How about Our Rural Neighbor’s Mental Health?

Those of us who live and work in cities often forget there is a whole other way of living alongside our own metropolitan or suburban way of life: A large part of the US is still rural. According to US census bureau director John H Thompson, rural areas cover 97% of our land area and contain 20 percent of our people (60 million people).

Rural America is facing a health crisis.  Although the prevalence of mental illness is similar between rural and urban residents, rates of suicide are not.  Suicide rates (Reference – See chart attached) have been growing in the US as a whole since 2000; increasing by nearly 30 percent for both adults and children. That alone is cause for concern.  But the suicide rate in rural areas has increased by more than 40 percent in the same period.  Data from:  Trends in Suicide by level of Urbanization – United States, 1999 – 2015

Growing up in the country and on a farm in the 50’s and 60’s gave me some firsthand appreciation of rural health concerns, including mental health. My father became ill with was what then called a “nervous breakdown”. It was something shameful and no one talked it. It was all a personal failing.  Besides, the work never stops, how could one take “time off” to recover lost mental health?

I think about this issue every time I drive on our nearest rural county highway. I wonder about the health of my rural neighbors. Most of the farms are family farms and their appearance suggests times are tough.

A report entitled The Stigma of Mental Illness in Small Towns notes another of the barriers contributing to the rise in rural mental health problems is that many residents believe that that “I should not need help.”  Or simply don’t know where to go for assistance. Many times there is no mental health professional near and it is a significant burden of time and distance to travel for help.   

A study published in the journal JAMA Pediatrics in 2015 analyzed data on US youth suicide rates from 1996 to 2010. It found that the rates of suicides for rural Americans aged 10 to 24 was almost double the rate compared to their urban counterparts. This was attributed to social isolation, greater availability of guns and difficulty accessing healthcare

It seems that the stigma – that mental illness is shameful – may be felt more acutely in small rural communities. And there is a lack of anonymity there.

Again from The Stigma of Mental Illness in Small Towns:
“We as a society have a hard time asking for help, so it’s hard enough to ask for help without feeling that everybody’s going to know it,”……”Your neighbors don’t have a clue in a city if you’re to get some help. But everybody in a small town will know if your pick-up is parked outside the mental health provider’s office.”(same reference; quote by Dennis Mohatt, VP of the behavioral health at Western Interstate Commission for Higher Education (WICHE) and director of the WICHE Center for Rural Mental Health Research.

The upshot is that rural citizens with mental health needs enter care later in the course of their disease than do their urban peers; enter care with more serious, persistent and disabling symptoms and require more expensive and intensive treatment response.

A policy brief by the National Rural Health Association, The Future of Rural Behavioral Health, February, 2015, makes the case that rural needs can be met by behavioral health reforms addressing the availability, accessibility, affordability and acceptability of services. (new reference). “ Three-fourths of counties with populations of 2,500 to 20,000 lack a psychiatrist and  95 percent lack a child psychiatrist.” Primarily due to this shortage of mental health professionals, primary care caregivers provide a large proportion of mental health care in rural America and may lack the training and experience to handle serious mental health issues.

What would help the situation?

  • Increased emphasis on rural practice during professional training
  • Rural community residents, such as school counselors and members of the clergy, should receive educational material and information from Medicare, Medicaid, and private insurance companies concerning available resources for mental health issues.
  • Programs like Mental Health First Aid (MHA) may be useful in providing basic training to providers and other community resource people and reducing the stigma in the community.
  • Paraprofessionals and emerging professions can also augment the mental health workforce. One example is the emerging field of Peer Support Specialists. Peer Support Specialists themselves have personal experiences with mental illness and can offer invaluable perspective to patients in acute care settings.

And we all need to be more supportive of our rural neighbors.


I’d like to give you a feel for the burden of suicide in Wisconsin: A joint report released in 2014 (the most current data I have) says that, on average, 724 valued and treasured individuals in Wisconsin take their own life each year.

What do we know about these individuals as a group?

Four out of five persons who died by suicide were male.

For every person who died by suicide there were eleven hospitalizations or emergency visits for self-inflicted injury.  And approximately three out of five patients hospitalized for self-inflicted injury were female.

Taken together, one estimates 8,000 people attempt suicide every year in Wisconsin.  724 die.

Firearms were the most frequent means of suicide.  And Means Matter:  Men use firearms more often than women, and attempts with guns are more likely to result in death than those in which other means are utilized.

Death from a suicide attempt was highest among individuals aged 45-54.

Veterans accounted for one out of five suicides in Wisconsin.

Teens and young adults are more likely to be seen or hospitalized for self-inflicted injuries than any other age group.

Among suicides with known circumstances, fifty percent had a current mental health problem and approximately forty-five percent were currently receiving mental health treatment. Where toxicology testing was performed, 37% tested positive for alcohol and 20% tested positive for opiates.  Of the known life stressors, intimate partner problems, physical health and job problems were most often reported. Significantly, 35% disclosed their intent to die by suicide to at least one person.

724 deaths by suicide in Wisconsin.  Each year.

And yet, as the Harvard School of Public Health reports, 90% who survive their attempted suicide do not go on to die by suicide later.  This is a terribly important fact.  Help is possible.  Those who attempt suicide, much more often than not, do not go on to die by suicide later.

How can we offer help to someone contemplating suicide?

The good news: Everyone can play a role in protecting their friends, family members and colleagues from suicide. However, as a national poll found, 50% of American respondents found obstacles and barriers that stopped them from trying to help someone at risk for suicide. Two barriers were commonly raised: Many feared that something they would say or do would make things worse rather than better. And many, understandably, simply did not know how to find help for a person feeling suicidal.

  • Most suicidal individuals want to live; they are just unable to see alternatives to their deep struggles and setbacks.
  • Most individuals give definite warnings of the suicidal intentions.
  • Talking about suicide does not cause someone to be suicidal.
  • Surviving family members not only suffer the trauma of losing a loves one to suicide, they may themselves be at higher risk for suicide and emotional problems.

Let’s look at what we as individuals can do to help.

  • Hopelessness
  • Rage, uncontrolled anger, seeking revenge
  • Acting reckless or engaging in risky activities, seemingly without thinking
  • Feeling trapped-like there’s no way out
  • Increased alcohol or drug use
  • Withdrawing from friends, family and society
  • Anxiety, agitation, unable to sleep or sleeping all the time
  • Dramatic mood changes
  • No reason for living, no sense of purpose in life
  • Be available. Show the person interest and support.
  • Ask if he/she is thinking about suicide.
  • It’s ok to be direct: Talk openly and freely about suicide.
  • Be willing to listen. Allow for the expression of feelings, and accept them.
  • Be non-judgmental. Don’t debate whether suicide is right or wrong, or if one’s feelings are good or bad. Don’t lecture on the value of life.
  • Don’t dare him/her to do it.
  • Don’t ask ‘why’. This encourages defensiveness.
  • Offer empathy, not sympathy.
  • Don’t act shocked. This creates distance.
  • Don’t be sworn to secrecy. Seek support.
  • Offer hope that alternatives are available, do not offer glib reassurance; it only proves you don’t understand.
  • Take action: Remove means!
  • Get help from individuals or agencies specializing in crisis intervention and suicide prevention. The National Suicide Prevention Lifeline (phone:   text:) is a good place to start.

I was very fortunate when I was suicidal long ago. My husband enacted a good many of these helpful responses to me. He and we talked openly and freely about suicide. I did express some of my feelings about being suicidal and he accepted those feelings. Also important, I was offered empathy and most of all, I was offered hope. Hope offered when I had no hope. What a gift!

Lies your depression tells you when you are suicidal

He was middle aged and in the prime of life when he killed himself. He had family and children. A prestigious appointment at a respected University – and he had received several awards for his research. Wholesome looking and in good shape, he seemed to have had everything to live for. Do you know what? That’s right; he did have many things to live for, including a promising future.

Yet he went out of town for the weekend, quietly rented a motel room and died there by his own hand.

We all ask why. It seemed like the man had the world by a string. Why does anyone commit suicide?

It doesn’t make sense, does it? No it doesn’t and yet people take their lives every day. WHY?

Nearly always there is an intractable depression pushing the person into despair. Depression lies, and its false thoughts and lies are utterly convincing. Yet to the depressed person these thoughts feel completely real and desperately true. In my experience they are intense, persistent, and severely painful.  The person becomes overwhelmed by their depression’s lies.

I’d like to share insights from Amanda Redhead, Mother, Nurse, Writer, and Warrior from her Huffington Post blog entry of Sept 9, 2016:  Five Lies Your Depression Tells You When You Are Suicidal.

Here are five lies that depression imbeds in the head of a sufferer:


One: Your life is already over. You have screwed up beyond repair.

Wonderfully, there is no such thing as a life ‘beyond repair.’  Amanda writes “You may have messed up so royally that you believe that no one will ever forgive you. But there is life beyond this pain and there is life beyond whatever mistakes you have made.”

Two: Your loved ones are better off without you.

This empty lie is probably the biggest of them all.  Far from removing their pain, suicide only creates an emptiness in your loved one’s hearts. That hole remains. Your loved ones find only sadness and the pain of losing you. “You may be feeling like a failure right now but I cannot imagine a greater mistake than having your last act on earth be one that causes intense pain for each and every person you love.”

Three: The pain will never end.

It feels like a pain that will never end.  I remember looking for just a brief reprieve.  Silently I bargained for relief in minute increments. The pain of depression felt very catastrophic and chaotic to me. I couldn’t believe that the rest of the world would or could go on functioning with my pain in it.  A moment in this pain feels like a year.

But there IS an end to the pain, unlikely as it seems now. As Amanda said, “I cannot tell you when that end will happen, but I can tell you that the end is somewhere.” You may have to work for it, your may have to get help or take medication or reach out when you want to stay silent, but the end of the pain is out there on the  horizon.

Four: You are not worthy of life or love.

Another big lie. This lie and others like it are invasive and seem so accurate. Everyone is worthy of love, no matter the mistakes they have committed. Everyone is worth living! You are only seeing the negative things about yourself right now. Remember depression colors your thoughts. You are a valuable human being and deserve to be alive and loved.

Five:   …You must keep your thoughts about harming yourself quiet.

#5 is the ultimate lie: Yes, your depression wants you to stay silent. Depression wants you to take your life. There is great shame around depression, anxiety and suicidality.  When we talk about the depression, we erase some of that shame and stigma.

Please believe me: There is no need to suffer in silence.

Pick up the phone and call one person and tell them what you’re struggling with. This may be the hardest thing you will ever do, but it gives life – your life – another chance.

Here I must add a word of hope:

Yes, depression distorts the depressed person’s thoughts. And depression’s thoughts can be deadly.  The five lies illustrate various cognitive distortions.  And forms of cognitive therapy can assist depression suffers to learn to recognize and combat false and irrational thought patterns – depression’s lies. Today recognizing and analyzing distorted thoughts that feed depression is called cognitive behavior therapy (CBT). There is a promise of hope for recovery.

Psychiatrist Dr Aaron T. Beck laid the groundwork for the study of these distortions. His student, David D Burns, MD, continued research on the topic. Dr Burns’ book, Feeling Good: The New Mood Therapy, was first given to me in the mid-eighties by my psychiatrist. I glanced at it and rejected it, thinking that my doctor was telling me I should learn ‘positive thinking.’ I knew depression was a disease more serious than superficially thinking right. But in the 1990’s I was able to accept the book and its premises. Soon I underwent a group therapy session during which some of the basics of CBT were taught. I was able to learn those basic principles and asked for a therapist to do CBT regularly with me.  The short of the story is that I did find a therapist, who had a PhD in psychology and had done significant graduate work specifically with CBT. He was willing to take me on weekly for several months.  Cognitive Behavioral Therapy became one of the essential pillars undergirding my recovery from suicidal depression.

Depression now sometimes gets a grip on me. But with medication that works for me, with the practice of cognitive behavioral therapy, with a supportive family, and with a doctor’s ongoing psychiatric care I no longer develop full-blown depressions. Depression occasionally gets a start, but CBT’s corrective is powerful, and negative thinking doesn’t get a hold on me for long.

Thanks for reading,
Gail Louise

Suicide is frightening to talk about… Part 1

What might we experience as a Suicide Survivor? _________________________________

(This, the first in a series of postings on suicide issues, is based on a very real need for me and my family to know how to support people experiencing the death of a loved one by suicide.

The people left behind when suicide has occurred face not only grief, but a complicated grief, full of many questions and challenges.  We who are left behind are often referred to as suicide survivors…..)

Most of us have experienced the death of a loved one. And we can appreciate that the grief that follows is always difficult, even though it is an instinctual and helpful reaction. Suicide survivors too, are left with grief and feelings of loss, sadness, and loneliness after the death of a loved one. Yet these are often magnified by feelings of guilt, confusion, rejection, shame, anger, and the effects of social stigma and personal trauma.

As suicide survivors we are plagued by the need to make sense of the death and to understand why suicide appeared to our loved one as their only option. We may overestimate our responsibility, as well as guilt for not being able to prevent the tragic outcome. Survivors may replay events up to the last moments of their loved ones’ lives, looking for clues and warnings that they blame themselves for not noticing or taking seriously.

We might recall past disagreements or arguments, plans not fulfilled, calls not returned, words not said, and ruminate how if only we had done or said something differently, perhaps the outcome would have been different. If it is easy for we who are suicide survivors to get caught up in self-blame, it may help to understand that many (most) people who complete suicide were struggling against mental illness when they died.

Suicide survivors sometimes feel rejected or abandoned by the death. Survivors may see the deceased as choosing to give up and leaving their loved ones behind.   Also survivors can feel bewildered, wondering why the relationship they had with the person was not enough to keep them alive.

Anger is a common response: Directed at the person who died, or at themselves, or perhaps at other family members, at professionals, at God or the world in general. “Why did my loved one not seek help or feel our love and concern?”

Suicide is stigmatized. The bereaved may find it difficult to talk to others about their loss because others often feel uncomfortable discussing a death by suicide. This can leave the family/friends feeling isolated. For all of us, talking about a loved one’s death is vital for our recovery. Stigma concerning suicide poses an unwelcome barrier to the healing process.

Finally, survivors of suicide find themselves at a higher risk for suicidal thoughts and behavior than are other bereaved individuals (Dialogues in Clinical Neuroscience, Vol 14, No. 2, 2012).

Suicide is frightening to talk about… Part 2

What can we do to help support suicide survivors? ___________________________________

Individual counseling and suicide support groups can be particularly helpful. While there are many grief support groups, grief support focused specifically on suicide appears to be much more valuable for suicide survivors.

As Dialogues in Clinical Neuroscience, Vol 14, No. 2, 2012 reports, “For many friends and family of a suicide victim, participation in support groups is felt to be their only access to people whom they feel can understand them, or the only place where their feelings are acceptable.”

As the support group talks together, we who are suicide survivors may obtain assurance that we are not alone in our feelings. Others, we find, have faced similar experiences and have survived not only intact but often able to better bear their grief. The bonds that form among participants can be very strong as they offer each other mutual support. Also there is practical advice for such real-life obligations as dealing with legal issues, talking to others (including one’s children), developing fitting memorials for the deceased, coping with holidays and special events, and setting realistic goals including care for one’s self.

Successful suicide support groups share the characteristics of other successful groups:  They provide accurate information, give permission to grieve, help normalize emotional and behavioral episodes that are out of keeping from one’s usual personality and deportment.  Most importantly, successful groups convey to survivors that they are not alone.

Please note, a support group may be especially effective for children who have lost a parent or family member by suicide.

Support groups can be found on Web sites of such groups as the American Foundation for Suicide Prevention (AFSP) and the American Association of Suicidology (AAS) which host directories for hundreds of suicide support groups in the United States.

Suicide is frightening to talk about… Part 3

Here are some tips for supporting a grieving suicide Survivor


*Accept and acknowledge all feelings

(Let the grieving person know that it is ok to get angry; to break down. It is ok to cry.  Grief is emotion, so we suicide survivors need to feel free to express our feelings without fear of judgment, criticism or argument.)

*Be willing to sit in silence.

(It is a true comfort to a survivor to simply be in your company. Offer eye contact, a squeeze of the hand or a reassuring hug.)

*Let the bereaved talk about how their loved one died.

(Those grieving may need to tell their story over and over, sometimes in painful detail. Repeating the story is a way of processing and acceptance. Pain lessens with each retelling.)

*Offer comfort without minimizing the loss.

(Again, the emphasis is on listening and asking the other to tell you how they’re feeling. Avoid hollow reassurance.)


Just as we might in the aftermath of any death, we may offer to –

  • Shop for groceries or run errands
  • Drop off a casserole or other food
  • Stay to take phone calls or receive guests
  • Help with insurance forms or bills
  • Help with housework like cleaning or laundry
  • Watch their children or pick them up from school
  • Drive them wherever he or she needs to go
  • Go with them to a support group meeting
  • Accompany them on a walk, lunch, or movie


* Our ongoing support may be more important at this time than ever.

(Stay in touch with the grieving person, periodically checking in, dropping by, or sending letters or cards.)

(Don’t make assumptions based on outward appearance; some may be struggling on the inside.)

*Avoid saying things like “You are so strong” or “You look so well”.  Also avoid comments like “He/She is in a better place now.” Or “This is behind you now; it’s time to get on with your life.”

(These comments are well intended, but put pressure on the survivor to keep up appearances and to hide true feelings.)

*The pain of this loss may never fully heal.

(Life may never be or feel the same. You don’t get over the death of a loved one. The suicide survivor may learn to accept the loss. Pain may lessen but sadness may never completely go away.)

*Offer extra support on special days.

(Holidays, family milestones, birthdays and anniversaries often reawaken grief. Be sensitive on these occasions. Let the person know you are there for whatever they need.)


*It is common for a suicide survivor to feel depressed.  Or to feel confused and disconnected from others, or that they are going crazy.

(If the bereaved symptoms don’t gradually fade —or they get worse with time- this may be a sign that the grief has become a more serious problem, such as clinical depression.)

*Encourage suicide survivor’s to seek professional help if any of the following warning signs are observed after the initial grieving period:

  • Difficultly functioning in daily life
  • Extreme focus on the death
  • Excessive bitterness, anger or guilt
  • Neglecting personal hygiene
  • Alcohol or drug abuse
  • Inability to enjoy life
  • Hallucinations
  • Withdrawing from others
  • Constant feelings of hopelessness
  • Talking about dying or suicide


*Families often feel stigmatized and cut off after a suicide.

*From the Harvard Women’s Health Watch, July 2009, Left Behind After Suicide:

“If you avoid contact because you don’t know what to say or do, family members may feel blamed and isolated. Ignore your doubts and make contact. Survivors learn to forgive awkward behaviors or clumsy statements, as long as your support and compassion are evident.”

Grief works at its own pace.

Three Key Messages

Suicide is the tenth leading cause of death in our country. Unlike many of the leading causes of death, the suicide rate has shown no appreciable decline over the last 50 years. [see the footnote at the end of this post]That this should be so, losing so many people to this mental illness outcome, is a tragedy. It is also a tragedy we can do something about.

Over 41,000 people in America died by suicide in 2013….

Recently reforms have been recommended in suicide planning and care. The new recommendations, which I will comment on in this post, are found in three documents.

  • The Way Forward (2014 pdf).  Released by the Suicide Attempt Survivor Task Force of the National Alliance for Suicide Prevention.
  • Suicide Care in Systems Framework (2012 pdf).  Report by the Clinical Care and Intervention Task Force of the National Alliance for Suicide Prevention.
  • Continuity of care for suicide prevention and research (2011 pdf).  A report commissioned by the Suicide Prevention Resource Center.

Download links to each of these reports, and much else, can be found here on my website.

What am I asking us to do?  TO INFORM OURSELVES about the reforms these reports recommend in suicide prevention planning and care! TO BRING THE NEW RECOMMENDATIONS to our local institutions, mental health organizations, doctors, therapists as well as to our families and to our loved ones with a mental illness!

In my opinion, these three are the most significant and far reaching of the recommendations:

 1.    Add suicide loss survivors and suicide attempters to the committees or task forces appointed to develop prevention efforts. Representation is an essential and important first step in suicide prevention (The Way Forward, 2014).  We can learn from suicide loss survivors and attempt survivors both what was and what wasn’t helpful and, importantly, what was missing in preventing suicide – and solicit their suggestions for improvement.

2.    Here is the second essential change: As with people who experience a stroke or heart attack, all persons in suicidal crisis should have immediate access to care – effective treatment and support services must be available to persons in crisis, how and when they need them (Suicide Care in Systems Framework, 2012). This report details a successful example of a large organization providing immediate access to care: The Henry Ford Health System restructured its behavioral health care system with the goal of Perfect Depression Care, and now offers same-day-drop-in-care for persons in crisis.

3.    Especially, we need an infrastructure for continuity of care.The third document, (Continuity of Care for Suicide Prevention and Research, 2011) focuses on the care provided after discharge from emergency and in-patient stays, noting: “As many as 70 % of suicide attempter of all ages will never make it to their first out-patient appointment. The report continues: “[Although] patient attributes such as having few skills, minimal resources, socioeconomic distress make it hard to engage them in out-patient treatment … organizational attributes can be altered.”   “Continuity of care and coordination of care require the support of cohesive health services infrastructures rather than numerous disconnected facilities and care provision arrangements.”

Organized, accountable, actionable continuity of care is essential.

The Task Force responsible for our second report (Suicide Care in Systems Framework, 2012) believes that making suicide a never event must be the nation’s vision. “Public and behavioral health organizations save countless lives every day. By creating an organizational culture where suicide attempts and deaths are unacceptable events, and managing a care environment around that cultural shift, even more lives can be saved.”

A powerful statement.  Won’t you, along with me, be participants in advocating these reforms and that vision?


Re “…the tenth leading cause of death” see Targeting Suicide by Thomas Insel, M.D., Director of the National Institutes of Mental Health, April 2, 2015.  “Indeed,” Dr Insel notes, “the rate among middle-aged Americans is increasing, and for young people ages 15-34, it is not the tenth, but the second leading cause of death.”

In contrast with suicide, whose rates have not declined, mortality from other medical causes such as stroke, AIDS, heart disease, has declined significantly.  Clearly our suicide prevention efforts have not been effective enough nor engaged enough people to change this rate.

Suicide: It’s not inevitable

Could we say ….
that even one death resulting from a suicide is acceptable in mental illness? Clearly, we wouldn’t want that one person to be OUR relative, neighbor, friend, right?  That one person can’t be anyone’s relative, neighbor or friend. So zero deaths by suicide should be our goal.

Are you a clinician dissatisfied with the suicide prevention approach used at your center? Or perhaps are you a survivor concerned that suicidal feeling will recur and you question who or what is going to truly help you??? Or maybe you’re someone whose relative attempted suicide last year and was found in time, and you’re hunting for a more proactive and effective suicide prevention program but unsure where to turn?

I have an approach that I’d like you to consider for your clients, or for yourself or for your loved ones: I recommend the Zero Suicide ( program.  Zero Suicide, an approach and program developed for the health care system, views suicide deaths as a preventable outcome and insists that the goal of zero suicides among persons receiving care is a goal that system can and should accept!

Zero Suicide, a project of the Suicide Prevention Resource Center (SPRC), grew from work done by the National Action Alliance on Suicide Prevention (NAASP). It is a specific set of tools and strategies. It is a concept, a practice, and a goal.

NAASP views suicide as preventable and the goal of zero suicides as a goal we should all aspire to accomplish. The word ALL is significant. This initiative requires the engagement of suicide attempt survivors, family members, policymakers, and researchers, and the clinic or hospital. The effort seen by the NAASP and Zero Suicide is a community endeavor—an effort including but beyond health care providers and clinicians.  Beyond heroic efforts of individual practitioners.

Where did this Zero Suicide program come from? The approach builds on work done in several health care organizations, including the Henry Ford Health System (HFHS) in Michigan.  The Henry Ford Health System had already applied a rigorous quality improvement process to problems such as inpatient falls and medication errors. They also realized that mental and behavioral health care could be similarly improved … an individual involved with the quality improvement group challenged the team:  “Why don’t we adopt zero suicide as our improvement goal?” As a result HFHS developed the Perfect Depression Care model, a comprehensive approach that included suicide prevention as an explicit goal. Both best and promising practices in quality improvement and evidence-based care are applied in their model and they have had wonderful, life-affirming results—-an 80% reduction in the suicide rate among health plan members.

NAASP’s Clinical Care and Intervention Task Force then identified essential elements of suicide prevention for health care systems having a defined population of individuals with mental illness. The Zero Suicide approach is created around these essential elements.

Here’s what I like about their approach:

Zero Suicide asks for a change in culture with firm leadership buy-in. The workforce – this includes both clinical and non-clinical staff – is to be trained using the Zero Suicide Toolkit.  The cultural milieu is to foster a caring, non-judgmental workforce.  Considerate and compassionate caring has sometimes been absent when the person being cared for has attempted or considered suicide (c.f. The Way Forward report).  Suicide risk among people receiving care is identified and assessed systematically. Every person has a suicide care management plan, or pathway to care, that is timely and adequate to meet their needs.  Finally, I’m very encouraged that this planning includes collaborative safety planning and restriction of lethal means.

It is also vital that treatment address the person’s suicidality. The patient’s own suicide planning needs to be discussed in detail and taken apart and turned into a scenario where the person is once again safe. Contact and support for the suicidal person, especially when in transition between emergency room and home or inpatient care and home, must be continuous. Many suicides occur after discharge from the hospital or emergency room (c.f. The Way Forward and Continuity of Care for Suicide Prevention reports).  Deaths that occur after discharge aren’t inevitable; they can be tackled by better transition and discharge planning with greater attention to detail.

Fellow advocates, we can do better.  Zero Suicide’s program can help.

Eight Core Values

Writing again about new thinking emerging on suicide prevention – The Way Forward: Pathways to Hope, Recovery, and Wellness with Insights from the Lived Experience, 2014 .

There are eight core values The Way Forward’s Task Force agreed should be behind all activities designed to help attempt survivors, or anyone who has been suicidal:

  • Foster hope; help people find meaning and purpose in life
  • Preserve dignity; counter stigma, shame, and discrimination
  • Connect people to peer supports
  • Promote community connectedness
  • Engage and support family and friends
  • Respect and support cultural, ethnic, and/or spiritual beliefs and traditions
  • Promote choice and collaboration in care
  • Provide timely access to care and support

I deeply agree with these core values.

Fostering hope is the very first item. It must be so: Help finding hope can be a comfort, for even small hopes are so valuable. Let’s embrace interactions with the suicidal person that boasts their dignity, for chances are they have only a fragile self-respect — but all of us cling to our dignity. Connecting to peer support can be helpful; working with someone who has been there, knows what is what, someone who can be empathetic and a role model to boot. This is both wise and practical. Connecting to the community brings belonging, meaning and purpose from the community into the self. Thus respect and support for cultural, ethnic and/or spiritual beliefs is a fundamental good within human interaction. Promote choice and collaboration! Don’t we all need to have a say in our care, no matter the circumstance? Choice and collaboration gives us some respect and some feeling of effectiveness in our own care. Timely access to care. Indeed, when people have strokes or symptoms of heart attack, they expect fast, efficient life-saving care. The systems to provide that care exist in every little hamlet and metropolis. Surely we can create a system that continues care through and after a suicidal crisis, care that is intensive, smooth, protective and effective.


“For many years, suicide prevention has not engaged the perspectives of those who have lived through suicidal experiences,” declares The Way Forward.

Let me finish with a word about the two leaders behind this initiative.  They are, respectively, a survivor of suicide attempts and mental health advocate and, the other, a psychologist with years of experience working with people in suicidal crisis:  Eduardo Vega, MA, Executive Director, Mental Health Association of San Francisco and John Draper, PhD, Project Director, National Suicide Prevention Lifeline.

It is the hope of the Task Force and it’s co-leaders that The Way Forward will help bridge conversation about suicide prevention between mental health policy makers and consumer advocates. As a stimulating and thoughtful resource, it “…may enable these two powerful forces for change to come together and develop new, more effective approaches to reducing suicide attempts and deaths”.

Communities in Action to Prevent Suicide, part IV

Dr. Whiteside, concluding her keynote address to the Communities in Action to Prevent Suicide conference, April 2015, asked us to visit the websites below for a look at what suicide attempt survivors have to say for themselves.  Their words offer important insights. is a wonderful and compelling collection of portraits each linked to a suicide attempt survivor story, as told by those survivors. LiveThroughThis shows through these remarkable stories that everyone is susceptible to depression and suicidal thoughts. It does this simply by showing portraits and stories of attempt survivors — profoundly sharing that they are people no different than you or I.

As the website’s author Dese’Rae L. Stage writes, “…these feelings could affect your mom, your partner, or your brother, and the fear of talking about it can be a killer.”

The second website  is a now-completed project of the American Association of Suicidology. This site also features attempt survivors who have spoken up and told their stories. This website’s editor taught me a valuable lesson also. She wrote that people continually ask survivors about suicidal thoughts and actions, saying “Why would you want to do that to yourself?” As she noted, this question represents a shocking and a fundamental misunderstanding. You see, as when inquiring about any potentially fatal health issue the question needs only be, “Why is this happening to people we love?”

Do you see the stark difference between these two questions? The first, intentionally or not, is accusatory and focuses on blaming the suicidal person. The second question reflects concern for the person and asks why it is that this has happened to this individual, without seeing the act as a personal fault — and in truth, suicide is usually the result of a mental illness process.

Thank you for reading and for hearing and listening to them.