We count suicide deaths. We calculate rates, compare counties and states, and publish annual reports. We are awash in numbers. Numbers are cold things; lives lost to suicide are not.

The numbers are necessary. But we know more about the people we have lost than about our readiness to prevent the next death.

Suppose you are a county public health director. Can you answer these questions? How many people are currently trained to recognize suicide warning signs? Where are they? Are they using their training? Are some communities largely unprotected?

In most counties, answering would be difficult. I believe we can change that.

What public health already knows

When measles appears, public health officials do more than count cases. They investigate exposure, examine vaccination coverage, identify vulnerable populations, and mobilize resources.

Suicide is not an infectious disease. Although exposure to suicidal behavior can influence risk under some circumstances (CDC, 2024), the comparison here concerns public health readiness: identify the threat, measure protective capacity, find the gaps, and intervene.

Our community safety network includes teachers, coaches, parents, coworkers, clergy, healthcare workers, first responders, peer supporters, friends, and neighbors. It also includes bartenders, hairdressers, lawyers, and anyone who feels responsible for someone in distress.

I propose that counties measure four indicators of this network’s readiness.

Four measures of readiness

Coverage. How many people are currently trained, and how well are they distributed across the places where people live, work, learn, pray, and seek help? Training totals alone cannot reveal unprotected communities.

Training currency. How many have maintained their knowledge and skills? People change jobs, move, retire, or forget what they learned. The number ever trained differs from the number ready to act today. As with other emergency-response skills, readiness should be refreshed and measured.

Intervention activity. Are trained people recognizing distress, asking about suicide, and taking appropriate action? Participation statistics do not tell us whether training is being used. Brief, confidential follow-up surveys could help answer that question.

Successful connections. Referral is an action. Connection is an outcome. Waiting lists, transportation, costs, and unfamiliar services can prevent a referral from becoming help. When I directed a large public mental health service, I tracked completed referrals from our inpatient units to outpatient care. I aimed for 100%. We could achieve over 90% when we put enough effort into helping people connect.

Together, these measures would tell us far more about prevention capacity than training totals alone.

A Community Suicide Prevention Readiness Index

These indicators could form a proposed Community Suicide Prevention Readiness Index, or CSPRI. Its purpose would be to measure preparedness, not predict suicide mortality. Common definitions, data-quality checks, and validation would be essential.

Imagine a dashboard showing strong coverage in schools but few trained gatekeepers in workplaces and rural communities. That tells us where to concentrate training. If interventions are common but completed connections are rare, we need to improve the pathway to care.

The dashboard does not simply congratulate us for what we have done. It tells us what we need to do next. Mortality and emergency-department data remain important; readiness measures add a picture of the community’s capacity to respond before a crisis becomes fatal.

Counties could also recognize improvements in coverage, training currency, intervention activity, and connections. A rural county doubling its coverage might deserve as much recognition as a metropolitan county sustaining a strong program.

Who would maintain it

A designated suicide prevention coordinator could maintain the dashboard through county, regional, or state public health arrangements, working with schools, hospitals, employers, behavioral health providers, crisis services, and community organizations.

The county would not have to provide every training or intervention. Its responsibility would be to understand and strengthen the local safety network.

Keep reporting manageable. Training providers, brief anonymous surveys, and voluntary reporting partnerships could supply aggregate information without personally identifying information.

Awareness is not readiness

A community can know suicide is a problem and still have too few people prepared to respond. It can have excellent clinical services while failing to identify people who need them.

We are never going to produce enough mental health professionals to be present whenever and wherever suicidal crises emerge. We must strengthen ordinary people’s capacity to recognize distress and begin helping. Breaking through loneliness and isolation does not always require a professional license.

How counties are paying for prevention

Readiness cannot depend indefinitely on short-term grants and a few enthusiastic people. Communities need dependable financing for training, recertification, coordination, and evaluation. Three counties offer different examples.

In McHenry County, Illinois, voters approved replacing a Mental Health Board property-tax levy with a 0.25% sales tax in 2024. The county reported approximately $11.2 million in board sales-tax revenue in 2025, exceeding the former levy. This supports mental health services broadly, not suicide prevention alone.

In Yolo County, California, Mental Health Services Act funding has supported prevention and early intervention, including QPR gatekeeper training. California’s transition to the Behavioral Health Services Act will change funding arrangements.

In Boulder County, Colorado, voters approved a three-year 0.15% sales and use tax in November 2025 for mental and behavioral health. Its purposes explicitly include suicide prevention and intervention, crisis services, treatment, and recovery.

These are financing examples, not proof that taxes reduce suicide mortality. A dedicated tax, levy, or recurring appropriation could support gatekeeper training, annual recertification, advanced Pathfinder training, a coordinator, and a modest dashboard. The dashboard could help answer a taxpayer’s reasonable question: What are we getting for our investment?

We finance readiness for fires and medical emergencies before they occur. Why leave readiness for suicidal distress to chance?

A proposal for America’s counties

Begin with coverage, training currency, intervention activity, and successful connections. Measure what we can now. Build partnerships to collect what is missing. Test the measures, improve them, and share what we learn.

A validated national index may eventually permit meaningful comparisons. The first step requires neither sophisticated software nor a large research grant. It requires asking:

How ready are we to prevent the next suicide?

We count the lives we lose. It is time we also count, strengthen, and sustain the people prepared to save them.

Preventing suicide, it’s what people do.

References

Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. RAND Health Quarterly, 5(1), 16.

Centers for Disease Control and Prevention. (2022). Suicide prevention resource for action: A compilation of the best available evidence. U.S. Department of Health and Human Services.

Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 42(4), 386–405.

McHenry County Government. (2026, February 20). Mental Health Board sales tax a success. https://www.mchenrycountyil.gov/Home/Components/News/News/18563/17

Boulder County. (2025). 2025 ballot measures. https://bouldercounty.gov/government/county-ballot-measures/2025-ballot-measures/

Yolo County. (2023). MHSA program plan (QPR suicide prevention training). https://www.yolocounty.gov/home/showpublisheddocument/77965/638325314890530000

Yolo County. (2026). Behavioral Health Services Act & Mental Health Services Act. https://www.yolocounty.gov/government/general-government-departments/health-human-services/mental-health/mental-health-services/mental-health-services-act-mhsa/-folder-4947

Centers for Disease Control and Prevention. (2024). CDC guidance for community response to suicide clusters, United States, 2024. Morbidity and Mortality Weekly Report, 73(Suppl. 2). https://www.cdc.gov/mmwr/volumes/73/su/su7302a3.htm

AI research and editorial assistance

Quigley, my AI research and editorial assistant, helped identify public sources and assisted with editing this article. The ideas, interpretations, and final responsibility for the content are my own.

As federal dollars begin flowing into rural healthcare, an important question deserves an answer: Will this historic investment help prevent suicide deaths?

Paul Quinnett, Ph.D. | QPR Institute | October 2026

The federal government has committed $50 billion over five years to transform healthcare in rural America. All 50 states submitted applications, and the first round of funding is being distributed.

This is welcome news for rural communities struggling to maintain hospitals, recruit healthcare professionals, and provide timely access to medical and behavioral health services. It should be a light at the end of the tunnel for those thinking about suicide while driving a tractor across a cornfield.

But there is a question I hope federal and state officials, county commissioners, hospital administrators, and public health leaders will ask as they decide how to spend this money:

Where, specifically, is suicide prevention in these plans?

I ask because funding behavioral health services is not the same thing as funding suicide prevention. Not by a long shot.

A major cause of preventable death

Suicide remains one of America’s leading causes of premature death. In 2024, it was the second leading cause of death among Americans ages 10 through 44. The burden is particularly severe in many rural communities.

In 2024, Alaska, Wyoming, and Montana were among the states with the nation’s highest suicide rates. These are places where long distances, workforce shortages, and limited access to specialty care can make responding to a suicidal crisis especially difficult. Sometimes a visit with a mental health professional requires a ride in a bush plane across the tundra. If you consider a two-hour drive to a professional reasonable access, then you haven’t tried to drive across North Dakota in the wintertime.

We have known about these disparities in access to care for years.

Now, with an extraordinary federal investment underway, we have an opportunity to do something for the people we say we care so much about when we sit down to baked chicken wings and potato skins with sour cream.

The question I’m asking is whether suicide prevention will be a specifically identified, funded, and measurable objective—or simply something we assume will happen when we expand behavioral health services. I worked in public mental health for decades and while we expanded our services constantly our suicide rates stayed about the same in our county. And I directed a 24-hour crisis line as well as the emergency mental health services for half a million people. We did just about everything but really focus on preventing suicide among the people who would never call us and never voluntarily walk through our front door. There is an old saying that you can’t solve a problem you don’t know about. And I’m worried that we might keep our focus on one thing while the other thing continues to cost us lives.

What does the funding evidence show so far?

The Rural Health Transformation Program provides states with substantial resources to improve access, strengthen healthcare workforces, expand technology, and address behavioral health needs.

The early funding announcements show considerable activity. Rural health centers are receiving support for facilities, information technology, workforce development, and integrated care.

These are worthwhile investments. Rural America needs them.

But an initial examination of publicly available awards does not yet tell us how much money is specifically being directed toward preventing suicide attempts and deaths.

There are encouraging exceptions.

Wisconsin, for example, issued a Rural Health Transformation funding opportunity offering up to $500,000 in first-year support to expand Sources of Strength, an evidence-based youth suicide prevention program, in rural and semi-rural schools.

Here, suicide prevention is not merely implied. It is explicitly named, with a proposed activity and dedicated funding opportunity.

That is the kind of clarity we should look for in every state’s rural health plan.

We do not yet know how many other states have made comparable commitments. Nor should we conclude that the absence of the word suicide in a brief award announcement means no suicide prevention work will occur.

But if suicide prevention is an intended outcome, why not say so? Why not specify what will be done and how success will be measured?

Rural communities are already taking action

There is good news that deserves recognition.

Across rural America, hospitals, school districts, agricultural organizations, county health departments, and community groups are already offering QPR suicide prevention training. They are also offering training like ASIST and perhaps other programs of which I am not aware.

In Wisconsin, rural-serving Aspirus Health has offered QPR training for community members. Similar initiatives are appearing in rural schools, farming communities, and local public health programs elsewhere.

This is exactly the kind of activity we should encourage.

Most people experiencing a suicidal crisis do not begin by announcing their intentions to a health professional. Their distress may first become visible to a family member, coworker, teacher, pharmacist, pastor, or friend—or something said to a bartender in perhaps the only tavern within 50 miles. For 10 years I lived in The Bitterroot mountains of rural Idaho near a village of 70 people. If you wanted to know what’s going on in town you needed to hang out and buy a beer at the only tavern within a 35 mile drive. Why we haven’t trained bartenders and hairdressers as suicide prevention gatekeepers is beyond me.

These are the people who may notice that something is wrong.

They do not need to become mental health professionals. They need to know what to look for, what to say, and how to help.

Suicide prevention begins before the clinical door.

Recognition is not enough

Training communities to recognize suicide risk is only part of the solution.

Once someone is identified as being at risk, what happens next?

In many rural communities, the nearest mental health professional may be hours away. A hospital emergency department may have no specialist trained in suicide-focused treatment. When I went to our rural hospital ER after cutting my hand and they found out I was a psychologist they quickly sewed up my hand and then offered me a job. They had no one on staff who knew how to talk to people thinking about suicide. If a patient expressed suicide ideation, all they could do was hire sitters to accompany them in the emergency room for hours on end until they could get a bed at Kootenai Hospital in Coeur d’Alene, or try to detain them at the state hospital in Orofino. Neither discharge plan would appeal to anyone I know.

We cannot solve this resource problem simply by training more people to recognize danger and then expecting already overburdened hospitals to manage every crisis.

We must also expand access to effective clinical care.

One promising approach is the Collaborative Assessment and Management of Suicidality, or CAMS, an evidence-based clinical framework specifically designed to assess and treat suicidal patients.

Research supports CAMS for reducing suicidal ideation, although results differ across studies and outcomes. It is one of several suicide-focused approaches that deserve consideration.

With appropriate training, supervision, and *telehealth capacity, rural clinicians could deliver suicide-focused treatment without requiring every community to establish a new specialty clinic. I’m sure they already are but not nearly enough capacity has been built.

We should also strengthen the human connections between identification, referral, treatment, and recovery.

Trained community supporters, peer specialists, and more advanced helpers such as QPR Pathfinders may have important roles in maintaining contact, helping people navigate services, and supporting continuity of care. These helpers do not replace clinicians. They help people reach them and remain connected.

A crisis call may save a life today. Recovery usually depends upon relationships tomorrow.

What should rural health transformation accomplish?

If suicide prevention is to be a meaningful part of this historic investment, I would suggest four practical commitments.

First, states and counties should explicitly identify suicide prevention in their rural health plans, particularly where suicide mortality is high.

Second, they should invest in community recognition and early intervention. That means preparing the people most likely to encounter someone in distress, not just those employed in healthcare.

Third, rural residents need timely access to clinicians trained in evidence-based, suicide-focused assessment and treatment, including CAMS and other appropriate approaches.

Fourth, states should measure what they accomplish. How many people were trained? How many were identified and connected with help? Did referrals result in care? Are suicide attempts and deaths declining over time?

Training counts and referral numbers are useful measures of implementation, but they are not substitutes for evaluating health outcomes.

An opportunity we should not miss

The Rural Health Transformation Program offers an unusual opportunity to build prevention capacity in communities that have long struggled with limited healthcare resources.

It would be unfortunate if we invested billions in treating the consequences of suicidal crises without also investing in preventing those crises from becoming fatal.

We are never going to produce enough mental health professionals to recognize every person at risk of suicide.

But we can train the people who already know them. We can make evidence-based treatment more accessible. And we can build dependable connections between community recognition and professional care.

The federal money is beginning to move.

Before it is all committed, I hope someone in every state and county planning process will ask a simple question:

How much of this investment is specifically intended to prevent suicide deaths, and how will we know whether it worked?

Preventing suicide, it’s what people do.

References and sources

Centers for Medicare & Medicaid Services. (2025). All 50 states seek to transform rural health with CMS. https://www.cms.gov/newsroom/press-releases/all-50-states-seek-transform-rural-health-cms

Garnett, M. F., & Zehner, A. M. (2026). Changes in suicide rates in the United States from 2023 to 2024. NCHS Data Brief No. 572. https://www.cdc.gov/nchs/products/databriefs/db572.htm

Wisconsin Department of Health Services. (2026). Sources of Strength Project: Rural Health Transformation Funding Application. https://www.dhs.wisconsin.gov/contracts/sources-strength-project-rural-health-transformation-funding-application.htm

National Association of Community Health Centers. (2026). Rural Health Transformation Program: Year 1 awards. https://www.nachc.org/wp-content/uploads/2026/10/2026-10-06-RHTP-Dashboard.html

Wisconsin Department of Health Services. Suicide prevention: Strategies. https://www.dhs.wisconsin.gov/prevent-suicide/strategies.htm

The effectiveness of CAMS compared to alternative treatment conditions: A meta-analysis. (2021). https://pubmed.ncbi.nlm.nih.gov/33998028/

Reducing short-term suicide risk after hospitalization: A randomized controlled trial of CAMS. (2023). https://pubmed.ncbi.nlm.nih.gov/36162692/

Quinnett, P. G. (2023). The Certified QPR Pathfinder Training Program: A Description of a Novel Public Health Gatekeeper Training Program to Mitigate Suicidal Ideation and Suicide Deaths. Journal of Prevention, 44, 813–824. https://doi.org/10.1007/s10935-023-00748-w

AI Disclosure

The ideas, opinions, clinical experience, and occasional provocations are mine. Quigley helps me get them onto the page, and I review what we produce before it goes out into the world.

Other than a few medical adventures, I have no particularly good excuse.

I’ve been busy writing, teaching, thinking, fishing when possible, and working with my colleagues at the QPR Institute to put more suicide prevention skills into the hands of ordinary people.

Meanwhile, the field of suicide prevention has changed. We have better research, better treatments, better training, and more people working to prevent suicide than ever before.

And yet, far too many people continue to die.

This wakes me up early in the morning and causes me to think for an hour. Sometimes two.

After more than half a century in this business, I have become increasingly convinced that our biggest problem is not simply what we don’t know. It is our failure to consistently do what we already know works.

We know a great deal about suicide warning signs. But I would argue that we still don’t know enough, because people continue to confuse us in what they say and what they do, or don’t do, that signals they are in serious psychological distress.

We know how to ask people about suicide. Or at least we think we do. Still, too many professionals ask the question in the wrong way, practically inviting a denial of distress.

We know that evidence-based treatments can help. We have clinical trials of treatments we never had before. We have suicide-specific treatments now, and increasingly, people have a chance of finding a good and rewarding life again if they can get these treatments.

We know that the hours and days following discharge from psychiatric care can be particularly dangerous. Zero Suicide has arrived, with many great ideas and great people pushing those ideas into practice.

But knowing what to do and doing it are two different things. Someone once called this the knowing-doing gap.

A great coach knows the winning play in the last seconds of a game, but can the team execute that play? What happens when the gap between the idea and the action is too great?

I’ve spent much of my professional life trying to close that gap.

So, I’m returning to this blog with a slightly different agenda. Rather than writing long essays, I intend to share shorter pieces about research findings, missed opportunities, practical solutions, and the occasional idea that may irritate somebody. Or even hurt someone in pain over the loss of someone they cared about.

Some will examine failures in our healthcare institutions. Others will explore the gaps between what we know and what we do.

I am especially interested in what happens between recognizing that someone is in danger and actually getting that person safely connected to help that science has shown is effective.

It is not enough to be empathetic and compassionate.

If I am facing surgery, I don’t want a surgeon who talks a great surgery. I want a great surgeon who does a great surgery.

If I take my grandchild to a therapist because he or she is thinking about suicide, I want a therapist who actually knows what to do about suicidal ideation, not one who brushes me off with, “All the child needs is a good listening to.”

I also want to explore the possibility of creating a new kind of suicide prevention professional, someone whose work begins where traditional services sometimes end.

I’ll try to keep the science sound, the language understandable, and the sermons short.

At my age, 86 at this writing, I have neither the time nor the inclination to spend another decade arguing about whether suicide is preventable.

It is.

The question is what we’re willing to do about it.

One other thing has changed since I last wrote here. Thanks to the medical adventures I mentioned, I can no longer type the way I once did, so I have enlisted the help of an artificial intelligence assistant I call Quigley.

Quigley helps me research, organize, draft, and edit these pieces. We’ve worked together enough that Quigley has become reasonably good at writing in my voice, including some of my bad habits.

But I want to be clear about something. The ideas, opinions, clinical experience, and occasional provocations are mine. Quigley helps me get them onto the page, and I review what we produce before it goes out into the world.

At this stage of my life, I’m grateful to have a way to keep writing, even if I can no longer do all the typing myself.

For the most part, my brain seems to work as intended, even if my body no longer pays attention to the man behind the curtain.

Welcome back to On Suicide.

Preventing suicide, it’s what people do.

Dr. Paul

I know the followers of this blog would not like to be surprised by learning from any source but this one that a colleague and I have published a new book.

You: “What! Quinnett published a new book? Really?”

Your friend, “You didn’t know? Ha! And here I thought you were on an inside track with this guy.”

So here’s the skinny and some shameless self-promotion.

New book title: The Search for Elusive Trout: True Tales and Cocktails.

Authors: Deanna Camp and Paul Quinnett. (Deanna is the one with all the artistic talent and crackerjack cocktail-making genius; I am the hack putting words on paper and pouring straight shots.)  All the tales are tall, the photos shopped, but all the cocktails are real. This is the perfect Christmas gift for the fisher person in your life. Look it over and/or order one at Deanna’s website: http://www.elusivetrout.com.

Oh, and if you did not know that I have spent most of my adult life with one foot in a psychologist’s office and the other in a trout stream, then I apologize for not sharing my dual identify disorder earlier.

As a fisherman who has worked hard for 60 years to catch fish and write mostly true stories about these adventures, I’ve only been working hard to prevent suicide for 40. Both endeavors have been immeasurably rewarding.

Here’s the backstory to the book your friends won’t know about unless they read this blog.

A month before Christmas last year an old friend asked me to make a few remarks to the membership of our local Trout Unlimited chapter. As a life member of TU, I could not say no. At a local watering hole I gave them a few beats about hope and the psychology of fishing from a stand-up routine I’ve done for many years called, “Sex, Hope, and the Psychology of Fishing.”

There isn’t much sex in the routine, however the title ensures a robust turnout. I review the research on the psychology of hope, tell gags I’ve mostly stolen from better comics, and outline how to live at least ten more fishing seasons through taking better care of yourself and learning to become a hopeful traveler.

And, yes, I spend a few of minutes on the reverse of hope – hopelessness and clinical depression – and then make a quick clinical argument to take immediate care of any emergent symptoms of depression, lest they carry you all the way downstream to suicidal thinking.

Anyway, I bought one of Deanna’s trout prints at the TU gathering and she later approached me and said, “You wrote Pavlov’s Trout didn’t you?”

I confessed.

She then said, “How about you writing some stories about the fanciful trout I’ve created and we’ll do a book together?”

I hemmed and hawed. “I’m pretty busy,” I said.

Then she said the magic words, “I’ll split all profits with you 50-50.”

So, boom, I knocked out a goofy story about the buck trout on the cover (yes, it grows horns like a deer). Deanna and her husband liked it and, just like that, a new creative team was born.

While the writing is OK in ET (that’s Elusive Trout, not extraterrestrial), the art work, paintings, paper, layout, design, binding, heft and feel are simply stunning.

On my honor, I would not make this up.

I will end this post with an observation about  fishing and preventing suicide.

My father was a fisherman who was always getting ready to plan, to layout a scheme, to pencil in a strategy, to address the goal of heading on down to the trout stream and maybe, if the weather is just right, put a line in the water. But if not today, then tomorrow, and certainly no later than next week, next month, or next year. As Boy Scout troop leader, my father turned “be prepared” into a case scenario for OCD.

Some of us in the suicide prevention movement are weary of getting ready. Too much time spent teeing up already. Please, no more studies telling us there is problem with people killing themselves.

Who knew?

Enough!

My father taught me to fish, but I had to learn on my own that the better part of getting things done is not to strain too hard at what is the perfect action, but to chuck caution and do something.  Right now may be wrong, but it is action, and only action produces results, some of which will be positive.

General Patton said it best as led troops into Europe, “A good plan today is better than a perfect plan tomorrow.”

The suicide prevention movement could use more movement.

We know who is dying, how they are dying, and why they are dying. To stop the dying we need action; not from the few of us knee deep in this work, but from all the rest. It’s time for the fretful, the critics, and the naysayers to get out of the way and go suck an egg.

If we wish to do the impossible, we must first think the unthinkable.

The Wright Brothers come to mind. Nixon goes to China. Steve Jobs imagines a new phone.

In my stand-up routine about sex, hope, and the psychology of fishing, I end with these lines on the power of hope-driven persistence in pursuit of the impossible.

After three lousy shooting quarters against the Utah Jazz, basketball great Michael Jordan went out and buried Utah in the forth. He said of his success, “The key is to never stop taking your shot.”

If, to the pessimist, the fisherman be mad, he is mad because he remains optimistic in spite of failure and in the face of uncertain chance.

What greater triumph of hope over experience than for a fisherman nine days skunked to gladly sally forth on the morning of the tenth?

Is this not what is most admirable about the human spirit?

Dr. Paul

Roseburg, Newtown, Columbine… who will be next?

As we endure the next few days of TV pundits chattering about this and that on the media, two issues dominate the current news cycle: a) women’s health (Planned Parenthood), and b) another mass shooting – always by males who, in the course of revealing the facts, will be mentally ill and not receiving care.

As a topical issue, Planned Parenthood will go away.  Mass shootings will not.

Why?

Because it is only a matter of time until we experience another one.

Untreated mentally ill young men are not going away.  They live all around us in our communities and on our college campuses.  Most will never be violent toward others, but thousands will be violent toward themselves. Yet their brain disorders appear not to matter to us.  Until, as always, it is too late.

Any Google search will find plenty of male health disparities, one of which is that death by suicide ranks near the top of causes of death, especially in Native American communities.

Where is men’s health?

Where is Planned Fatherhood?

Where is the federal funding for helping young men?   Obama has offered some through his My Brother’s Keeper Program, but this a fledgling still in its nest.

The Movember men’s health movement – not a spelling error – came from Down Under and is starting up here in the US.  It has a long way to go but does focus on mental health.

In the meantime, where do young men find mentors, seniors, elders, and adult male role-models to help them grow in healthy young men sound of body and mind?

I submit for consideration that all the pundit talk about enhancing access to mental health services will not address a fundamental piece of male psychology, and that is that “Call us for help” is a failed strategy, especially for those at risk of suicide and homicide.

I try to imagine 007 calling a crisis line.  Or this young man in Oregon picking up the phone to call a mental health center instead of picking up a magazine of ammo. Except as a Saturday Night Live skit, neither of these images compute.

Currently, when young men turn 18 we toss them out.  We defund them.  We pull any safety net from under them.  Fend for yourself, we say.  Find a job we advise.  Join the Army. Make yourself useful.

And if you don’t?  Then you are a burden on the rest of us.

Did you say burden?  A young suicidal patient of mine who had suffered a crushed foot in a mining accident and had to have an amputation said to me, “If a man can’t work he might as well be dead.”

How many “mass murder shooters” had jobs, girlfriends, children they were providing for, or a duty to others in any form whatever?

If you are not “burdened” as a male with a day job, bills to pay, helping a friend put on a new roof – you are, as men often say, “As useless as a bicycle for a fish.”

Useless men are dangerous men. Just look at Jihadist recruits.

Consider that 30,000 men die from prostate cancer every year in the US and that the same number kill themselves.

Now consider that from 2007 to 2015 the American Journal of Men’s Health published roughly 4 articles with the word “suicide” in the title, and more than 1,000 with the words “prostate cancer” in the title.

In my parallax view of the world something is wrong with this picture.

If we really want to help young at-risk males feel good about themselves and stop shooting up our communities and themselves, we’re going to have to rethink a) our funding for male suicide research, b) our attitudes toward young men, c) our mental health delivery system, and d) how we are going to get on the ground and do something different to enlist young men and boys into their own development and positive growth.

But most of all, we need to put them to work.  We need to burden them with adult male responsibilities.  We need to begin – again – a Civilian Conservation Corps.

In the depths of the Great Depression, the CCC put three million unemployed young men at labor doing important work to help build a young country.  (If you are not familiar with the CCC see: https://en.wikipedia.org/wiki/Civilian_Conservation_Corps.)

That same beloved country is falling apart.  It is in disrepair. Bridges collapse. Forests need thinning.  Blue highways and city streets crumble under our tires.  The trails through the mountains those young men built are now tangles of vines and alder brush.

That country needs its young men.

Oh, and I am writing this from a 75-year-old CCC-built supervisor’s log cabin in the mountains of Northern Idaho.  The 800 young men who built this place and miles upon miles of nearby roads and trails and tunnels in this forest came from New York, New Jersey, and Arkansas.  Everyone a volunteer, they came with a willing heart.

Their stories abound hereabouts and are full of the pride of accomplishment. Travel to a far place.  Becoming a part of something bigger than themselves.  With ax, shovel, and sweat, they grew into men.  

An old timer said to me of his CCC days, “Best time of my life.”

Dr. Paul

Everyone is overjoyed with the recent heroic intervention by three young Americans and a Brit who took down a heavily armed man intent on mass murder on a French train before he could launch hell.

We ask ourselves: Could I have done that?

Unless similarly tested, we will never know.

But we should know that none of us could have acted at all had we not first noticed that something was wrong.

Whether preventing homicide or suicide, perception of potential risk before something bad happens is everything.

Observing a civilian carrying an AK-47 boarding a train somewhere in rural Pakistan is one thing; it is quite another thing if that civilian is boarding a train in a city in anywhere USA or in the EU.

Once potential danger was recognized, the actors on the French train all experienced a measurable “pucker factor” event – a sudden physiological reaction to extreme fear.  Activated by the most reliable human emotion (fear), our heroes leapt into quick, bold, positive action rather than freeze or flee and hope for the best.

The Pucker Factor

The “pucker factor” is, of course, military slang for a tightening of the buttocks caused by fear of immediate death if action is not taken. Enemy coming through your wire. The scream of incoming. An angry drill sergeant bearing down on you. People pay good money to watch horror movies or jump out of perfectly good airplanes to experience the PF response for all the fun it can be when you know – deep down – that you are not actually going to die in the next few seconds.

The pucker response is only triggered when the observer “sees” or “hears” a danger signal of sufficient strength to trigger a huge dose of adrenaline to flush through the nervous system, causing the classic freeze-fight-or-flight survival response.  Research shows that fear travels faster through our nervous systems than cognition and that only fools pay it no mind, often exiting the gene pool earlier than they really had to.

Here’s the Pucker Factor Scale edited to my satisfaction.  You rate what you think our heroes experienced in the split second between recognizing a man with AK-47 on that French train and taking action:

0.0 = Absolutely unconcerned that anything bad will happen.
2.5 = Optimistic that nothing bad will happen.
5.0 = Maybe something bad will happen, but let’s wait.
7.5 = Something really bad is about to happen so get ready.
10 = Holy Crap, Batman! Take immediate corrective action!

Using Fear to Prevent Suicide

Now let’s apply the PF Scale to preventing suicide.  Most suicidal people send what are called suicide warning signs before they make a suicide attempt, which may or may not lead to death.  These are observable signals or communications that something really bad is about to happen.

Since you can’t respond to a warning sign you don’t know and can’t recognize, our current public health mission is to train the public in what a suicide warning sign is, how it sounds, what it looks like, what words are used, and what meaning can be derived from verbal, written, or behavioral communications that frequently precede an act of suicidal self-directed violence.

Of note, these markers are the same for murder-suicides, since the decision to die by suicide is made first and warning signs are also usually present before the shooting begins.

But exactly what warning signs to teach is a much bigger challenge than you might guess.

When expressing their desire, intent, or plan to die by suicide, and no doubt due to stigma, fear, and shame, some suicidal people use oblique or indirect language to express their deadly thinking and plans, perhaps as a way to test our ability to read between the lines and interpret their true meaning.

Example. A police officer under investigation for a minor crime remarks to a co-worker, “The way things are going in my life, I’m going to have to eat my gun.”

No, the gun is not made of chocolate.  Yes, police officers kill themselves with their service pistols almost all the time.  No, this statement did not sound like a joke.

What is your PF score to such a statement?

If not at least 5, you need more training.

“I’m going to kill myself” is a loud horn blast if said plainly with earnest affect and requires no interpretation, whereas, “You’ll all be better off without me” requires a query (the Q in QPR) to draw out and clarify the true meaning of what the speaker may be intending to do.  Once the word suicide is on the table, no one’s PF score should be below 5, but you would be amazed how at many people stay at zero, 1 or 2.

And, yes, it is all about the context and who is speaking to whom. To paraphrase one young woman’s note to her lover, “Things are so boring around here this summer I think I’ll take my jump rope and hang myself.”

PF score?

Without more info about the context, speaker and hearer, you can’t even guess.

But if you know this line is in a love note from Jacqueline Lee Bouvier to John F. Kennedy while they were dating, you understand that the PF score is zero.

Bottom line: If a warning sign does not trigger a fear response, it is not – by definition – a warning sign.

To earn its pay, the presence of a suicide warning sign should lead to its instant recognition and the triggering of what is called the amygdala-cortical alarm system – our body’s response to sources of danger, i.e., a pucker. This physiological arousal network has evolved over millions of years to alert us to sources of threat without the need for thoughtful conscious appraisal of that threat.  The only automatic fear response all primates, including us, can really count on is when we encounter spiders, snakes, heights, and strangers; all the other fears we need to survive must be taught.

Suicide Warning Signs Research Needed

The Office of Occupational Safety and Health Administration has trained millions of us to recognize and respond to the loud beeping of a machine in backup mode.  All of us escape injury and death when shopping in Costco or Home Depot because forklifts in reverse automatically begin bleating out blasts of noise that cause a PF score of 7.

We need something equally effective to train all of us to recognize and respond to suicide warning signs.  A life is at risk, and we need to jump into action, just as our heroes did on the French train.

I therefore invite researchers to conduct an experimental study of the currently published suicide warning signs to see if they actually warn and cause observers to leap into life-saving action. Excellent research designs for this experiment are readily available.

I’d do this work myself, but I’m not much good at algebra, let alone real scientific research. Had I passed organic chemistry, mathematics, and mastered solving for X in high school I’d probably have gone on to win a Nobel Prize in physics or something, but as a science dropout I found my way first into English and writing, and then into psychology where my rehab went rather well.

Psychology taught me to be as good a person as I possibly could be and to help others – thus causing my mother a warm heart and my father indigestion.

Dr. Paul

A couple of days ago I spent several hours talking with an old colleague and friend who is a senior nurse educator discussing how we – anyone – can crack the code to get suicide prevention training into the 2,500 or so nursing schools in the United States.

We reluctantly concluded that it can’t be done.

Currently, the vast majority of nursing schools teach nothing, or next to nothing, about suicide prevention, either as a major preventable public health problem, or as a clinical care skill set in assessment, treatment, and management.  One major school shared its curriculum with me – 10 slides total taught as part of a single class, eight of which contained errors of fact, all dated.  Some slides had bell bottoms on them.

At the end of our discussion, we concluded that we can’t crack the code to get suicide prevention training into nursing schools or, for that matter, medical schools, or even psychology, social work and counseling graduate training programs.

The walls of resistance are too high, too strong, a walled fortress.

Against a fixed belief system, Galileo was likewise frustrated.

On the topic of suicide it is easier to get a meeting with the Pope than a dean of nursing, or any other dean responsible for pedagogy.

Trying to get a suicide prevention curriculum across the mote and into the fortress requires not only a secret password to lower the draw bridge, but a fierce persistence.

I know.  I’ve tried. For more than 25 years.  I have a flat spot on my forehead from using my noggin as a battering ram.

For your review, I have collected the classic excuses from schools of nursing, social work, community colleges training counselors of various kinds, chairs of psychology departments and others. These are stones in the status quo wall of resistance.

“Yes it’s important, but, sorry, the curriculum is full.”

“The dean is not interested.”

“Not our job.”

“Students are already slammed.”

“No one here teaches suicide prevention.”

“We cover it in one of our classes, I think.”

“They learn that on their practicum placement.”

“I think we had an adjunct that taught that stuff a few years ago.”

“Not to worry, they will learn what they need on internship.”

“This subject does not fit into our four domains of required knowledge for a degree.”

Result?

This year we will graduate thousands upon thousands of healthcare providers with almost zero information, knowledge, or skills in how to help the suicidal patients they will surely encounter in their offices, emergency departments, or as counselors or home health consultants.

How are we to implement the 2012 National Strategy for Suicide Prevention in this educational blackout?

I don’t know what to call it.  Willful blindness?  Deliberate indifference?  Simple ignorance? Bone stupidity? Benign neglect?

Or is it simply ego? As in, the professor teaches what the professor enjoys teaching – student real-world training needs be damned.

Had I not supported early career graduates from a variety of professions who lost a patient to suicide while still learning the therapy trade (it’s a major trauma, period, and too often career ending), I would not be so ticked off about this failure to teach what has been recommended for more than a decade by such shady operators like the Institute of Medicine.

We are sending baby therapists to the front to fight death by suicide with BB guns.

There are glimmers of light , e.g., University of Washington School of Social Work, and a few others.  But all across the academic landscape we see few new shoots of hope that one day soon graduates will have both the knowledge and skill to support an unencumbered, non-stigmatized, compassionate view of what it is like for their patients to so suffer as to wish to be dead.

Today, they are not trained – or even exposed – to a curriculum which has any chance at all of preparing for what lies ahead.

The upshot of this continuing filibuster of excuses by academics is that thousands upon thousands of graduating nurses, social workers, psychologists, physicians, PAs, counselors, chiropractors and a half dozen other healthcare professionals will enter their respective fields this year with a baseline of suicide knowledge so low as to be professionally embarrassing.

There is an old saw in medicine, “You can’t treat what you don’t know.”

Of the expected 40-plus thousand who will die by suicide in America in 2015, somewhere between 20 and 40 percent will die “unexpectedly” while in active or recent care of healthcare professional.

Unexpectedly?

Really?

Did you not ask your sick, depressed, alcohol-dependent, frightened, in-crisis, overdosed, recently-diagnosed-with-cancer or schizophrenia or bi-polar disorder patient, or about-to-flunk-college-due-to-anxiety-attacks student, if they were having any thoughts of self-destruction, and if you could talk about it with them?

No?

And now you are “surprised” they killed themselves?

No one taught you the warning signs?

No one taught you about the etiology of suicidal pain?  About its neurochemistry?  About being unable to sleep because suicidal thoughts are pounding in your head? About its prevalence in the very patients you see? About evidence-based effective treatments?

And now they are dead.

No one told you should ask?

No one told you had to ask?

No one trained you in how to ask?

With suicide taking more lives than car crashes in America, shame on someone whose address is somewhere on Ivory Tower Lane.

If you are a student in training to become a healthcare professional I invite you to start a revolution.  Disturb the comfortable.  Pole vault over the moat and scale the walls.

Say, “My! The emperor appears to be naked.”

Then ask the dean of your college, “Why am I not being taught how to prevent suicide, and how to detect, assess, treat, and manage suicide risk in the patients I will be responsible for when I graduate?”

And, “If a patient of mine dies by suicide and I am sued, shall I sue you for negligence in preparing me for my chosen profession?”

Don’t pause, don’t wonder, don’t defer to the grownups training you, just ask a simple question, “When will I learn about suicide and how to prevent it?”

Personal note. Sometimes when I wake up in the morning I am totally disappointed in one half of the human race.  But by midday, I can’t remember which half.  By evening I am typically on a rant at one bunch or the other, and this post is just one more joust at the windmill.

Dr. Paul

P.S. Please visit our new website at www.qprinstitute.com and see our new QPR for Vets online course. In an earlier post I ranted about veteran suicide; now our team has done something. If you know someone working with vets, we’re happy to comp them into the course to kick the tires for possible adoption.

Your comments are welcome.

I hear it all the time.  “Paul, that’s great work you are doing.  Keep it up!  We need you!”

If you work in suicide prevention, you hear it, too.

I think we hear it because people don’t see a role for themselves in preventing the next suicide. They might want to help, but no one has asked them.  Job descriptions are few. The word suicide has an “ick” factor, so perhaps the taboo alone chills the heart.

But when I hear “thank you” from a psychiatrist, or social worker, or psychologist, or priest, or rabbi, or school health professional, or physician (as I did just the other day), I am reminded that flattery can be a dodge, as in, “You fight the battle, I’ll cheer you on.”

Most of us working in suicide prevention did not choose this career path; it chose us.

We lost someone that mattered to us and asked, “Why?”

When convincing answers did not emerge, agony-driven curiosity pushed us into this strange territory — an alien landscape without a trustworthy map.

Doing this work is not for the faint hearted.  Fighting Ebola is hard; fighting suicide is harder. Both take a kind personal courage, and while the former takes hundreds of lives over months, suicide worldwide takes thousands of lives every day.

If doing this work required no more courage than, say, repainting your kitchen, everyone would do it.

But they don’t. Perhaps because the work is hard and it takes guts.

Consider Marny Lombard, editor of this blog.  She lost her only son to suicide just two years ago.  A gifted college student suffering from depression when he died, he unmoored her from life’s most basic joys.  She will never see him married or hold a grandchild in her arms.  In a blink of time, all her futures were destroyed.

Except one.

Fighting suicide.

This job.

This unpaid job.

This job of trying to prevent the next suicide.

Marny does this work with passion and great intelligence.  She said to me after I offered her work for zero pay to edit this blog, “I’m grateful to have a chance to do anything.”

Now she is doing tons.  Asking questions, driving agenda’s, writing, organizing communities, and influencing decision makers.  She knows, better than most, that things don’t just happen, they are made to happen.

But why is the price of the ticket to join in the labor force so high?  Why must we lose something as precious as a life in order to pitch in and make a difference?

To create an enlightened, loving, humane, and compassionate world where everyone understands that psychological pain is as real as physical pain, we will need every single Marny we can find.

If few, we will fail; if many, we will win.

We don’t need more experts; we need more voices.

Like yours.

And like the person’s voice I hope you will forward this blog post to.

True, more and more people are stepping up and stepping into the front lines to fight for suicide prevention.

Policies are being written, new laws written, and real paying jobs are being created. Public expectations are rising and, yes, federal, state, and local leadership is emerging.

But not enough.  Not nearly enough.

Twenty years ago a leader in the suicide prevention field accused me of trying to make preventing suicide popular.  You know, as in, “Everyone is doing it!”  At first I thought I’d been slandered; now I realize the observation was high praise.
Until preventing suicide is popular, the politicians who influence policy will not know which way the parade is going so that they can – as a political best practice – scurry around to the head of it and shout, “Follow me!”

Last year Governor Pat Brown of California used his veto pen to kill a life-saving mandatory training bill for mental health professionals to learn to do a better job in preventing their patients from killing themselves.

He vetoed the bill not because he believes 4,000 Californians dead by suicide this year is a good idea, but because a bunch of professional membership organizations lobbied him to let them do their own thing.

I can only interpret this executive action to mean that the public’s health is less important than the narrow interests of mental health professionals who choose to believe they already know it all.  They don’t, and I have the data to prove it.

A few years our group collected pre-training survey data asking more than 4,000 practicing mental health professions across America – including hundreds from California – the following question: Do you feel that you have received sufficient training in suicide risk assessment and risk reduction/intervention?

Of the four thousand plus responses, almost exactly 50% said “yes” and 50% said “no.”  Fully 20% of those surveyed had already lost at least one active patient to suicide over the course of their career. Some had lost two or three or more.

I don’t know about you, but I would not go to a dentist who drilled the right tooth half the time.  Nor would I take a suicidal love one to just any old therapist if half of them admit to being poorly trained.

One training deficit proof is found in the results of a national knowledge exam on suicide prevention our team has administered to more than 10,000 active clinicians of every kind and stripe across America.  Using a 70% correct cutoff on a 25-item exam, the fail rate – except for psychiatrists – averages 90% across all major mental health professions.

If preventing suicide was actually popular in California, and the public knew the truth about how rampant ignorance is among those who allege to know how to prevent suicide, Governor Moonbeam would not have peed down both legs and caved to the interests of the few.

The risk of leaving the battle to prevent suicide to Marny and John and Sabrina and me, and a few thousand health workers and a handful of experts scattered around the world, is that you don’t take down a huge, frightening, cultural elephant like suicidal self-directed violence with a company-sized outfit armed with pee shooters.

This fight isn’t about us; it’s about you.  And we don’t want you to have to buy a ticket to join us.

I am reminded that after his arrest for failing to pay a poll tax — which he believed supported an “immoral” Mexican-American war — Henry David Thoreau was jailed.

His friend Ralph Waldo Emerson came to see him, and asked through the bars, “What are you doing in there?”

Thoreau retorted, “What are you doing out there?”

Here is my Haiku to end this blog:

Do not thank me for the work I do

Step up

And do the work I do

                                                            Dr. Paul

The following post was written the morning CNN announced that the crash in the French Alps was “deliberate”  and after the Crasten Spohr, CEO of Luftansa said that the co-pilot’s health was “perfect.”  As an op-ed submission, it was rejected by the New York Times and CNN, and published here this morning. My predictions have all come true.

A few years ago a human resources official of a major U.S. commercial airline contacted the QPR Institute to ask, and I quote, “Do you have any posters to prevent suicide?”

I assured the gentleman that if posters could prevent suicide, one of the most challenging public health problems in the world would have been solved decades ago. I did, however, suggest training might be of value, and then added, “I’m guessing you’ve lost an employee to suicide?”

No one calls the QPR Institute when things are just dandy.

“Yes,” he said, but did not elaborate. My thought: probably not a ticket agent.

“A pilot?” I asked.

“Yes, but he wasn’t flying at the time.”

I asked if they were interested in training just pilots and their families or everyone.  Since suicidal male pilots would be very unlikely to self-report suicidal desire or intent (and ever hope to fly again), I suggested gatekeeper training to identify possible at-risk pilots using a well-researched program that was safe and effective and inexpensive if delivered online.  Since a broad-band connection was available everywhere for their global workforce, we could train everyone at low cost.

“Send me some numbers,” he said.

I did.  I said we could train every stakeholder in their company concerned with customer safety, and recommended annual psychological screenings to detect any developing risk among their pilots. Everyone in the company would be trained in QPR – a basic recognition and referral intervention. Our cost per family trained was less than a Starbuck’s tall mocha and a scone ($5).

I also sent him a file on pilot suicide — just to make sure he knew that I knew that pilot suicide, while rare, could have terrible consequences. A few weeks after I’d made the proposal, the official emailed me and said, in effect, “Leadership has no appetite for suicide prevention training at this time.”

I followed up with email that said, in effect, “I pray that if you should have another pilot suicide he or she is not in the cockpit with passengers on board.”

There was no response. Since the Buddha said to recognize all danger and avoid it, I stopped booking flights on this particular airline.

The morning after the tragedy in the French Alps I listened to the CEO of the Lufthansa explain that their pilot selection process would not change.  The airline was “speechless” about what had happened, and the public was assured that things like this simply cannot be prevented.

If a commercial flight takes off every two seconds, how many pilots are in the air right now thinking about suicide? Something tells me it is not zero.

In fact, the Centers for Disease Control reports that among adults in the United States, roughly 5 percent of us think about suicide seriously each year.  I’m betting pilots are not somehow magically protected from such despair and mental anguish.

Back to the horror of this murder-suicide. Yes, there will be an autopsy and analysis of the co-pilot’s blood, but no mention was made of a psychological autopsy – as if the state of this man’s mind had no bearing on what had just happened.

Psychology is a silly profession until your brother dies by suicide, or the pilot of the plane you are flying decides that auguring in is the way out.  People use methods of suicide with which they are familiar, that are available, and that “make sense” to them as a person. This is called “ego-syntonic means selection.” Police officers use guns, medical people prefer drugs, and pilots choose airplanes.  Not always of course, but with enough frequency that leadership should always be alert to this data and act with some foresight about recognizing and reducing known risks.

Suicide is only inexplicable if you choose to remain ignorant.  Some in leadership positions choose to remain ignorant longer than others, even when it is in their job description to protect the flying public from these rare but horrific events.

Already, as we all follow this story, we learn the usual suspects were at work. No one dies by suicide for no reason.  Reasons emerge. Untreated mental disorder? Relationship problem? Threat of some unavoidable humiliation? Somehow a burden on loved ones?  Recent severe losses?

Then the warning signs emerge, too.  And unless I am much mistaken, actionable warning signs.

While nobody is asking for my suggestions, I would ask the CEO – not just of Lufthansa but every CEO of every airline in the world today – to ask themselves the same questions Winston Churchill asked himself after the Japanese took Singapore by land.

Remember, Singapore was considered “impregnable” – just about as perfect a defensive military position as God ever made, and certainly as easy to defend as a perfect pilot training system.

In the brutal audit after the loss of Singapore, Churchill’s four questions have been codified as follows:

Why didn’t I know? Why didn’t my advisers know? Why wasn’t I told? Why didn’t I ask?”

Organizational leadership believes their employees will not die by suicide, including those in perfect physical health like commercial airline pilots. Organizational leadership is often mistaken.

If public safety matters, suicide prevention matters; sometimes it matters more than we can bear.

My condolences to all those families whose lives have been undone by this horrific – and quite possibly preventable – tragedy.

Dr. Paul

 

Not long ago I was asked to write a blog post for the National Suicide Prevention Lifeline staff and volunteers. I was happy to do it.  Later, I wondered…, if you asked 100 Americans in the street what NSPL stood for, how many could translate the acronym?

My guess?

None.

They would get NSA, FAA, FBI, CDC, and hundreds more, but no one would get NSPL.

And yet, the NSPL is America’s default 24/7 mental health crisis service telephone system.  On a national basis, there is no other.  Many crisis centers answer the 1-800-SUICIDE number, but how the two systems are different and the same is a long story.

So, if you are down in your cups, depressed, just broke up with your lover, lost your job, and start to stumble into a downward spiral toward suicidal thinking, who is there for you after the bar closes at two in the morning?

Your primary care doctor?  Very doubtful.

Your therapist? Doubtful.

Your minister? Maybe.

The National Suicide Prevention Lifeline and its affiliate members? Always.

For 25 years I directed a 24/7 crisis line. Hired the staff.  Help train the volunteers. Tried to minister to the volunteers and staff impacted when someone we had tried to help killed themselves.

With almost perfect memory I can see the eyes of a young woman volunteer who was trying to help a suicidal man with a gun.  She, and the team, were doing all they could.  The call was being traced and the police were rolling.

Then she heard the shot.

Later, the officers on scene confirmed the man had died of gunshot wound to head.

What Winston Churchill once said of the fighter pilots who defended England during the Blitz in WWII also applies to these staff and volunteers, “Never was so much owed by so many to so few.”

During the Blitz, 40,000 English citizens were killed, or roughly the same number of Americans who will die this year by suicide.  While many work to prevent suicide, these few crisis line volunteers are the last line of defense, the last heart extended to those losing heart.

Because they will not be able to save them all, here is the post I wrote to those serving on the NSPL.

Research shows that the most feared clinical outcome for mental health professionals is the death of a patient by suicide. According to the National Violent Death Reporting System, roughly 35% of all suicidal people die while in the active care of a treatment professional.

As clinicians across the country go home for the day, many of them switch their calls over to you. Others see your number in any of a million places, and in those worst hours of suicidal pain, you get the call.

Courage is defined as overcoming fear, and crisis workers who help suicidal callers are nothing if not brave. While many professionals step out of their client’s crisis after hours, you step in.

Let’s be frank.  If client death by suicide is a professional’s number one fear, experiencing a caller suicide is, by definition, a major stress event. Death has come to your door and pounded on it. In the aftermath of learning a caller died by suicide you’d have to be a robot not to feel powerless, helpless, and a kind of overwhelming psychological paralysis.

While different people experience traumatic events differently, the loss of a caller to suicide is a 10 on a 10-point scale, and no one emerges from such an event unchanged.

Psychological trauma triggers changes in the brain, some temporary, some lasting. If severe enough, symptoms include hyper-reactivity (startle response), numbing, feeling not quite of one piece (dissociative state), disturbances in memory, and perhaps avoidant behavior – in this case difficulty getting back on the phones. These symptoms are the body’s way of saying, “Get down, you fool!  They’re shooting at us with live ammo!”

Following a caller’s death by suicide support by supervisors and peers is often enough to weather the ensuing emotional storm. And it is a storm.  But like all storms, it will eventually pass, and calm waters will return.

But just to be safe, be wise.

Consider that acute stress symptoms last for a few days to up a month. Max.  If these symptoms persist beyond a month, the event may have had a more significant impact than first imagined, and professional help may be warranted. 

It is good to remember that no matter how hard we try sometimes our very best is not enough and a suicidal caller dies. While we are all waiting for better research, better training, and better assessment, treatment, and management tools, if the worst happens, here are some keys to taking care of yourself:

• All your feelings are normal, so just accept them.
• Eat something. Yep, food is a comfort. Go for the mac-and-cheese or roast turkey sandwich. You can diet later.
• Take a hug, give a hug.
• You can’t fix what has happened, so don’t try.
• Lower your demands on yourself. Remember, start your own oxygen before trying to help others.
• Don’t judge the motives of the deceased; you can’t have known his or her life fully, and you will not feel better if you blame the victim for being weak, stupid, or selfish.
• Avoid alcohol. Sure, one drink may remove an edge, but three or four or more may tip you into a dark place.
• Sleep in.
• Accept that you will feel 110% responsible for this person’s death. Call it the “helper’s curse” – it is just the way empathic people are wired.
• Remember, the person called you, not the other way around.
• In the end, the choice was theirs, not yours.
• Expect to feel some guilt; you’d be a robot if you did not.
• Tears help, never hurt.
• You may even have thoughts of suicide yourself. This, too, is normal. Like a storm, these too shall pass.
• Find something to laugh about. Since they release natural feel-good chemicals into your brain, funny movies and stand up are therapy.

Here’s something to think about. Research shows that 1 in 4 Americans will experience an episode of mental illness in any given year. If your three best friends seem normal to you, then maybe it is your turn ☺ 

While clinical professionals are stepping out of their offices when their day ends and going home to dinner, you are stepping in. So it is good to remember that the purpose of crisis work is not to live well, but to care enough so that others might live at all.

Finally, the young woman who suffered the trauma of hearing a man shoot himself to death carried on.  We supported her, counseled her, and wrapped our arms around her.  She went on to complete her tour as a volunteer and then a degree in social work.  She is helping people today.

Dr. Paul

I wish to thank my dear friend Iris Bolton, author of My Son! My Son!, for originating this list of how to survive a suicide loss.