There is a crack in everything. That’s how the light gets in.

Thank you for the lyric, Leonard Cohen.

There’s a crack in Washington state, and the light is pouring in. 

History was made in Washington this week.  Big, memorable, Wikipedia-quality news.  While working on a blog about how the Catholic church helps shove suicide victims and their families down into the black pits of hell (post coming soon), the Washington State Legislature just helped to pull them out and into a new light.

Here’s what happened.

Thanks to a small, fierce, and determined group of suicide prevention advocates, the Washington State Legislature turned its back on lobbyists from the Washington State Psychiatric Association, the Washington State Medical Association, and the Washington State Nursing Association, and others and voted its conscience. 

To remain licensed to practice, all 148,000 doctors and nurses in Washington will be required to complete one six-hour training session in suicide risk assessment, treatment and management.  In so doing, the legislature changed the face of suicide prevention in America and the world.  More, they helped unravel the fabric of stigma, shame, and ignorance that has cloaked suicidal self-directed violence for centuries. I trust that Gov. Jay Inslee will have the good sense and the heart to sign the bill into law.

Blog followers will recall my recent posts about legislative activity in the state of Washington. While the bill to require training  of primary care providers passed the Democratic House, most of us figured the chances of getting past the heavily-lobbied Republican Senate were less than 50-50. 

 We were wrong.  Yes, the opposition was backed by thousands of voters with money and paid lobbyists – while we had fewer than 100 without money or a lobbyist, but we won.  We showed up.  We told stories about lives lost or nearly lost to suicide. We corrected distorted facts and stepped up to testify with passion and courage. The opposition sent lobbyists.  Turns out passion and courage won. The Senate vote?  49 in favor, zero against.

We wanted the mandate to require six hours of training every 8 years.  We didn’t get it (that was the compromise to get the bill out of committee), but I’m satisfied with a one-time training provided – and this is a big one – their professional rules committees don’t so water down the requirement that it will fail to have the desired impact on quality of care for suicidal patients. 

From the top of one of the organizations resisting the bill the following line in an email was mistakenly routed to me: “Bad news.  It looks like we will need to do a couple of one-time suicide seminars, as we did with the HIV CME requirements.”

Bad news?  Really?  Did you not see “Dallas Buyers Club” or “Philadelphia” or have a relative or someone you know die of AIDS?

The risk for a least-possible-effort approach to the required training lies in our penchant for quick-and-dirty drive-by seminars.  Attendees need do nothing more than be a warm-body-physically-present to pick up a “Certificate of Attendance.”  While passively listening to the facts roll by “trainees” can watch a Seahawks football game on a smart phone or text with the office to stay on the “real job.”

Ignorance is not relieved by indifference.  You can’t learn a skill by watching a video. A passive educational approach to “assessment, treatment, and management” will not reduce avoidable clinical errors, and half-measures only create more risk for patients.   As one of my staff said about working with suicidal patients, “You have to be willing to pull on your hip waders and get down there in the muck of existential despair if you hope to really help people planning to kill themselves.”

You only mandate training when there is a crying need to fix a problem that is causing avoidable morbidity and mortality.  You only mandate training when willful ignorance has been winning.  And willful ignorance has been winning for far too long. 

Yes, we currently lack a deep battery of proven suicide prevention interventions, but we have some that actually work to save lives, and to not learn these amounts to willful ignorance.  Besides, there is a reason for our confessed lack of evidence about what works to prevent suicide.

Just look at the National Institute of Health’s per-person research budget by cause of death. For each death by HIV-AIDS, we spend $15,665 on research; for each heart disease death, $6,664; for each breast cancer death, $3,875; for each prostate cancer death, $1,635, etc..  How much do we spend to understand and prevent suicide and life-threatening behavior per death? A lousy $254 dollars.  Compared to all other major causes of death, research funding for suicide prevention is a rounding error.

Consider this quote from the widely-ignored 2002 report from the Institute of Medicine, titled Reducing Suicide: A National Imperative, “There is every reason to expect that a national consensus to declare war on suicide and to fund research and prevention at a level commensurate with the severity of the problem will be successful, and will lead to highly significant discoveries as have the wars on cancer, Alzheimer’s disease, and AIDS.”

This is the same Institute of Medicine that, more than 10 years ago, strongly recommended the very training required of health professionals in the new Washington State ESHB 2315. For those medical professionals who think being asked to learn something new about how to save lives is “bad news,” I say get over it or get out of medicine.

My prediction is that once medicine realizes its role in how we can all work together to slow this terrible and avoidable carnage, doctors and nurses will move quickly to take the lead. And if they do, then they can help the rest of us pry open the crack that lets the light in.

Finally, it is helpful to realize that since St. Augustine’s determination that suicide was a mortal sin, which then became a capital crime (yes, suicide attempters were once hanged by the state),  our collective understanding of suicidal behavior has remained in the Dark Ages.  With few exceptions, we have brought no light, no understanding, no compassion, and but a little science to better comprehend our fellow travelers whose experience of life is so unbearably painful that only death promises relief. 

While I am as jaundiced as the next American about the democratic process in the other Washington, I am reborn this week to believe things can and do change in this Washington. With the push and passion-fueled actions of a few, a moral victory can be won, and one was won right here in my backyard.

The Washington State Legislature has thrown open a window to let the light pour in.  It is bright and hurts the eyes, but it is light, light, light.

 I say, celebrate!

 I say, rejoice!

I say,  dance and sing!

And now that we have found the crack in the bell where the light comes in, pass these laws in your state!

Dr. Paul

Note: There are too many heroes to thank for what just happened.  But you know who you are.  Good on you!

For a review of the bill and how it all happened go to:

5 thoughts on “There is a crack in everything. That’s how the light gets in.”

  1. “…get over it (and yourself) or get out of medicine.” Exactly. Strong work team. Has anyone determined why our culture is so resistant to talking about death and dying? We have many support groups for grieving but precious few for preventing death by bucking the status quo. You have made a chink in that armor letting in the light in Washington State. Good on you!

  2. Paul;
    WOW this is how things start to change and I am so happy that slowly, ever so slowly, perhaps the ship is changing course. It seems so odd that depression or the “taboo” topic of suicide is not discussed by the people who are often on the front line for assessment. I think part of the problem is that if a patient acknowledges problems the PCP may think “Now What do I do?”.

    I would like to talk with you about this more. I am thinking of doing a little “dog and pony show” with myself and one of the psychiatrists in our clinic to do an outreach to various doctors/groups and not only give them literature but also some quick assessment tools AND a name, phone number and an expedited way for them to get an appointment for the patient they are concerned about. This would be a person that one of the doctor’s staff could call and set an appt.

    I know myself, the difficulty I have had as a therapist in the past trying to get a patient admitted to a local hospital. It is easier now with our group but now there are other issues with the hospitalizations. Perhaps if doctors get the training AND know there is a dedicated resource out there for their patients who are not appropriate for the sliding fee clinics, the subject of death and dying might not be so scary to talk about.

    Quite frankly I would like to get the process, assessment tools and contact information out there sooner rather than later. It is such a frustrating thing to have a new patient come in that has been on an anti depressant for years with no referral. Likewise I am sure that docs want to know if a patient came in and updated chart notes, so it is a two way street.

    Oh my…I am a little chatty cathy today. This is a subject very much dear to my heart.

    1. Hi Janice,
      The new bill – ESHB 2315 – includes funding for a pilot project that will provide PCPs with “support in the assessment and provision of appropriate diagnosis and treatment of individuals with mental or other behavioral disorders and track outcomes of the program.” You can see this case consultation model in Section 3 at: I would encourage your group to explore this section and see how you can play a role in it. Paul

  3. Hi Paul, Loved this post! Would you please send me the bill # for this legislation. I would like to send it to our state senator who campaigns on his interest in and support of mental health legislation and suicide prevention.

    Thanks, and congratulations! Well done. Charlotte

    Charlotte Ross Fisher

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