Suicide Prevention And Valentine’s Day
Suicide is a community issue, not an individual one, — and we can solve it.
Trigger warning: This article is explicitly about death by suicide. Reader discretion is advised.
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Two Years Earlier
When the ambulance arrived, EMTs loaded Khel in the back and strapped her down to a gurney against her will. I swung my foot up inside the back to climb inside with her. The driver grabbed my arm and yanked me out.
“You can’t go back there with her!” he said. “You have no idea what she’s going to do in this state, you need to ride up front.” His eyes told me he was frightened.
“I’ve known her for seven years, she’s not going to hurt anyone.”
At the hospital, I followed her into an examination room. Her parents haven’t gotten there yet, and I’m worried how she will be treated. Her being misunderstood feels inevitable, despite how brilliant, kind, and gentle she is.
When the doctor arrives to perform an evaluation, he looks at me to ask who I am. I say I’m a longtime family friend, I came with her because her parents weren’t in the area yet. He tells me I have to leave. I look at my friend and say, “Do you want me to stay with you?” She nods yes. The doctor backs me out of the room with his hands on my shoulders.
“If you don’t leave, I’ll section you next.” In his eyes, I saw indignity and anger.
She was sectioned after being triggered by this interaction — an interaction that could have been avoided.
Two and a half years later, Khel died by suicide on February 14th, 2020 after an intrepid journey with schizophrenia, autism spectrum disorder, and a world unprepared to make room for her.
Her parents tell me stories of the social workers and program staff at her group home who affected her life positively; how they created space for inclusion and belonging in her life in all the ways they could. The end of her life was not the fault of any single individual — nor is any suicide. However, current prevention standards in our medical system are grossly insufficient.
Like the driver of the ambulance and the doctor at the hospital, the truth is our perception of suicide is so rooted in ideas of violence and liability that we don’t imagine the opportunity to create dialogue.
Reading Between the Lines
Despite an increased presence of suicide prevention programs, national rates of suicide are skyrocketing. According to the National Institute of Mental Health, $100 million was spent on suicide prevention research in 2017. Yet the rates continue an upward trend. The suicide rate has increased 35% since 1999.
Khel’s baseline — or standard temperament — actually mimics what traditional suicide prevention programs describe as “warning signs.” She was withdrawn and chronically depressed. Her final days were, in stark contrast, ones of relative peace and increased social interaction with her family; all things that, in hindsight, were warnings in part because they were out of the ordinary for her, but in the moment, they were positive signs of improvement.
What, then, do we say to the families left behind who are now dealing with guilt, who “missed” the signs?
There truly is no real universality to expressions of suicidality. More than that, the general public are not educated in deciphering the nuances between a baseline and an active risk for suicide. We’re given a general list of possible behaviors and expressions, but by the national evidence that suicide rates are rapidly rising, we know these lists are falling extremely short.
Missing the Mark
In terms of the problem with inpatient treatment as a response to suicidality, this study, a meta-analysis of 100 studies of 183 patient samples, says “the post-discharge suicide rate was approximately 100 times the global suicide rate during the first 3 months after discharge and patients admitted with suicidal thoughts or behaviors had rates near 200 times the global rate.” Even many years after discharge, previous psychiatric inpatients have suicide rates that are approximately 30 times higher than typical global rates.
What does this say about our psychiatric care model?
The Heart of the Problem
Another troubling reality of our current model of care is in lack of training. According to recent studies in the U.S., residency trainees, junior physicians and clinical psychology trainees report receiving little training or reading assignments on the assessment and management of suicidal behavior. On top of that, clinicians are directed to be uncomfortably straight forward in questioning a patient about suicide, relying heavily on self reporting. Now, I can tell you as someone who has lived through the medical system that folks who have these feelings or thoughts are pretty adept at self-preservation. In other words, you can count on many inaccurate responses to the suicidality question in clinical environments in order to avoid traumatic inpatient stays.
Suicide is a Community Issue
How can we put faith in people reaching out for help as an effective form of prevention, the be-all-end-all, if the system is punitive? How do we tell millions of people to “talk about suicide,” but reinforce a model that clearly hasn’t helped slow suicide rates and creates a culture of distrust for the field?
On a larger level, prevention programs are focusing on making resources known, but that doesn’t make them available. For people without health insurance, every level of mental health support is unavailable, from private sessions to inpatient care and medical treatment. As Dr. Amy Barnhorst puts it:
“Initiatives like crisis hotlines and anti-stigma campaigns focus on opening more portals into mental health services, but this is like cutting doorways into an empty building…Antidepressants can’t supply employment or affordable housing, repair relationships with family members or bring on sobriety.”
This all harkens back to your psychology 101 textbook, where you learned about Maslow’s hierarchy of needs.
While yes, anyone can experience depression and suicide ideation in many different classes, we know that those without food, shelter, medicine, rest, shelter, community, and safety, folks are more susceptible to drug and alcohol use and other forms of harmful coping. As always, we need to keep intersectionality as the lens through which we view the issue of suicidality. If lower-income folks are more at risk for not having their bottom-tier needs met and we do nothing, suicide rates will continue to increase.
Generational trauma, poverty, mental illness, and substance use are proven risk factors for future generations of vulnerable people. The more your identity is part of the underprivileged, the more at risk you are.
Where Do We Go From Here?
Prevention cannot just be money spent on a suicide hotline. Research and lived experience speaks to this idea of social determinants of health. SDOH, according the CDC, are factors of a person’s environment that positively or negatively affect their well-being; housing, healthcare, access to meaningful work, and social connections are all SDOH. By improving these conditions for people who are mentally ill or suicidal, we can make an impact on the rate of suicide.
An example of creating safe spaces could include groups like Alternatives to Suicide, where folks can truly normalize their experience with ideation. We can go a step further in supporting folks in crisis by reaching out to teams like Boston Emergency Services (BEST) to perform mental health evals as an alternative to calling 911. Alternatives such as these all offer a chance to subvert possible traumas from an ill-equipped medical model. I personally can speak to the efficacy of BEST, as in my previous work with nonprofit psychiatric rehab, we relied on them often as a non-invasive form of intervention, and I saw great success with them.
In processing Khel’s death, I took a ride on the merry-go-round of “I could have done more, I was the most equipped,” and all the other visceral parts of processing death by suicide; the parts where you obsess over your own mortality. I also had to take inventory of my way of being in this world. The ways I belong, the ways I do not, the ways I make others feel, and what I do to cultivate a world where others want to stay here — and, especially as someone in recovery, a world where I want to stay here. Part of what makes this approach so challenging, especially in 2020, are the never ending political hurdles one must clear in the journey to reform, or in this case, a complete overall of the system. It is an overwhelming task.
As September is Suicide Prevention Month, ask yourself: To what capacity can I change someone’s perception of their life here on this Earth with me?
Dedicated to Khel McGeehan, August 17th, 1994 — February 14th, 2020
“To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment…it is not the length of life, but the depth” -Ralph Waldo Emerson
