and whether certain structures might impede or prevent access to the tracks."

This approach - of looking simultaneously at individual characteristics and environmental conditions and designing interventions based on what you find - is comprehensive and potentially very effective, as it uses research evidence to develop a program.

"What leads a person who dies by suicide to be on the tracks at that time to kill themselves?" asks Karen Marshall of AAS. "If we can begin to get to the bottom of this as a method of choice, then we can begin to design prevention programs around it."

How college campuses are reframing, revamping, and repositioning mental health

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 23 Sep 2009 14:47:42 +0000

As yet another school year kicks off, I want to draw attention to college and university campuses that are working to increase accessibility to mental health services by renaming, repositioning, and de-stigmatizing these services.

Cornell University, for one, has as a goal reaching out to international students. According to the Monitor on Psychology article on campus suicide prevention outreach from earlier this month, Cornell has developed a program that allows students to visit mental health professionals at sites that "don't have a ‘mental health' stigma attached to them, for example in academic buildings and student centers."

At the University of Michigan, "the campus mental health center is boosting its accessibility by keeping its doors open four evenings a week."

Since 2001, the organization Active Minds has been using the student voice to "change the conversation" about mental health on campuses nationwide. Students run mental health awareness, education, and advocacy efforts at over 200 campuses.

Campuses are micro-communities, so can the initiatives of campus communities serve as examples for what we might do on a larger scale?

- Could we link mental health to other health issues, like Columbia University does with Go Ask Alice!, a health Q&A Internet service? Go Ask Alice! frames mental health as "emotional health."

- Could we make mental health more a part of everyday life, so that people who find themselves in need of help do not feel different or bad about it? (Cornell's efforts to locate mental health services in places where students already hang out is one example.)

- Could we make mental health more accessible so that people with a lot to balance don't have to miss class/work/time with family to meet with someone who can help them? (As the University of Michigan is doing by keeping mental health services open later hours.)

I don't want to slight the importance of college for college's sake. If we were only to look at campuses as places where the next generation of minds are growing up, that in and of itself demonstrates the value of promoting mental health.

Additional resource: Promoting Mental Health and Preventing Suicide in College and University Settings, a publication of the Suicide Prevention Resource Center

Awareness of What?

Elana Premack Sandler, L.C.S.W., M.P.H. — Wed, 16 Sep 2009 15:47:09 +0000

Following up on last week's postings for Suicide Prevention Week, I wanted to take a little time to think critically about the purpose of activities for awareness weeks.

Awareness of what? is the main question I want to ask. We have pretty solid evidence indicating that education alone does not lead to behavior change, despite our attraction to educational activities as a means of prevention. I should know - I adore facilitating educational workshops, designing brochures, and tabling at events! But, much to the disappointment of my ego, these kinds of activities do not, by themselves, contribute to changing an environment in such a way that supports suicide prevention.

What supports suicide prevention is a comprehensive approach, of which educational or awareness activities are a part. A comprehensive approach has at its heart a set of goals and a group of activities that support those goals. Activities can certainly include some of those I've named above. But, it's important that these activities are directly connected to the goals of the approach. If a goal of a suicide prevention program is to increase the number of youth seeking help at local mental health centers, then that goal should be kept top of mind for the activities that are a part of that program.

I want to suggest that the goal of all awareness activities should not be to prevent suicide. Sometimes the goal is to raise awareness about mental health resources in a community. Sometimes, it's about raising awareness about signs and symptoms of depression. Or, the goal might be to raise awareness about risk factors for suicide. All of these elements help contribute to an environment in which suicide may be prevented. But, using a measurement such as a decrease in actual suicide deaths may not demonstrate success for these activities. Can we really, truly link an activity like a movie showing to decreased rates of suicide?

So, how do we measure success? Do we ask people before and after an awareness activity if they knew about specific resources, signs or symptoms, or risk factors that were presented as part of the activity? How might we do that? Through a survey? Person-on-the-street interviews? Focus groups? What are the implications for each of these methods?

For events, we often measure our success by the number of people who attended. But, what do those numbers indicate? Do they indicate the kind of success we really want to be achieving? If the achievement of your goal will be having more youth seek help at mental health centers, then you must find a way to measure that outcome.

Awareness weeks are dynamic, important opportunities for raising the profile of issues we care about, like suicide prevention. Let's use them in the best way we can, by being clear about our goals and purposeful in measuring our outcomes.