Crisis Response Models for Suicide Are Not Enough

Envisioning a better, stronger model—a communal response to crisis

Posted Nov 14, 2016

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The suicide rate is at a 30-year high, and rising.* With the exception of older adults, suicide rates have steadily increased across all age groups.** Crisis response models are trying to plug the dam but these data are clear: the dam isn’t holding.

Current suicide prevention models assume that the saving of a life happens in a therapist’s office. This has driven concerted efforts to train clinicians to be more skilled in addressing suicidality. Similarly, expansive mental health care systems continue to roll out new screening tools and structured clinical interventions that are based on well-researched therapeutic techniques. And these interventions are certainly important.

Ultimately, however, our current model cannot be the only answer to the epidemic of loss we are seeing. And it may not even be wise to disproportionately resource these programs to the detriment of developing other models that may be equally or more powerful in addressing suicide.

Consider this: Do patients who are in crisis choose to fight through despair because of their relationships with their therapists? (If this were true, then logically the "no suicide contracts" that were formerly used by mental health professionals would have been retained as an effective tool?) Or are people in crisis more likely to stay in the fight for those with whom they choose to share their life—their parents, partners, children, respected mentors and trusted friends? If the latter, then why do we continue to place the therapeutic relationship at the center of crisis interventions? Therapists may try to plug dams, whereas loved ones build them in the first place.

And, in any case, given that the dam is cracking faster than it can be plugged, we have to think bigger—we need to question all of our insidiously unhelpful assumptions and open ourselves if necessary to a total re-envisioning of crisis response. If we want the dam to hold, what is needed is a radical redistribution of responsibility for preserving life—a communal response to crisis. Skilled mental health providers certainly have a role to play, but loved ones have at least five strategically critical advantages over mental health professionals when it comes to saving lives.

To facilitate applied understanding, let’s create a fictional person who seems to be in crisis. Let’s say that he is a combat-experienced US Army Veteran and let’s name him Edgar. Finally, let’s label those with whom Edgar has deep love and trust as his “tribe.”

1) Those who live with or regularly interact with Edgar are best positioned to observe behavioral changes that may signal a potential state of crisis. Those in Edgar’s inner circle have developed a very good understanding of how he usually is and are best able to notice deviations from his normal patterns—things like social withdrawal, changes in his behavior, and increased use of alcohol or other drugs. Even if Edgar were to be engaged in a long-term course of weekly therapy, his therapist will still be reliant on very brief snapshots in the context of the life he leads outside of therapy. In the best-case scenario, his therapist will have one hour of data per week in a 168-hour week.

Therapy is also heavily reliant on self-report and the amount of honest disclosure in a patient’s self-report is largely a function of trust. What if Edgar is not even engaged in mental health treatment? (i.e. he presents in a state of crisis to a therapist he has never met?) What if he and his therapist are still building trust? Patients who may be most vulnerable to crisis may also be the most challenging to engage. Trauma and childhood ruptures of trust have a long tail. As such, it can take years to build a solid trust with some patients. What if Edgar only comes once a month or only when he is in crisis? Assuming he is even meaningfully engaged in care in the first place, relative to loved one’s ability to observe signs of a potentially brewing crisis, what basis for judgment will a mental health professional have in comparison? In most cases, a member of his tribe has a tremendous tactical advantage where observation of critical changes is concerned.

2) Members of Edgar’s tribe have the power of touch. Touch has the power to drive an awareness of connection into a person’s psyche more deeply than verbally exchanges. The touch of someone who is trusted and felt to be safe can help ground us. Research has shown that a hug releases oxytocin (a bonding hormone), lowers blood pressure and decreases cortisol (a stress-related hormone).*** In the context of a healthy marriage, the act of holding one’s partner calms the inner chaos and restores a sense of connection and safety.

A loved one can sit right next to Edgar, lean into him, put their arm around him. A loved one can hold Edgar in a prolonged embrace. This felt sense of connection conquers the fundamental lie that fuels the suicidal mode, which is the thought: “I am a failed human and others would be better off without me.” A loved one can say absolutely nothing at all and yet communicate a profound sense of connection with the power of touch.

3) Members of Edgar’s tribe can express their attachment needs directly. Clinicians may feel a form of love within the context of a strong therapeutic alliance. But it would be very odd (and probably unethical) for a therapist to say to a patient, “I love you and I need you so let’s figure out how to walk through this valley together on the basis of the love and trust we share.” But this is precisely what a member of Edgar’s tribe is empowered to say. To some who are in crisis, these are life-saving words. And loved ones can deliver them with direct impact at a critical point in time.

4) Members of Edgar’s tribe have the power of old stories. Again, it bears repeating—suicidal patients do not stay in the fight because of their relationships with their therapists. They stay in the fight because they feel connected in relationships of deep love and trust with family and loved ones.

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In my suicide prevention work, I have often referred to the suicidal crisis mode as entering “a tunnel of despair and disconnection.” In this tunnel, the walls progressively close in. As this happens, patients subjectively report that it is hard to access information and memories stored in other parts of the brain, especially positive memories. In this dank and hope-deprived tunnel of despair, many begin to make a case for why it would seem rational to end their life and how their loved ones will not be deeply impacted (commonly, the fundamental lies that compel suicidal behavior).

In addition to deploying the power of touch, loved ones can also tap the power of stories that highlight tribal connection. Stories have the power to blast into tunnels of despair. They can restore hope. They can place Edgar where he rightly belongs, as a valued and integral member of the tribe. Sometimes these stories are irreverent and hilarious (“remember that time we were downrange in Iraq when Private Jones...”) They nonetheless have a profound power to stimulate re-connection with older memories that consolidate mutual attachment.

A good therapist is also a repository of stories, but typically these are sacred stories of pain, struggle and trauma, not stories about hope and connection. This is something I think we need to work on as therapists, but until we do (and even if we do), loved ones are much more likely to hold the kinds of stories that effectively wage war against despair. This then is a fourth tactical advantage—loved ones can become lifesaving historians.

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5) Finally, members of Edgar’s tribe know the other members of the tribe and have the power to directly orchestrate a tribal response as needed. One of the beautiful things about a tribal response is that no one individual, including Edgar, is the holder of either the pain, or the hope. There is a collective responsibility for responding to crisis that maps directly onto the ways in which military service members operate as members of military units. When one or more members of the tribe notice the beginning of a downward spiral, they can close ranks against the threat of loss of a brother or sister. In the best of situations, a mental health provider can be an extension of the tribe—someone with whom Edgar also holds deep trust. But a mental health provider does not know who else is in Edgar’s tribe like members of his tribe do.

Even in cases where there is less than optimal mental health support (or none at all), members of the tribe have the ability to call in fire support in the form of mental health treatment providers. They can sit with Edgar as they make a call together to the crisis line (National Crisis Line 1-800-273-8255 - Press 1 for Veteran support). If Edgar happens to be a Veteran and he is not in immediate crisis, they can call Vets4Warriors, a confidential 24-7 peer support line (855-838-8255). Members of his tribe can walk Edgar into a local mental health treatment facility and stand by his side while he gets connected to mental health care.

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To wrap up and summarize, in my work with veterans, one of the more common requests put to me is for guidance on how to help a brother or sister who seems to be in crisis. Every situation is different but as a consistent rule, I try to help decrease the fear and discomfort in approaching a loved one who may be in crisis. I tell my patients that in many ways they have the tactical advantage over someone like me.

I tell them to stand in loving watch of each other.

I tell them to deploy the power of touch.

I tell them that if their love is stronger than their fear or pride, they will move in close.

I tell them that despair and disconnection are the enemy and that love and trust are natural antidotes to this poisonous influence.

I tell them to speak clearly and directly about their love, respect, and need for continued connection with a loved one who may be in crisis.

I tell them to tell stories, especially the irreverent, hilarious ones.

And I tell them to call in as much firepower as the situation requires to help their loved one stay in the fight.

*http://www.cdc.gov/nchs/products/databriefs/db241.htm

**http://www.nytimes.com/2016/04/22/health/us-suicide-rate-surges-to-a-30-year-high.html

***http://www.cnn.com/2011/HEALTH/01/05/touching.makes.you.healthier.health/