Suicide Prevention and Public Health Social Work

1. Suicide Prevention and Public Health Social Work Elana Premack Sandler, LCSW, MPH Associate Professor of Practice at Simmons University

2. Presentation Outline • Become oriented to current health issues and trends in suicide prevention (SP) • Identify existing roles of social workers within SP • Perceive opportunities, as well as challenges, for “wide-lens” public health social work (PHSW) in SP • Discuss examples of what PHSW looks like within SP • Articulate how PHSW can improve population health related to SP • Map strategies for expanding PHSW within SP

3. Overview of Suicide • Suicide is 10th leading cause of death in US (Murphy et al., 2017) • Edwin Schneidman, father of the study of suicide (suicidology), defined the concept of “psychache” as unbearable psychological pain (Schneidman, 1993) • Suicide prevention “lives” at the intersection of mental health and public health: When suicide prevention is approached in a comprehensive way, it not only works to promote the mental health of individuals, but the health of populations, and the health of the public and society • Prevention can take place on primary, secondary, and tertiary levels • Understanding of “psychache” is the basis for understanding prevention at these different levels

4. Key Terms and Definitions Suicidal ideation: Self-reported thoughts of engaging in suicide-related behavior Suicidal behavior: A spectrum of activities related to thoughts and behaviors that include suicidal thinking, suicide attempts, and completed suicide. Suicide attempt survivor: A person who attempted suicide and survived the attempt. Survivor of suicide: A bereaved person who has lost someone to suicide. (Also called loss survivors)

5. Additional Terms and Definitions Clinician survivor: A mental health clinician who has lost a client to suicide Lived experience: Knowledge gained from having lived through a suicide attempt or crisis Postvention: Activities following a suicide to help alleviate the suffering and emotional distress of survivors, and prevent additional trauma and contagion Contagion: Suicide risk associated with knowledge of another person’s suicidal behavior, either first-hand or through media Prevention-focused language: Shifting away from use of term "committed suicide" to "died by suicide" which destigmatizes suicide & removes connotations of sin or crime

6. Current Landscape: Key Organizations and Leadership • American Association of Suicidology • American Foundation for Suicide Prevention • National Suicide Prevention Lifeline • Suicide Prevention Resource Center • National Action Alliance for Suicide Prevention (Action Alliance) • Zero Suicide • National Strategy for Suicide Prevention: A report from the U.S. Surgeon General and the Action Alliance that details 13 goals and 60 objectives for reducing suicides over the next 10 years

7. Current Landscape: News Synopsis Finding hope: Battling America’s suicide crisis (CNN Special Report, 2018) Wait for mental health treatment in Mass. can take months, study says (Freyer, 2017) A crisis is at hand in soaring rates of suicide (Ruth, 2018) U.S. suicide rates are rising faster among women than men (Chatterjee, 2018) Awareness of and interest in suicide prevention has increased in the public health social work community as suicide has increasingly been in the national spotlight

8. Social Work Involvement in Suicide Prevention Social workersare involved at all levels of suicide prevention and hold numerous key roles: • Primary, secondary, and tertiary prevention, including in “postvention” • Clinicians working with individuals, families, communities (including school and faith communities) • Community organizers working with geographic or demographic communities • Advocates working on educating individuals and communities • Research on all aspects of suicide • Program design, implementation and evaluation • Many social workers hold hybrid roles (clinician-researcher, clinician-advocate)

9. Comprehensive Approach to Suicide Prevention • Social workers of all types will work with people who are suicidal • Important to understand how to be effective on 1:1 level • Also important to contribute to systems change

10. Roles for SW: Identify and Assist Persons at Risk Warning Signs for Suicide Risk The following behaviors should prompt you to immediately call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or a mental health professional • Talking about wanting to die or to kill oneself • Looking for a way to kill oneself, e.g. searching online or obtaining a gun • Talking about feeling hopeless or having no reason to live

11. Warning Signs for Suicide Risk Other behaviors may also indicate serious risk—especially if the behavior is new; has increased; and/or seems related to a painful event, loss, or change. • Talking about feeling trapped or in unbearable pain • Talking about being a burden to others • Increasing use of alcohol or drugs • Acting anxious or agitated; behaving recklessly • Sleeping too little or too much • Withdrawing or feeling isolated • Showing rage or talking about seeking revenge • Displaying extreme mood swings

13. Roles for SW: Increase Help-seeking Social workers can play an important role by teaching people to recognize when they need support—and helping them to find it—thereby enabling them to reduce their suicide risk. • Self-help tools, such as apps designed to build resilience, can help people learn more about themselves and their moods, and can help in managing emotions • Outreach campaigns lower barriers to obtaining help by increasing knowledge about what services exist.

14. Increasing Help-seeking Other interventions might address social and structural environment by, for example, fostering peer norms that support help-seeking or making services more convenient and culturally appropriate Example: Man Therapy https://www.mantherapy.org/ Fostering peer norms and supporting help-seeking for working-aged men “It’s okay to cry, even when it’s not about sports.” “It’s a physical for your feelings, but you get to keep your pants on.” Using humor to make help-seeking more accessible and normative

15. “Man Therapy” Billboards

16. Roles for SW: Ensure Access to MH Care Key Element of Suicide Prevention: Timely access to evidence-based treatments, suicide prevention interventions, & coordinated systems of care Suicide prevention interventions, such as safety planning and evidence-based treatments and therapies, delivered by trained providers, can lead to significant improvement & recovery Reducing the many financial, cultural, and logistical barriers to care is another important strategy for ensuring access to effective mental health and suicide care treatment, and a role that social work can play

18. Roles for SW: Care Coordination, Linkage, Support Social workers can reduce suicide risk by ensuring individuals have uninterrupted transitions of care and by facilitating exchange of information among various individuals & care providers Individuals at risk for suicide and their support networks (e.g., families) must also be part of that communication process Tools and practices that support continuity of care include formal referral protocols, interagency agreements, cross-training, follow-up contacts, rapid referrals, and patient/family education

19. Importance of Care Management

20. Roles for SW: Effective Suicide Response • Individuals under severe emotional distress often need a range of services • A full continuum of care includes not only hotlines and helplines but also mobile crisis teams, walk-in crisis clinics, hospital-based psychiatric emergency services, and peer-support programs • Crisis services directly address suicide risk by providing evaluation, stabilization, and referrals to ongoing care

21. Roles for SW: Postvention Planning A postvention plan: set of protocols to help organization or community respond effectively and compassionately to a suicide death; immediate focus on supporting those affected by suicide death and reducing risk to other vulnerable individuals. Postvention efforts should also include intermediate and long-term supports for people bereaved by suicide

22. Roles for SW: Reducing Access to Lethal Means Public health has shown that reducing access to lethal means of self-harm is a key primary prevention death by suicide is to prevent individuals in suicidal crisis from obtaining and using lethal methods of self-harm. • Educating families about safe medications and firearms storage • Distributw gun safety locks • Changw medication packaging • Install barriers on bridges • Check out “Means Matter” • https://www.hsph.harvard.edu/means-matter/means-matter/

23. Roles for SW: Enhance Life Skills & Resilience Life Skills: Social workers help clients build life skills, such as critical thinking, stress management, & coping, important tools for preparing people to safely address economic stress, divorce, illness, and aging Resilience—the ability to cope with adversity & adapt to change—is a protective factor against suicide risk. While it overlaps with life skills, resilience encompasses additional attributes such as optimism, positive self-concept, and the ability to remain hopeful. Skills training, mobile apps, and self-help materials are examples of ways to increase life skills and build resilience.

24. Roles for SW: Promote Social Connectedness Supportive relationships and community connectedness help protect individuals against suicide, despite the presence of risk factors in their lives. Social workers can enhance connectedness through community and agency development of social programs for specific population groups (such as older adults or LGBT youth) and through other activities that reduce isolation, promote a sense of belonging, and foster emotionally supportive relationships.

25. Connectedness The Centers for Disease Control (CDC) defines connectedness as “the degree to which a person or group is socially close, interrelated, or shares resources with other persons or groups” (CDC, 2018) Connectedness can include: • Connectedness between individuals (e.g., friends, neighbors, co-workers) • Connectedness among family members • Connectedness to community organizations (e.g., schools, faith communities) • Connections between groups (e.g., ethnic groups) to cultural traditions & history

26. The Survivor Movement Suicide prevention began because people who had lost loved ones to suicide spoke out for two primary purposes: • To overcome stigma of speaking publicly about suicide loss and to guide others through loss • To advocate for postvention/aftercare and prevention (before there was suicide prevention science)

27. Supporting Survivor Advocates • Iris Bolton • “Of course, back then, if you think of 1977, nobody talked about this. But quietly, in church, people would whisper after we made it public, because rumors were going around and we thought, ‘No, we have to tell the truth.’” - Iris Bolton, created suicide survivor support groups after losing her son to suicide (American Foundation for Suicide Prevention)

28. Clinician/Survivor Movement • One in every five social workers will lose a client to suicide (NASW, 2015) • Long tradition of not talking about losing clients to suicide in mental health: fear of being seen as failure, liability concerns and stigmaNeeded a place and a way to grieve • More recently, clinicians have developed Clinician-Survivor Task Force Clinician-Survivor Task Force: Provides consultation, support and education to psychotherapists and other mental health professionals to assist them in understanding and responding to their personal/professional loss resulting from the suicide death of a patient/client and/or family member. http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm

29. Lived Experience Movement Lived Through This is a photograph and story collection of suicide attempt survivors https://livethroughthis.org/ SAMHSA focus on Suicide Attempt Survivors dedicated to elevating - not hiding - the stories of attempt survivors and looking at this population as key to better understanding suicide prevention. Sponsors Lived Experience Summit, bringing people with lived experience together with mental health providers - bridging the gap

30. How can PHSW improve SP practice? Social work can contribute to suicide prevention in variety of ways. • Support research on lived experience-related movements by contributing to evidence base of survivor & other lived experiences • Move beyond individual cases to demonstrate public healthapproaches (i.e., approaching suicide attempt survivors as population) • Continue to show social work specific impact by by publishing research demonstrating the impact of suicide prevention interventions at all levels (1:1; community; policy) • Exercise: Live Through This Discussion

31. Syntheses PHSW already sees “the person in the environment” by using public health and biopsychosocial approaches. Synthesis can happen through being the profession that can hold both the big picture and individual experiences. PHSWers can serve as • Coalition-builders • Conveners • Representing the “micro” and the “macro”

32. Widening the Lens by Using the PHSW Model Seeing populations of risk rather than just individuals • Using the PHSW approach enables social workers to design interventions that address needs of communities at risk, as well as individuals... • LGBT youth • Veterans • Native American youth • Who needs to be within the lens? • Mental health providers • People who can be cultural/communal brokers • People working on other prevention issues • Suicidologists and public health practitioners • All affected communities

33. Obstacles to Expanding SW’s Roles in SP Working in silos • We must work with others and across divisions Example: Opioid epidemic is connected to suicide prevention How can we work with those who are working on opioid overdose prevention to move the needle on overlapping risk factors? Funding in the current climate • Current political climate is less supportive of prevention • Funding cuts to SAMHSA, major Federal mental health agency and HRSA, workforce training agency, affect suicide education and prevention Use the Social Work in Health Impact Model to identify opportunities….

34. Visualizing SW Health Impact Social Work Health Impact Model (Ruth, Wachman, Marshall, Backman, Harrington, Schultz & Ouimet, 2017)

35. Using the Social Work Health Impact Model The SWHIM (Ruth et al. 2017) can help profession visualize methods for expanding its impact, even during challenging times. Ask yourself, “What other interventions could we do?” Keep in mind that the more we address SDOH, the greater the impact we will have on this major issue. • Clinical interventions: identify and assist via knowing warning signs; safety planning; evidence-based treatments; increasing life skills and resilience; mobile crisis teams; walk-in crisis clinics; hospital-based psychiatric emergency services; peer-support programs • Prevention and health promotion: increase help-seeking via outreach campaigns; increasing life skills and resilience; increasing connectedness; postvention • Influencing systems within the current context: fostering peer norms that support help-seeking; making services more convenient and culturally appropriate; reducing access to means; formal referral protocols and interagency agreements; • Addressing the social determinants of health: reducing financial, cultural, and logistical barriers to care Next: Practice using the exercise listed in the Notes

36. Examples & Exemplars

37. Examples and Exemplars Ken Norton, LICSW, ACSW Director, NAMI New Hampshire Created Connect, a program to train professionals and communities in suicide prevention and response, a model program for comprehensive suicide prevention http://www.theconnectprogram.org/

38. Examples and Exemplars Stacey Freedenthal, PhD, LCSW Author of Helping the Suicidal Person: Tips and Techniques for Professionals Maintains website of resources as a place for “individuals and their loved ones, survivors, mental health professionals, & the merely curious” https://www.speakingofsuicide.com/

39. Examples and Exemplars - Research Suicide prevention research by social workers: • Jodi Jacobson Frey : Social work researcher on role of workplace in preventing suicide (2018) • Sean Joe: Review of social work research literature on suicide prevention (2006) • Philip Osteen: Preparation of social work students for suicide prevention (2014) • Betty J. Ruth: Why social work education should include suicide prevention (2012)

40. Potential Future Expansion of PHSW in SP Focus on suicide risk and prevention among marginalized populations (i.e., older adults, LGBT communities, Native Americans) • Research • Evidence-based practice • Practice-based evidence What can we learn or do we know from social work practice that can inform the evidence? How can we promote our knowledge so that it becomes practice?

41. Potential Future Expansion: Research Areas of research need where SW can make a contribution: • Suicide attempt survivors • Clinician survivors • Postvention and community-level intervention/prevention • Educating the social work workforce for suicide prevention

42. Potential Future Expansion: Evidence-Based Practice and Practice-Based Research Social workers can be involved in teaching others what’s learned from practice, translating research into practice and testing intervention to determine what works: • Health social workers in emergency departments implementing a protocol across all patients and tracking data on outcomes (Wharff, Ross & Lambert, 2015) Social workers can share, through peer-reviewed journals or continuing education training seminars, practices that are working in specific communities or settings: • American Indian/Alaska Natives • Emergency Departments • Faith Communities

43. Conclusion Social work - particularly PHSW - has a critical role in SP Utilization of social epidemiology, a key component of PHSW practice, aids in recognizing and responding to current suicide trends Look for expanding opportunities to integrate PHSW models and skills that “widen the lens” for social work impact in SP Significant needs continue to exist in SP at the individual, family, community and societal level - these all influence population health

44. About the Author Elana Premack Sandler is Assistant Director of Field Education and Associate Professor of Practice at Simmons University. Elana approaches health issues from a social perspective, viewing elements of the social environment as crucial factors in promoting individual health and well-being. Elana worked with the national Suicide Prevention Resource Center, providing consultation to organizations on using evidence-based interventions and best practices for developing suicide prevention programs. She holds a Master of Social Work and a Master of Public Health from Boston University and writes a monthly blog for the journal, Psychology Today, entitled “Promoting Hope, Preventing Suicide.” You can read more of her work on this issue here: https://www.psychologytoday.com/us/blog/promoting-hope-preventing-suicide

45. Acknowledgements • The Advancing Leadership in Public Health Social Work Education project at Boston University School of Social Work (BUSSW-ALPS), was made possible by a cooperative agreement from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number G05HP31425. We wish to acknowledge our project officer, Miryam Gerdine, MPH. Thanks also to Sara S. Bachman, BUSSW Center for Innovation in Social Work and Health, and the Group for Public Health Social Work Initiatives • The ALPS Team: • Betty J. Ruth, Principal Investigator bjruth@bu.edu • Madi Wachman, Co-Principal Investigator madi@bu.edu • Alexis Marbach Co-Principal Investigator alexis_marbach@abtassoc.com • Nandini Choudhury, Research Assistant nschoud@bu.edu • Jamie Wyatt Marshall, Principal Consultant jamiewyatt1@gmail.com