Are You Feeling Suicidal?
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Description
Season 2 Finale! We started this season on a bridge but told you not to get caught up in the romantic notion of saviors and last minute interventions. Suicide isn’t about one moment in time. But if you or someone you love is suicidal, a single moment can be the difference between life and death. So, this week we’re doing a toolkit episode all about crisis response. What do you do when help is needed right now? This week, we role play with a suicide hotline employee, give the Cliff’s notes version of QPR suicide prevention training, and hear about what happens when therapists go on strike.
This episode features a host of talented people, including Tara Consolino (director of suicide prevention and substance abuse, Detroit V.A.), Dr. Julie Goldstein Grumet (director, Zero Suicide Institute), Dr. John Draper (executive director, National Suicide Prevention Lifeline), Susan Whitney (licensed marriage and family therapist, Kaiser), Sal Rosselli (president and co-founder, National Union of Healthcare Workers), and Matt Zils (child clinical psychologist, Kaiser).
Resources from the episode:
- Read up on QPR from the QPR Institute and the Suicide Prevention Resource Center
- Zero Suicide Institute, their general toolkit, and population-specific toolkits
- National Suicide Prevention Lifeline
- Lifeline’s 5 Steps to Help Someone in Crisis #Bethe1To
- NUHW Kaiser Don’t Deny campaign webpage
- NUHW Care Delayed, Care Denied white paper
- Learn more about SB 855 via CapRadio
If you or someone you know is struggling emotionally or feeling hopeless, it’s important to talk to someone about it now. Contact one of the resources below for a free, confidential conversation with a trained counselor anytime.
National Suicide Prevention Lifeline: 1-800-273-8255
Crisis Text line: Text “Connect” to 741-741
The Trevor Project: 1-866-488-7386
Season 2 of Last Day is created in partnership with The Jed Foundation. The Jed Foundation (JED) empowers teens and young adults with the skills and support to grow into healthy, thriving adults. You can find tips, tools and resources for taking care of your emotional health available at: www.jedcares.org/lastday
To follow along with a transcript and/or take notes for friends and family, go to https://lemonadamedia.com/show/last-day shortly after the air date.
Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia.
Click this link for a list of current sponsors and discount codes for this show and all Lemonada shows.
Transcript
SPEAKERS
Kaiser Ad, Becca, Stephanie Wittels Wachs, Dr. Julie Goldstein Grumet, Tara Consolino, Susan Whitney, Matt Zils, Dr. John Draper, Sal Rosselli
Becca 00:06
(phone ringing) Hi, who am I speaking with?
Stephanie Wittels Wachs
I’m Stephanie.
Becca
Hi, Stephanie. Are you feeling suicidal today?
Stephanie Wittels Wachs
Yes.
Becca
Okay. All right. I’m really, really glad that you called and reached out. The best thing you could possibly do. And I have a lot of questions for you. We’re going to talk about..
Stephanie Wittels Wachs
For a while now, I’ve wanted to call a suicide crisis hotline, because everyone knows we have to include the number for the crisis hotline anytime you talk about suicide. But for something that I’ve copied and pasted countless times, I don’t actually know that much about it. I mean, I’m not a monster I know not to call the crisis hotline without a crisis. But as luck would have it, we got an email from a listener, let’s call her Becca, who works at a call center, she agreed to do a little roleplay with me.
Becca
So, I want to talk to you about your suicidal feelings. Can you give me a sense on a scale of one to five? One is having thoughts, and five is I’m going to do something to kill myself in the next 24 hours. Where are you on that scale?
Stephanie Wittels Wachs
I think I’m at like a three or four.
Becca
Okay, good. I’m really glad you called. Anytime you’re over three, you want to be sure to reach out and talk to somebody.
Stephanie Wittels Wachs
We started this season on a bridge. But we told you, not to get caught up in the romantic idea of saviors and last-minute interventions. Because suicide isn’t about one moment, there’s usually not one thing that makes someone want to die. And there’s not one thing that convinces them to live.
Stephanie Wittels Wachs
But today, for the final episode of the season, it’s time to look at the moment of crisis. What happens, when help is needed right now. We’ll look at it from the point of view of the person in crisis, the people around them, and the health care workers who step up to provide care. And in every case, it means leaning into the shit that makes us uncomfortable. So we’re taking a page from the crisis hotline playbook.
Becca 02:18
When we ask difficult questions and you give squirly answers, we’re not going to let it go at that. Our job is to meet you where you’re at, to go into the dark. We’re going to go for the pain.
Stephanie Wittels Wachs
I’m Stephanie Wittels Wachs, and this is LAST DAY.
Stephanie Wittels Wachs
Before we jump back in to the suicide improv hour with Becca and stuff, let’s break down how the National Suicide Prevention Lifeline actually works.
Dr. John Draper
There’s been a lot of misunderstanding, when you call something National Suicide Prevention Lifeline. The state thinks “Oh well, the federal government is providing that, there must be some national call center somewhere.”
Stephanie Wittels Wachs
This is Dr. John Draper Not to be confused with Don Draper, the main character from the TV drama Mad Men, which is how we’ve been referring to him behind the scenes. No, John Draper is the executive director of the National Suicide Prevention Lifeline. And he’s very familiar with people copying and pasting the number without totally getting it.
Dr. John Draper
And a lot of the states have even put the National Suicide Prevention Lifeline on their state mental health website. Not knowing that, “Oh, you know what? Those calls when you call them, they’re coming from Wyoming and they should be answered in Wyoming, they’re not going somewhere else. So you actually have a responsibility to take care of your people. We’re just basically creating a national portal for local service.”
Stephanie Wittels Wachs
Local services matter. Because if we’ve learned anything about this country in recent years, it’s that there are regional differences. If you’re feeling isolated, it’s comforting to hear from someone who feels close to home. Dr. Draper learned this early on.
Dr. John Draper 04:14
My first job out of my internship was working on a mobile crisis team, which is basically a service that goes into people’s homes, in this case throughout Brooklyn. And we would go into people’s homes who had severe mental health problems, who could be at risk, but were either unwilling or unable to go get care for themselves. And interestingly, that’s a lot of people.
Stephanie Wittels Wachs
If you’re really depressed or experiencing psychosis, it can feel like a pretty tall order to just get out of bed, let alone put-on clothes and leave the house and get to a clinic for a 9AM appointment on a Tuesday.
Dr. John Draper
The system was not really built for them. So here are these mobile crisis teams that actually come into people’s homes, and serve them in the environment where they’re comfortable, as opposed to where us providers are comfortable. That sense of control that they have actually enables them to be more open or available. And also for me to see the world around them, I can see how they’re taking care of themselves are not taking care of themselves in their home.
Dr. John Draper
I can talk with the people who are important in their lives, who might be living with them, who could be helping and instrumental to supporting them. It’s a very different way of thinking about care. So I found that to be regulatory. And when I was given the opportunity to start, New York City’s first crisis hotline, I thought, well, this is another way that we can bring care into people’s lives.
Stephanie Wittels Wachs
Call Center employees aren’t coming to your living room, but they are there for you 24/7, which is pretty critical.
Dr. John Draper
They can’t schedule a crisis. And most people find at 3AM or 3PM, right after school, that that’s when they need care, and they need it right in the moment. And mental health is a weird thing, because it’s a very abstract notion and you don’t really know what mental health is until you don’t have it. And when you don’t have it means you’re suddenly in crisis. And that crisis can occur at any time. And that’s when you want care.
Stephanie Wittels Wachs 06:25
So you can call any time, but how do you know it’s the right time for you? The crisis is kind of a subjective thing, right? I mean, how much of a crisis do you have to be in to call?
Dr. John Draper
The way we like to define crisis is when your emotions so overwhelm, your ability to function, or think or act in ways that might calm you or help you cope, that you can’t cope. And that can be temporary. In fact, crises by their very nature, are temporary. But in the moment, they feel like things are never going to end.
Stephanie Wittels Wachs
Okay, I know that I said suicide prevention is more than one moment in time. And that is true when it comes to long term mental health outcomes. But if someone is in crisis, and they have access to deadly means, a moment can be pretty fucking important. When you are feeling totally overcome by despair, your brain is literally going into emergency mode.
Dr. John Draper
Your cerebral frontal cortex shuts down and says, we’re going to fight flight or freeze.” So our job is to help you feel like no, you don’t need to run, you don’t need to freeze. You don’t need to fight. We’re here for you. You’re not alone. And then we know that when people feel safe, connected and not alone, the temperature of their emotions begins to decelerate and de-escalate.
Stephanie Wittels Wachs
Which brings us back to our roleplay, my brain is running hot, Becca’s job is to cool me down.
Becca 08:06
Do you have an idea of how you’re going to do it?
Stephanie Wittels Wachs
Yes.
Becca
Okay. Okay. Can you share that with me?
Stephanie Wittels Wachs
No.
Becca
No? Okay. Then let me just ask you one thing. Do you have the means to do it? In front of you? Near you?
Stephanie Wittels Wachs
Yes.
Becca
Okay. Is there any way you could put that aside, put that somewhere that it’s not in your line of sight? Or give it to somebody?
Stephanie Wittels Wachs
There’s no one else here, but I’ll put it out of my line of sight.
Becca
All right. Cool. And I understand that it could be comforting to see it. You know, it’s different for different people. But while we’re talking, I need to make sure that you stay safe.
Stephanie Wittels Wachs
Okay.
Becca
So you’re at a three Have you ever attempted to take your life before?
Stephanie Wittels Wachs
No.
Becca
No? Okay. So this is probably scary, like, have you had this level of suicidal thoughts before?
Stephanie Wittels Wachs
No.
Becca
Okay. All right. So tell me what happened to make you feel that way today.
Stephanie Wittels Wachs
I just feel really hopeless today. I feel like I don’t have anyone in my life that really matters, or that is here for me, I’m alone. I nobody really would care if I was gone. And I just don’t think it matters.
Becca
Totally, totally get that. Are you able to do anything to take care of yourself, distract yourself? Distracting yourself is kind of the name of the game, when you’re at this point, when these thoughts are overtaking you. It’s really quite simple, you know our brain gets in kind of a rut and we want to distract ourselves and the only, there’s two ways to do that.
Becca
There’s either a person that you know, you can talk to at any time. And think about who that person is for next time. Or there’s something that you can do. Like, play a video game, or listen to music. I’ll share with you that for me, it’s reality TV, because I can’t justify watching it any other time. It’s bogus. It’s bullshit. It’s whatever. But when I frame it as self-care, I’m gonna watch reality TV now. So what is that for you?
Stephanie Wittels Wachs 10:30
I like reality TV also.
Becca
What shows you what?
Stephanie Wittels Wachs
I like 90-day fiancé.
Becca
Okay. All right. I don’t know that one. All right.
Stephanie Wittels Wachs
Oh, it’s really good. There’s a lot of them. I like the Bachelor.
Becca
Cool. Cool, so the bachelor could save your life. I love making people laugh. I love making people laugh, you can laugh on a suicide hotline.
Stephanie Wittels Wachs
If I was in crisis, this is exactly how I want to be handled. Becca genuinely made me laugh. And I legitimately felt better when we got off the call. Which is the point, the person answering the call will assess immediate risk, establish rapport, listen to your story, create a safety plan, and then offer to follow up in 24 to 48 hours as needed. It’s a simple but effective model.
Stephanie Wittels Wachs
Independent researchers interviewed callers 6 to 12 weeks after contacting the lifeline, and nearly 80% said that the call provided hope and kept them from carrying out the suicide. Now, not everyone likes to joke when they’re sad, I guess. And it’s important to know that not everyone who answers the phone will take back as approach. The primary script is pretty uniform. But as they say, results may vary. The important thing is that everyone working at a crisis center cares.
Becca 12:05
I crave connecting on this level, even though it’s brief, it’s very powerful. And I’m constantly thinking to myself, I would never talk to this person in real life, we would walk right past each other in the street, I would just never know, I would never know and to be able to, it’s such a sounds like cliche, but it is a privilege to be able to see people like this.
Stephanie Wittels Wachs
And this privilege is not just reserved for people like Becca and Dr. Draper.
Dr. John Draper
Hey, it just ain’t us hotline workers that can do this. Please kids, try this at home. I think we’ve disempowered people by saying your only hope is to call the hotline your only hope is to call 911 which is the worst-case scenario in many cases. And or your only hope is to go see a therapist. Yeah, all of that most of that is really good and helpful.
Dr. John Draper
But it’s not always practical. When you have somebody who’s close to you who’s saying, I’m thinking about killing myself, or feels utterly hopeless, I may not be practical for you to phone, they may not want to talk to somebody on the phone, and they certainly may not want to go see a therapist and it may not be practical for them to do so. So what do you do?
Stephanie Wittels Wachs
We will answer that important question thoroughly after the break.
Stephanie Wittels Wachs
We are back. Before the break. Dr. Draper said “Hey, kids try suicide prevention at home.” Which our team kind of did during pre-production. We have a chance to get formal QPR training with Tara Consolino. Remember Tara? My BFF from Episode Six?
Tara Consolino
My name is Tara Consolino, I’m the director of Suicide Prevention and Substance Use Disorders over at the Detroit VA in Detroit, Michigan.
Stephanie Wittels Wachs 14:02
We’ve mentioned QPR briefly before it stands for..
Tara Consolino
Question, Persuade, Refer.
Stephanie Wittels Wachs
Similar to CPR, QPR is a set of steps to potentially save a life in the event of mental health emergency. So we’re going to give you the CliffsNotes version of QPR, because even though every episode this season gives some insight into what to look for, it’s really hard to know what to do when you think someone you love might be considering suicide. Let’s start with the myths that stop us from intervening in the first place.
Tara Consolino
So a common myth that has come up is that why do you even bother doing suicide prevention? Nobody can stop suicides. It’s inevitable. If somebody wants to die by suicide, they’re gonna do it. And so the good news is, is that’s not true.
Stephanie Wittels Wachs
Also not true that people who talk about suicide aren’t actually going to follow through with it. This one is steeped in a lot of stigma. The truth is, people who talk about it may try or even complete suicide, they also might engage in self-injury that can lead to accidental death. Another myth, once a person decides to die, there is nothing anyone can do to stop them.
Tara Consolino
But the fact of the matter is, is that suicide is the most preventable kind of death, and almost any positive action or interaction may save a life. Another myth that we have is if you confront somebody about suicide, well, this just make them angry. Will that increase the risk of suicide? What if someone isn’t thinking about suicide? And I asked them, “are you thinking about killing yourself?” What if I planted that seed? And again, fortunately, confronting someone about suicide does not increase that risk.
Tara Consolino
Actually, when you ask somebody directly? “Are you thinking about dying? Have you been thinking a lot about killing yourself?” anything along those lines, it actually lowers anxiety, and it gives people permission and safe space to say, “you know what, actually, maybe I don’t have a plan to kill myself. But yeah, I’m just not feeling. I’m not feeling good. I’m not feeling like life is worth living.”
Stephanie Wittels Wachs 16:25
Here’s the thing. Asking someone if they’re thinking of killing themselves, like you heard Becca do to me up top is scary. If you’ve never done it before. There are a lot of reasons to talk yourself out of it.
Tara Consolino
Let’s talk about how and when do you ask the question? Do you go up to John Doe at the grocery store and say, “Hey, sir!” No.
Stephanie Wittels Wachs
Right. Unlike CPR, QPR isn’t really appropriate for strangers, but you should take all signs seriously, when you see them. And people, you know, the more clues you observe, the higher the risk. Some signs are obvious, like someone directly saying, I wish I were dead. Or if X, Y and Z happens, I’m going to kill myself.
Tara Consolino
Oftentimes, you’re not going to see the direct verbal cues. I’ve been in the field about 20 years now. And I really wish that, that the individuals that I’ve lost to suicide were more direct. Oftentimes, descriptions such as “I just want the world to stop turning, I’m so overwhelmed.” You know, that’s one thing to kind of wrap up in a cocoon due to weather. But when someone is really saying, “I need the world to stop, I need to pause and I want to sleep for a month” or “I just want to sleep forever. I just want out.” Kind of trying to read between those lines of what is exhaustion that’s more like a seasonal versus, “I don’t want to be around much longer. I don’t want to do this anymore.”
Stephanie Wittels Wachs 18:02
These are the signs that are easiest to talk yourself out of because they sound relatable, especially at times like this when everyone is experiencing some very dark days. That’s why you have to look at their behavior. Are they angrier or more irritable and usual? Is the person also giving away their belongings? Are they suddenly disinterested, and things that used to be important to them? Suicidal risk factors often are not uncommon on their own, it’s just a matter of what else is going on. Which brings us to the last set of signs to look out for, Situational Clues. These often come along with periods of transition,
Tara Consolino
when you’ve been fired, when you’ve been expelled, when you have retired, when you have switch jobs, when you’ve become divorced, death of a spouse, child, best friend, but especially if it’s by suicide.
Stephanie Wittels Wachs
Survivors of suicide loss may experience guilt, confusion, shame, anger, and the effects of stigma and trauma, all of which can increase the risk of dying by suicide. The thing most of these situations have in common is that when they happen, people need help, and needing help can make them feel like a burden, which is often the reason people don’t ask for what they need. So finally, how do you step up and ask instead?
Tara Consolino
The biggest fear that I have when I work with people and training them about how to do suicide prevention really comes down to “you’re telling me I’m just supposed to ask somebody, do you want to die? How do I just say, do you want to kill yourself?” It’s one of those things where, believe it or not, you don’t necessarily get used to it, anytime and again, I’m a therapist. I’ve been doing this for a while, but anytime, your adrenaline’s going in you’re realizing, “Okay, we’re in a serious situation here.” Pause, give yourself plenty of time. Do not rush through it. You just say, “I don’t even know how to ask this. I, Sally, I am worried about you. I’m really afraid that you’re thinking about killing yourself.”
Tara Consolino 20:21
And worst-case scenario, Sally’s gonna look at you and say, “what the hell are you talking about?” And then you talk about it. And you say, “Okay, I’m sorry.” you know, but best case, worst case, I’m not sure if this is a best case, best case. Maybe you’ve given Sally that platform that she didn’t have. And if there’s any reluctancy, say, you know what, I realized I’ve just put you on the spot. And I’m super uncomfortable that I’m even asking you this. But again, the more honest and open you are with the person, there is nothing wrong with admitting that you think you’re fumbling through this question. Okay, rock on. But Honest to God, that first step is asking the question. And you might not be that comfortable saying.
Tara Consolino
“Do you feel like dying? Are you thinking about dying?” So there’s different ways that are less direct. “Have you been unhappy lately?” “Yeah, it’s been bad.” “All right. Have you been very unhappy?” “I don’t know.” “Have you been so very unhappy that you’re thinking about ending your life, you can work up to it. Baby steps are okay. When in doubt, you can always go with the okay, man. I don’t know. Do you ever wish that you could go to sleep and not wake up?”
Stephanie Wittels Wachs
In the months that followed this training, I have used this approach to ask multiple people if they wanted to die. Maybe it’s COVID, the election or just destiny, but it has come up. The baby step approach is really helpful. But it’s also okay to just speak honestly about what you see.
Tara Consolino 22:04
You look pretty miserable. I’m wondering if you’re thinking about suicide. When people are as upset as you seem to be, sometimes they wish they were dead. I’m wondering if you’re thinking you’re feeling that way too.
Stephanie Wittels Wachs
Ask, don’t wait until it feels polite. Don’t wait until you have all the answers. If your gut says to speak up, listen to it. Now, having said that, a couple quick thoughts about how not to ask.
Tara Consolino
We don’t want to ask closed ended questions. “You’re not thinking of killing yourself are you?” “No.”
Stephanie Wittels Wachs
Y’all know this kind of question. “You’re not gonna wear that dress, are you?” “What? No, of course not.” I mean, this is the fastest way to make someone embarrassed and to end the conversation before it’s even begun.
Tara Consolino
You don’t want to say anything along the lines of “you wouldn’t do anything stupid, would you?” Because then you’re not just saying suicide is stupid. You’re saying you’re stupid. You’re stupid enough to make this decision. You’re stupid enough to be making these poor choices. And well, if I’m stupid, then you know what, I am stupid, and that’s why I’m killing myself.
Stephanie Wittels Wachs
Okay, fair, but nobody’s perfect. Don’t let the fear of doing this wrong stop you from doing it at all.
Tara Consolino
You might screw up the first couple of times you do this. That’s okay. Don’t you shut down. Because if you see that they may have shut down. Okay, totally fine. Just own it a 100% and move it forward.
Stephanie Wittels Wachs
So you’ve taken the big step and asked the cue of QPR. And your person said, Yeah, I am really struggling. So now what?
Tara Consolino
All right, persuade. So this is where you put on your salesman hat. And it’s not so much that you’re selling them on staying alive. In dialectical behavior therapy, which is a technique that Dr. Marsha Linehan developed years ago, sometimes in approaches, okay, so you want to die by suicide? Okay. Can you just give me today? Can you give me this week? Can you just give me time to hear you out. And let’s see if we can come up with a plan to get better together. Listen to what they have to say. Give them your full attention as much as you might want to start googling on your phone and getting resources and that is not the time, put the phone down, turn around, focus.
Tara Consolino 24:46
If you’re on the phone with them when you’re talking to them about this. See if you can get them on FaceTime. See if you can get them to see you to do Zoom. To really be able to focus on them. And remember that it’s not suicide that’s the problem. We’re not so much trying to prevent them from dying by suicide. We’re trying to alleviate the suffering that’s resulting in suicide being an option. That’s where we’re not looking to judge, or anything along this. “Oh, I can’t believe you’re thinking this way.” Nope. At this point, we are hope givers, we are focused on hope. What can we do to be able to support them and to persuade them.
Stephanie Wittels Wachs
Persuading is about keeping the person safe for a tangible amount of time. I mean, look at the lifeline. The majority of those calls are about 15 minutes, you are not responsible for convincing them to live every day for the rest of your life. Just buy enough time until you can connect them with someone who can actually help. Which brings us to the R of QPR, Refer.
Tara Consolino 26:00
Suicidal people often believe that they can’t be helped, that’s fine. The best referral involves making sure that you say, you know what, I don’t know what to do, either. But I’m in this, we’re here together, let’s do this. Let’s move this forward. And I’m going to find somebody who can help us, it’s not always possible to get a referral to a professional. So that’s where you go with anything that you can get your hands on. Whether it is another individual, whether it’s a teacher, whether it’s a school counselor, a licensed professional mental health counselor, if you need to get others involved, if you need to get family involved.
Tara Consolino
Friends, brothers, sisters, pastors, priests, rabbis, you name it, make sure that you know who you can get involved. The other thing is, though to remember, make sure you also know who you may be shouldn’t get involved, depending on the situation, depending on the environment, it’s also a good idea to make sure you’re asking those questions. Is there anybody who we should not include in this? Who might make the situation worse? Don’t make assumptions, you’ve got to make sure to ask that question too.
Stephanie Wittels Wachs
There are several variations of this step-by-step approach to suicide prevention. We have links to a few in the show notes. The key points are, ask the hard questions, let them know you care, make sure they’re safe, connect them with services, and then follow up. It can be a text, a call, a card, anything to let the person know you are invested.
Tara Consolino
And really what it comes down to with suicide, when all somebody wants to do is to stop that pain. To stop that suffering. All you have to do is plant one small seed of hope.
Stephanie Wittels Wachs
This was so helpful and clarifying for our team. But also we had some follow up questions. Like, what happens if the person you’re trying to help doesn’t want your help? You’ve identified that they’re in crisis and you try to make suggestions for a safety plan. But the person’s like, “No, I don’t think things will get better.”
Tara Consolino 28:16
To be perfectly honest though, so as I was talking, and saying, “Okay, this is the plan, we’re gonna get off the phone. I have to admit, in the back of my head, I think it’s funny that you’re calling me out on this, because it’s not going to go like that. It really comes down to them saying, you know what, nothing’s gonna change. Okay? You’re telling me nothing’s gonna change. At the same time you called me? You called me for help. So on some level, I’m hearing that you know that there is a possibility of change. When I’m coming up with all of these brainstorming situations with you, and you are coming back with no, no, no. What are you looking for from me? What do you want to hear? What can I do or say? Or do you just need tonight to say, you know what, it’s just shitty right now. And I don’t feel like it’s gonna change.
Tara Consolino
And honestly, I just kind of needed to vomit at you. And that’s okay. You know, what, if you are not ready for me to be your hope giver, I got you. I can sit here we can be on the phone for another 15 minutes. And we can do this. But tomorrow, I’m following back up with you. You’re going to be here, you’re going to be alive, you’re going to be whatever, because then at this point, I’m going to kick your ass.” And there’s nothing wrong with kind of going into kind of like, you know, a bit of humor mode or being direct because again, if you’re authentic, even if and this is where that struggle is okay, but if they kill themselves, and I was like, “Well, what the fuck do you want, right?” What do you want?
Tara Consolino
Then you’re gonna beat yourself up, but at the same time. When you’re getting nothing but no’s, no, it’s not gonna work. No, it’s not gonna work. No, it’s not gonna work. That’s where honesty and I mean, real honesty comes in. Dude, you’ve just given me seven no’s. I am really frustrated. And if I’m frustrated, you must be frustrated, because you’re telling me that this isn’t going to change. Well, crap, that’s got to really suck to feel like this isn’t going to change.
Stephanie Wittels Wachs 30:24
It can be really frustrating. I’ve been in this position before, feeling stuck on the phone, worried sick about someone, but also running out of things to say and feeling pretty out of my depths. I mean, this is a taboo thing to admit. But sometimes it feels really fucking overwhelming to be the recipient of someone else’s overwhelming hopelessness. And that is never included in the Suicide Prevention infographic. You’re just taught, people in crisis feel like a burden, and you’re in a position to help them. So even if it does feel like kind of too much, that feels like something that you are not allowed to acknowledge.
Tara Consolino
There’s nothing wrong with saying, I just, I gotta tell you I don’t have the energy for this this evening. I had the worst day and I love you to death. I’m trying to give you know, some things to focus on. But I got to be honest, at this point, I’m about ready to pass out, you know, and to just go that route? Because you’re not going to be any help if, if you just start saying Mm hmm. And then they feel that you’ve tuned them out. You’ve lost them. That is that’s, that’s the worst thing you can do. So yeah, you know what, I have had a really shitty day and I am so frustrated. Every time you call me drunk and call me this or call me that. Help me, help you. What can I do to help you right now? What do you really want?
Stephanie Wittels Wachs 32:01
Okay, so quote, Jerry Maguire. I’m writing that down. Help me, help you. Help me, Help you is a very good tagline for all of this. But remember, the goal is not to become the clinical social worker in charge of their case. No one person is responsible for doing this alone, you are creating a support network. The goal is to refer them to trained professionals. The expectation being, the professionals are trained, and ready and willing to carry the baton. After the break, we look at what happens when the helpers are the ones who need the help.
Stephanie Wittels Wachs
We’re back. So by this point, you’re basically a suicide prevention expert. And it’s not that complicated, right? The hardest part is knowing what to look for and then actually doing something about it. Suicidal people aren’t just walking around with signs on their backs. They’re your cousins and coworkers or maybe your patients.
Dr. Julie Goldstein Grumet
Healthcare systems are already taking care of people at risk for suicide. They’re coming in your doors every day, you may or may not know.
Stephanie Wittels Wachs
That’s Dr. Julie Goldstein Grumet director of the Zero Suicide Institute. She and her team are shifting the culture away from fragmented care and towards a collaborative approach to patient safety and quality care.
Dr. Julie Goldstein Grumet
What Zero Suicide does is it really puts the onus on the health care system and provider to ask each patient at every encounter, are they having thoughts of suicide? So what we know is that if you ask people directly, then people are more likely to tell you then if you hope, as a primary care doc or an emergency room doc, when somebody is there that they’ll tell you, “oh yes, I broke my ankle” or my stomach hurts. But I’m also having thoughts of suicide and want to share that”
Stephanie Wittels Wachs 34:06
Healthcare professionals have the same apprehensions and stigmas as the rest of us. So they need training to the Zero Suicide Institute has a seven-part framework that helps organizations adopt a comprehensive approach to suicide prevention. Systems that have used the framework faithfully and consistently, have reduced suicide by 65 to 75%, 65% to 75%, that is a lot of percent. And you know what, a lot of the steps for professionals are the same things taught to us civilians, asked directly, keep the person safe, refer them to get help. Now, that is usually where the amateur model ends. And actually, until recently, it was where most medical professionals stopped to.
Dr. Julie Goldstein Grumet
We know that it’s incredibly important when you make those referrals that there be warm handoffs, we can’t just say here’s a phone number on a piece of paper. Hope you go good luck. I get phone calls to remind me that I have a dentist appointment, or that my daughter had her wisdom teeth out, I get a phone call, how is she doing? You know, a day or two later? Do you have any questions is everything okay? But that’s not really the way we always traditionally approach behavioral health. And it should be because that’s what we do in the medical world. And there’s no reason that what we do and the care we provide and the attention and the concern should be absolutely the same for behavioral health and people at risk for suicide.
Stephanie Wittels Wachs
The same way that life transitions can be very precarious for people at risk, loss of job, divorce, retirement. Transitioning from one part of the healthcare system to another is complicated. And people fall through the cracks all the time.
Dr. Julie Goldstein Grumet
The medical side primary care or whole hospital systems, what they’ve tended to do is punt people who are at risk for suicide to behavioral health and hope, well they’ve got them.
Stephanie Wittels Wachs 36:06
The only problem in many cases, especially within whole hospital systems, is that they don’t got them.
Susan Whitney
Routinely, clinicians are having to tell their patients to wait 6 to 8 to 12 weeks for follow up appointments. When you know the community standard of care is you see somebody in a week or two.
Stephanie Wittels Wachs
This is Susan Whitney from Bakersfield, California. She’s a Licensed Marriage and Family Therapist at Kaiser Permanente. For over a decade, Kaiser has repeatedly found itself in hot water for providing inadequate mental health services.
Susan Whitney
Getting people in the door is not really a problem that Kaiser does very well. I do an intake with them that day or the next day. And then if I tell them, I have something, I do have something in a month. However it would be at 10 in the morning. And I know that you’re you know you’re working from home and you have two children in school or doing school on Zoom. And, you know, if you want that late afternoon or evening appointment, that really would work for you, that’s going to be you know, two months or more.
Stephanie Wittels Wachs
Now, we should be clear. In this respect, they are not alone. Most states are facing epic doctor shortages and mental health care workers are left with very few options. If they’re in private practice, they turn people away. If they work within a larger institution, their schedule is so packed that there’s no time for lunch or bathroom breaks. But unlike the majority of therapists in the US, Susan and her colleagues at Kaiser are unionized, which put them in a position to actually fight back.
Sal Rosselli
It’s about organizing right so that people have a voice and can control the relationship with their employer can stand up for their patients. Unfortunately, there aren’t many organizations in this country outside of California in New York, right? That are organizing hospital workers.
Stephanie Wittels Wachs 38:03
This is Sal Rosselli. He’s the president and co-founder of the National Union of Healthcare Workers, which represents 1000s of Kaiser employees. He’s a lifelong activist, the kind of guy who loves standing up for the little guy,
Sal Rosselli
our health care system today, it’s all about the bottom line. It’s not providing adequate care, you know. If someone that you love was diagnosed with stage one cancer, and they were told, “yeah, we’re gonna give you a therapy when it gets to stage four.” And that’s what behavioral health is like.
Stephanie Wittels Wachs
Kaiser’s mental health care workers joined the National Union, NUHW in 2010. From the very beginning, their work spelled out the consequences of delaying and denying care. They released white papers and set up a website called No More Kaiser Suicides,
Susan Whitney
You know, things that were routinely denied were access to timely care. And so people get sicker, and in the worst cases died. And I think, you know, anyone who’s been working in this field for any period of time has lost patience that they’ve worked with.
Sal Rosselli
We started learning about the horrible access problems, horrible workloads, right? So we went to the bargaining table proposed this positive stuff, got rejected. Kaiser took the position that “No, we’re perfect, we do everything fine.” And the war began.
Stephanie Wittels Wachs
And the union was waging a war against a powerful opponent, one with an enormous advertising budget. The same time they were claiming to be perfect to the union reps. They were also selling the public their message of total health and thriving. Because
Kaiser Ad
Because of Kaiser Permanente, we believe that everyone deserves the right to thrive.
Stephanie Wittels Wachs
Their pitch is strong, an integrated approach to quality care. Your doctors, your pharmacy, your insurance, everything working harmoniously in one system. What a dream. But in practice, Kaiser is structured less like a community support network and more like a law firm. It’s a medical practitioner partnership, if you’re a physician, you can become a partner. We talked to Matt Zils, a Kaiser child clinical psychologist and union steward with the NUHW.
Matt Zils 40:27
This is my observation alone. A lot of physicians see medicine as like the primary intervention and mental health as like a cherry on top. And so years and years and years that’s how they funded their mental health services. And I remember way back in the day when I was just a trainee, me being like, “Why don’t they give us enough money to do this, and this and this, and this” and my superiors, and my supervisors being like, yeah, that is not the culture within Kaiser, that mental health is like a perk that we offer patients, but it is not mainly what we do here.
Stephanie Wittels Wachs
One of the main things they do here? Make money. Kaiser is the largest integrated health system in the country, they’ve got roughly $20 billion in reserve. With that kind of cash, you can consider the federal parity law more of a suggestion than a mandate.
Sal Rosselli
Kaiser had such totally inappropriate influence. For example, there’s a state law that said, one had to get an initial appointment within 10 calendar days, that was a regulation not adhered to on any level whatsoever. And even with us demonstrating it, we couldn’t get them, we couldn’t get them to, to force implementation.
Stephanie Wittels Wachs
When institutions don’t comply, they can get hit with fines from the state. And in 2013, that is exactly what happened.
Susan Whitney
Kaiser got a $4 million fine at one point, well, they make billions a quarter, they don’t care about that.
Stephanie Wittels Wachs 42:04
At this point, the union and healthcare workers realized the fight couldn’t be waged with white papers, lawsuits and slaps on the wrist, it was time to take to the streets.
Susan Whitney
Therapists don’t usually go on strike, social workers don’t usually go on strike, it’s not in our wheelhouse. So, you know, convincing them to go in and be on a picket line, and not come in and see their patients, it’s really hard because you have to get to the point where we felt like not coming in and seeing our patients was the right thing to do versus coming in and seeing them.
Sal Rosselli
I remember, this one therapist said, “Now, Sal, don’t think any of us are gonna wear those red shirts or carry picket signs. We will wear our white jackets right, and we’ll be very polite.”
Susan Whitney
I would say that it sounded really tentative at first, and we definitely had to be led long.
Sal Rosselli
You know, the first one day strike we had, that lasted about two hours, and they quickly became very militant.
Susan Whitney
And then really comfortable with getting like loud and chanting and yelling and bringing in speakers and kind of pushing back to do what you need to do to be heard.
Stephanie Wittels Wachs
Since joining the Union, Kaiser’s mental health workers have staged multiple strikes. They’ve met with labor leaders and held candlelight vigils, memorializing patients lost to suicide. At first, these demonstrations felt radical, but eventually, they just felt necessary.
Susan Whitney
And I would say that over a process of years, we went from, like a minority feeling that, that was what we needed to do to a majority to a super majority, where everybody would be a picket line. The last strike that we had in December and there was a day where we all kind of masked in LA and marched up and down sunset and I have never heard anything so loud in my life, and it felt really, really powerful because we’re getting a lot of positive response.
Susan Whitney 44:29
People were bringing us pizza and water and snacks and a guy wrote up on a bicycle and he was wearing a MAGA hat and I thought “oh, he’s gonna cuss me out” so I kind of like approached him and he was like, “you guys are like healthcare workers, therapists right?” “Yeah.” And he goes “you guys gotta fight back. You guys got to do this. You guys are doing the right thing and I just brought you like water and granola bars” and he pedaled off and I was like, “what just happened?”
Stephanie Wittels Wachs
What was happening is that the tides were turning, people were more willing to stand up and demand better mental health and substance use treatment. Parity was officially a bipartisan issue.
Sal Rosselli
It was tremendously successful in terms of galvanizing political community support getting such the press. And it really helped push Gavin Newsom over the top.
Susan Whitney
What was just signed by Governor Newsome, who is an amazing advocate for mental health and truly gets it, I think, based on his personal experience that he shared about was a package of four bills and the one that that we’ve really been involved in pushing is SB855.
Stephanie Wittels Wachs
SB855 is legislation that strengthens the existing parity laws by closing some of the most egregious loopholes that insurers used to deny care. It’s a huge step forward for patients’ rights. And it only happened because people like Sal, and Susan, were relentless.
Susan Whitney 46:04
People who are, you know, work in politics and lobbying and as part of a broad coalition just, you know, got it, got it on the governor’s desk, and then he signed it and you know, called out to our Union and, and to Sal, you know, he said, “Oh, how can I forgot, parity. Because you people will never let me forget parity.”
Stephanie Wittels Wachs
For folks like Susan and Sal, it is a badge of honor to be called a broken record. And they have a lot to be proud of with SB855. It addresses the bizarre divide that exists in most states, between how we treat patients and how we charge patients.
Susan Whitney
There’s a gap between what you would reasonably a reasonable human being would expect, it would be covered by your insurance and what is actually not covered.
Stephanie Wittels Wachs
Like, say modern medicine, for example. Imagine if your primary care doctor was like, “hmm, I’d like to run some standard blood work for you. But heads up, your insurance only covers leeches, because they’re only required to meet medieval standard of care. So what do you say, leeches, or pay out of pocket. And PS, I can’t tell you how much the out-of-pocket cost is ahead of time.” I know it sounds wild. But that is pretty much how we are treating our brains.
Susan Whitney
The California legislation was enacted in 1999, which is like three or four diagnostic manuals ago. For example, post-traumatic stress disorder is not a parity diagnosis.
Stephanie Wittels Wachs
Meaning in most states, insurance companies don’t have to fully cover PTSD treatment, even under the parity laws.
Susan Whitney
The things that this law does is it just basically says the manual that we use the DSM, the Diagnostic and Statistical Manual, just like physicians use the ICD, whatever. And that’s their list of diagnoses. And those are treatable and diagnoseable and codable and billable that our diagnostic manual will be the standard for us. So it clarifies that sort of obvious thing that needed to be fixed. It defines medical necessity clearly, medical necessity has been this very broad category that’s used to deny services, as you’re probably well aware by now.
Stephanie Wittels Wachs 48:26
Oh, yes, I am very familiar with insurance companies trying to use the term medical necessity as a catch all excuse to deny care. Take my kids hearing aids, for example. We got a law passed in Texas in 2017, to require insurance companies to pay for them. But prior to that, they were considered cosmetic, which is another way of saying not medically necessary, which is another way of saying we’re not going to pay for that. And this relates to another new and amazing but also totally obvious update. If your insurance plan only covers in network doctors, but there aren’t any available in your area. That’s not your problem anymore, it’s the network’s
Susan Whitney
If the insurance company, or an insurer can’t provide the services with their network adequacy of network, they have to pay for it outside the network. I think it’s pretty darn huge. What’s in there and the implications as this plays out over the next couple years and I mean, it gives us hope for the future.
Stephanie Wittels Wachs
Yes, so much hope. And I want to really take a moment to celebrate this win. Because Lord knows we need to feel hope whenever possible. The law just went into effect on January 1st, so it’s very shiny and new. But we still have a long way to go before everything is as it should be when it comes to health care at Kaiser Permanente or anywhere else in this country. But even within a system that feels broken, there are people who care, who are willing to speak out and put their careers on the line for what’s right.
Susan Whitney 50:14
Complaining and being a broken record and speaking up works eventually, it takes a while. People should ask questions, people should push back, people should file complaints with whoever they can file complaints. And I think that the more people do that, and push back that that’s going to be a huge part of things changing, you can have all the legislation and regulations in the world, but if people don’t, don’t speak up, and don’t say, “hey, that’s not okay.” things either won’t change, or they’ll change slower.
Stephanie Wittels Wachs
Change is hard to come by. But it’s not impossible. That hearing aid law that I mentioned earlier, took six years to get passed. And that doesn’t even cover the time it took to actually go into effect. Also, now that it’s mostly working, I just moved to a new state. And guess what, the law doesn’t exist here. But you better believe that I’m going to wage the fight all over again. I mean, not right away. We’re in the middle of a pandemic, but I am going to eventually and it will get past. As much as we want it to be, change isn’t a moment, it’s a series of moments, which is sort of the point of this entire season. I remember in one of our earliest calls, Courtney from JED said something like “Suicide prevention isn’t about a single moment. It’s about a person’s entire life.” And I thought about that, when I talked to Sal.
Sal Rosselli
My background, you know, what’s primary thing that’s gotten me to this point, you know, in the early 80s, I was very involved in the gay rights movement, it was called gay rights movement back then. And it was in the beginning of the AIDS epidemic. And that’s when I started working for the health care workers union, and experienced such great fear among our workers, wanting to take care of patients. And I actually, you know, became a volunteer to do in home care for these men that were dying alone.
Sal Rosselli 52:27
And our union produced the first educational material for healthcare workers to help get them past that, right? So, you know, it’s those times seeing so many people die and suffer and the healthcare industry and the government not caring, right? That helped, you know, me with my, my principles and values, right? and helped inspire me to do this work. I really like in today’s COVID experience to that, again, we look at the lack of help from the federal government, etc. Then the suffering and the fear, and our healthcare workers are really standing up, it’s amazing.
Stephanie Wittels Wachs
I cannot help but make the connection to Sal’s experience offering in home care during the AIDS epidemic. And Dr. John Draper’s experience bringing treatment directly to people’s homes. When we look at these big, terrifying life, or death crises, whether it’s suicide or COVID-19, or HIV or addiction, it’s easy to feel demoralized by the statistics and the inadequate government response. But somehow, with each of these examples, so much can happen at the person-to-person level, whether it’s wearing a mask, volunteering at a crisis line, getting a vaccine, just having a candid conversation with the people you care about.
Stephanie Wittels Wachs 54:01
These things add up, and they make a difference over time. The answer to these big complex issues that feel largely out of our grasp isn’t just one thing. as annoying as it is, there is no magic bullet, which is sort of the conclusion we came to in season 1. The way to save lives is multifaceted. But one thing that is critical across the board is seeing people, all people with dignity and humanity and treating them that way in every sense of the word. We’re not going to solve suicide, any more than we’re going to solve addiction. But we can have better outcomes. We can save lives. The fight continues, so keep fighting.
CREDITS
LAST DAY is a production of Lemonada Media. Our supervising producer is Jackie Danziger. Associate producers are Giulia Hjort and Claire Jones. Technical Director is Kegan Zema. Music is by Hannis Brown. Executive producers are Jessica Cordova Kramer and me Stephanie Wittels Wachs. We are so thrilled to have partner with the JED foundation this season and grateful for all their wisdom and support. You can find them online at @JEDFoundation. And you can find more mental health resources at jedcares.org/lastday. If you want to hear more LAST DAY, we have an entire first season. Please go listen to that wherever you get your podcasts. And while you’re there, please rate and review and subscribe if you have not done so already. You can find us online at @LemonadaMedia, and you can find me at @wittelstephanie. I’m Stephanie Wittels Wachs, thank you for listening.
