Transcript for Episode 37: Suicide Prevention

Greg Wright: Welcome to Social Work Talks podcast. I am your host, Greg Wright. We are pleased to have one of the leading social work experts on suicide prevention as our guest. Jonathan Singer is an associate professor at the Loyola University Chicago School of Social Work. He is also the new president of the American Association of Suicidology. Major news organizations have tapped Jonathan's expertise on preventing suicide. These include New York Daily News, NBC News and Fox. Jonathan, how did you first get interested in the issue of suicide?

Jonathan Singer: Well, so right after I graduated with my MSW in 1996, just like most social workers, I was looking for a job. The jobs in Austin, Texas, that's where I was from.

Greg Wright: I thought you were from Philly. What's going on here?

Jonathan Singer: Well, yeah, yeah. Okay, so I grew up in the DC area, lived in Philly, but I got my MSW at UT Austin. I'm looking for a job. I can't find anything that's full time. There's a relief worker position at the outpatient community mental health children adolescence unit for their crisis division. The job was go out and do suicide risk assessments for suicidal kids, talk with homicidal kids, work with actively psychotic kids; but it was relief worker. So that meant that when the full time folks needed a break, they would call me.

Basically I was just like, "I need a job, I need some some money," and so I applied. Turns out the fact that I spoke Spanish because I lived in Mexico for a while meant that they were more interested in me as a full time employee.

They said, "Hey, you've applied for a relief worker position. What about full time employment?"

I was like, "Oh, yes." Then what I ended up doing for the next two, three years was I would do suicide risk assessments 10, 15 times a week. Different kids.

Greg Wright: It was all ages?

Jonathan Singer: Yeah, it was all ages. I would say most... and then I carried a caseload of maybe five to 10 kids for doing what we called short term stabilization therapy, which is where we get kids out of the suicidal crisis and ready to be transferred to somebody in the agency or out of the agency that could do more long-term work with them.

I got into doing suicide risk assessments and the field of suicide because that was my first job. I realized that the skills that I needed to do a good job working with suicidal kids and their families were the same skills that I had been taught in my MSW program with a couple of tweaks.

One of the tweaks is that I had to learn how to not be scared when a kid said, "I don't think anybody would care if I stuck around or not. I don't think people would mind if I were dead."

I had to learn to be like, "Oh no, we'd care a lot and we want you to stay," and just being able to tweak that was so important. That's what got me into suicide.

Greg Wright: What did you know about suicide before that job, and what kind of surprised you about it?

Jonathan Singer: One, I learned that when folks are suicidal, only part of them wants to die. The rest of them wants to live. When you're working with somebody who's suicidal, remembering that your job is to honor that part of them that doesn't want to live.

So honor that and say "Yes, that's a legit thing that's going on for you," and be strong for the part of them that wants to stick around because they're ambivalent. Part of them wants to live, part of them wants to die. Your job as the social worker is to be their advocate for sticking around, and not just sticking around but also having a life worth living. That's where the strengths perspective, the advocacy, the sense of being able to understand the intersection between the messages that are going on at the macro level in our society, as well as the individual everyday interactions. The social workers are understanding of that. There's nothing better when it comes to working with suicidal folks.

Greg Wright: I was wondering if you could give us an example of a young person that you work with. What were they like walking in? How did you actually identify a kernel within them that just wanted to live and actually watered that, grew it, and saved them, ultimately?

Jonathan Singer: I always hesitated from thinking about it in terms of saving lives because there's a lot that goes into people's decisions to stick around. That said, early on I worked with the 16 year old Latina adolescent. She and her mom had come over when she was a little girl and the mom, very traditional values in terms of girls couldn't be seen alone or couldn't be alone with boys, especially in that 16 year old girls. The mom found out that the girl had been walking home from school with another kid in her class. They weren't dating. There was nothing inappropriate about their relationship from an American perspective.

But the mom said, "You've brought shame onto our family. You're horrible person, and you're grounded."

What the girl did with that is she basically said, "Well, essentially my life is over. My mom has said I can't go out. I can't be. I can't be a kid here," and so she tried to kill herself. She was referred to our agency, and she was so despondent. She was really trapped, caught between these two worlds, loving her mom, wanting to be the daughter that her mom wanted to be, and recognizing that she didn't want to reject her mom's culture, which was partially her culture; but there was also this American sort of Texas thing that she was growing into.

What we were able to do is we were able to talk about, "When you and your mom have conflicts, your thoughts of suicide go up, but when you're actually able to connect with each other."

Which includes the mom saying, "Look, I understand what you're going through. I might not agree with it, but I understand it." That when that happened, her sense of hope increased. We actually ended up graphing this. Every week we would ... actually three or four times a week, when I'd see her for this month because we saw each other probably 20 times in a month. We would graph this conflict/hope and when conflict went up, hope went down. When conflict went down, hope went up. She was able to see that, and the mom was able to see that validating her kid, honoring her kid, and having a conversation where the kid honored the mom and they were able to get on the same page, that this brought out the part of her that wanted to stick around because she saw possibility in the future.

Greg Wright: Fast forward to now. Suicide rates are up all across the board. It's all races, all sexes, classes, et cetera. What's going on here, Jonathan?

Jonathan Singer: I wish that we knew. I wish that we knew why rates of suicide are going up. We know some of the reasons why people kill themselves. Some of that has to do with access to firearms. Firearms, nine out of every 10 suicide attempt with a firearm is lethal. We know that in states that have access to a firearms, that there are increased risk for suicide.

But even when there aren't firearms in the home, because kids under the age of 12 are more likely to die by suffocation in terms of suicide. This is where the question of why is it that more kids are dying, and we don't have a really good answer. If we did have the answer, we'd solve it.

Greg Wright: Has our nation had a change in attitude toward it, because it was a taboo topic. I remember as a youth, if a person died that way, in the obituary, it was not mentioned. Now I see it. Not all the time, but I see it. Are we more aware now?

Jonathan Singer: Yeah, I think there's been a big shift. I think one of the things that seems to be true is that the people that have been most afraid to talk about suicide have actually been the professionals. The people who have lost loved ones to suicide, people who have survived suicide attempts, people who are actively experiencing thoughts of suicide; they would love to talk about it as long as the professionals that they go to are okay with the conversation.

I think that what's happened in the last few years, certainly after Robin Williams died by suicide, is that there has been an acknowledgement that suicide isn't just about mental illness. Suicide isn't just about this person with like ... that's an ostracized person, that suicide is something that affects all communities. It is not just something that is this isolated group. Now the flip side is that most people never die by suicide. So there is that also that dichotomy that we have to acknowledge and recognize.

But getting back to your question about why are we talking about it now? I think because rates are going up, because there are reporting guidelines for the media in terms of how to talk about it safely.

You have people who have survived suicide attempts that are public and saying, "Look, this is what's going on."

Marsha Linehan, who developed dialectical behavior therapy, very publicly came out in 2011 and said, "I tried to kill myself several times." It was one of the first times that a major figure in the field of suicide prevention had ever come out and said, "This is my story, too."

Greg Wright: Why is it that professionals aren't more open about it?

Jonathan Singer: Well, I think one of the things about individual interaction is that mental health professionals are oftentimes terrified of getting sued. There is a myth that if I don't talk about this, then nobody can say I did something wrong if somebody ends up dying by suicide. I mean that's totally wrong. It doesn't make any sense. It's not going to reduce liability. So they think there's that side.

I think another thing that happens is that you have folks going through school that aren't trained in addressing suicide risk. In a classroom setting, and I teach at Loyola University Chicago.

I talk about it a lot in the classes that I teach, but there are a lot of professors who think, "Well this is really something for field internships. This is something that they're going to get in their field placement," and oftentimes they don't.

Even if there are suicidal folks at their field placement, many times interns are excluded from those interactions by staff who are like, "Well, they're not ready for it. Once they get trained in the classroom, then they'll have some skills and then we can bring them on."

The classrooms like, "Well, once they get trained in the field, then we can have conversations about it." Then it ends up-

Greg Wright: It's passing the buck here.

Jonathan Singer: Nope, that's right. Nobody gets ... Nobody trains. This is one of the biggest problems that we have is the lack of training in having this conversation.

Greg Wright: Overall, how can the social work profession handle this issue? They're already on the forefront doing this, but how can they do it better?

Jonathan Singer: Three things.

One, schools of social work can look at their curricula and say, "Where in the curricula do we explicitly train folks to assess for suicide risk and to understand how to intervene in a suicidal crisis," and make sure that is in there. It should be in the practice classes, not just advanced clinical. It should be in the foundational.

It should be in the foundational because students are walking into field placements, and they are talking with folks who are like, "Hey, I'm suicidal."

Then they call their supervisors and their supervisors like, "Hey, you're not prepped for this, so you leave," so they don't get the experience.

The second thing is that we need to acknowledge that social workers are the profession that work with the most number of suicidal people of any mental health profession. Just because of our sheer numbers and the fact that we are everywhere. There needs to be ongoing training, and education, and awareness. I would love to see NASW come out with some practice guidelines for how social workers should work with folks who are suicidal. Because working with an eight year old who's suicidal, and there are eight year olds who are suicidal, is different in some fundamental ways than an 80 year old who's suicidal.

The third thing that we need to do... you know that I'm the current president of the American Association of Suicidology, proud to be a social worker in that role because there are a lot of policies that the field of social work can acknowledge that can be helpful for those of us who are in practice to address issues of risk. There's the emergency risk protection order, the ERPO. This is a law that if there is somebody that is at risk for suicide, and they have a gun in the home, they can activate the ERPO and actually law enforcement can remove the firearms. This is not an infringement of second amendment rights. This is about keeping people safe. It's about safety. If a social worker is going into a home where that's the case, and the social work profession isn't on board with this, then it's an opportunity for protecting clients and the professionals.

There's three ways. There's the immediate education and awareness. There's the fact that you have all of these practice guidelines for professionals, and the fact that at a policy level we've got the American Association of Suicidology, we've got NASW, we've got these organizations that can partner on legislation that can protect and serve clients and professionals.

Greg Wright: On a state, local, national level, legislatively, what should be done?

Jonathan Singer: Well, I think that one of the things that we need to do is we need to make sure that there is an expectation that social workers get continuing education in recognizing and responding to suicide risk. There are lots of different ways that, that can look because every setting has some... if you're a hospital in an emergency department, that looks different than you're in community mental health or in a school. So I'm not saying what it exactly looks like, but we need to make sure that people are getting regular training, that's including continuing education, that, that is available for social workers in a way that's not going to be a financial barrier.

Seeing legislation, especially for schools, is understanding the role of the social worker with other people. The legislation that's been out there that says that teachers have to get training in suicide prevention. You have some states that have said only teachers have to get training in suicide prevention. It doesn't include mental health professionals. And I think that, that is a huge miss. It's a missed opportunity.

I mentioned the legislation around firearm safety, really important. I also think that there's opportunities for legislation around other restrictions of lethal means. This includes things like Tylenol, which can be very lethal. Let's make sure that we are limiting people's access to that, especially those who might be suicidal.

Greg Wright: You are now the new president of the American Association of Suicidology. What is your role there? What do you want to do with it?

Jonathan Singer: Yeah. My role is that currently I'm responsible for a couple of things. One, I'm responsible for organizing the annual conference. It's about 2000 people. Everybody from attempt survivors to parents who've lost loved ones to suicide, military vets, researchers, clinicians, crisis line workers, the whole gamut. In a lot of ways it's like social work where you have all of these different people in different sectors coming together around the same thing. We're planning the conference for Portland in April of 2020.

Another thing that I'm doing is I'm working very closely with the communications team on talking with journalists around issues that come up. So for example, "13 Reasons Why." They re-edited the ending of... Netflix re-edited the, the ending of "13 Reasons Why." We actually worked with Netflix before they made that decision about should they do that? Should they edit out the scene where Hannah Baker kills herself?

We were like, "Yes." I was involved in those conversations.

We've got partnerships with the Brady Campaign that I've been working, collaborating with our executive director on what is it that we as a suicide prevention organization need to be thinking about in terms of policy, in terms of education? How do we bring in the researchers in our organization?

Honestly like I feel like my training as a social worker has been such a good preparation for the role as president of AAS because it is so similar in terms of all of the different perspectives that's necessary to actually bring these voices in.

The other thing that I'm doing that's really important is really bringing the American Association of Suicidology into a space where it can acknowledge an expanded chorus of voices. It's a historically white organization. It was founded by psychologists, and so there's been a real strong sense of psychology and sort of the way that that discipline is organized. So acknowledging and diversifying voices both in terms of visible diversity, invisible diversity, and that can include things like are you an attempt survivor? Do you have a loss? Are you a student who's doing research, and you also have a parent that died by suicide and you have also experienced a suicidal crisis yourself.

All of these things, as president, I really want to make sure that people who care about saving lives and building lives worth living, see the American Association of Suicidology as a home that honors their voice and their perspective, and is a place where people can work together to advance legislation, to advanced practice issues, to advance trainings, all those sorts of things.

Greg Wright: If you have a loved one and you have a worry that they may be suicidal, what are some signs?

Jonathan Singer: Some of the signs that you should look out for is if there is a change in their sleep habits.

If somebody has stopped sleeping very well, so maybe they go from sleeping seven hours a night to, they're talking about like, "I've only been sleeping two or three hours a night." That could be something that they're sleeping two or three hours a night, and they have tons of energy or they have no energy. You want to look out for a change in sleep, particularly lack of sleep.

If they've stopped doing things that they used to do. So for example, it could be everything from like I used to post a lot on social media. I've stopped posting on social media. I used to go out once a week and hang out with my friends at this bar. I've stopped doing that. You're looking for pretty big changes in activities, particularly when it has to do with their social interaction.

Another thing, and this might sound obvious, but we ignore it a lot of the times is if they're making statements about being suicidal.

For example, if somebody says, "I think that the world would be better off if I weren't here."

A knee jerk reaction for people is to be like, "What are you talking about, man? You know everybody loves you, like we ... Come on." That's kind of a knee jerk reaction. But what you've just done is you've said, "I don't want you to talk about being suicidal." It could be because you didn't actually realize that they were legitimately sharing a warning sign, which is I am thinking about this.

Listening for those warning signs, "I don't think people would care if I were dead. I've been thinking about killing myself. I want to die." All of these statements are warning signs that somebody is suicidal.

There are a bunch of other risk factors, but those are some of the big ones that you can think about. These are really important things to look out for.

If that's the case for the general public say, "Hey, what's going on? I care about you. Tell me." Even though this might not be something that you ordinarily would do, "Have you had thoughts about ending your life?"

They're like, "Well, actually yeah, I have."

You're like, "Oh, okay. Well, so tell me about that." You're not ... as the general public, you're not expected to have the checklist that the professionals have, but you want to tell ... have them tell the story and then know that you can get them help. That doesn't necessarily mean sending them to the emergency department or calling 911. Call the National Suicide Prevention Lifeline. If you don't know what to say, get on crisis text line: 741741. Just text 'help,' and then you'll have somebody pop up on your cell phone.

You can be like, "Hey, I'm talking with a friend of mine here who doesn't want to talk to anybody else, but they're thinking about killing themselves. What do I do?" They'll help you through it. There are a lot of things that we can do, but those are a couple of them.

Greg Wright: You've actually done work on our language around suicide. For instance, a person died by suicide. Explain that more. Why is this so urgent for you?

Jonathan Singer: Yeah, so there are what we think of as preferred and problematic terms around suicide. Now, I'll say social workers have been on the front lines of honoring and acknowledging the fact that the way we talk about issues and problems and people changes reality.

We used to say "The schizophrenic person," and now we say "Person with schizophrenia." We use person first language. Sometimes we've acknowledged that that misses the mark, too. You wouldn't say a person who is deaf, you'd say a deaf person, because that is central to who that person is.

In the field of suicide prevention, we've heard from folks who have lost loved ones to suicide and folks who have survived suicide attempts that the word 'committed suicide' is problematic. It's problematic because of the association of the word 'committed' with 'committed rape,' 'committed murder.'

Even some people have said, "Well, you're talking about like committing someone to involuntary hospitalization, right?" There's a negative association with the term 'committed suicide.'.

You can say "Died by suicide," and the focus then is on the fact that somebody died. Yes, it died by suicide, so you're talking about the method, but really the focus is on death. That's where we want to focus because that means we've lost somebody that we care about. There's a death. Same thing that we don't say a failed suicide attempt or a successful suicide attempt because then it sets up the act as you fail if you live and you succeed if you die. That's a problematic balance because we want life to be seen as the success. We want people to have successful lives.

There are other terms that we don't say "People threatened suicide." We say, "People disclosed suicide," because it's making it sound like, "Well, you're threatening me by telling me that you're suicidal." Well, you're not.

You're just saying, "Hey, I don't think anybody wants me to stick around. That's not a threat. That's just where I am." It's a disclosure. There are these phrases and these ideas, and Sean Erreger, who is a social worker in New York. He and I wrote a piece for new social worker magazine called 'Language Matters.' It was talking about suicide and the terms that we use, and I was honored.

Greg Wright: Yeah, it won the NASW award. I forget the year, but...

Jonathan Singer: Yeah, I think it was like a 2016 NASW Media award, which is, I have to say I was so proud of that because it was NASW acknowledging how important it was to have this piece out there kind of doing some myth-busting and some education about how we talk about suicide. I was very honored and very, very proud. Those are some of the things about the language that we use around suicide, so I appreciate you asking about that Greg.

Greg Wright: I also want you to plug your own podcast as well, a very, very successful one.

Jonathan Singer: Since 2007 I have been doing the Social Work podcast. I talk about all things social work. Students and professionals have said how much they have learned from it. People have used it to help them study for licensure. Students... have listened to episodes because professors have assigned it, and sometimes they found it on their own because they didn't really understand what was going on, and so they found that the interviews that I do or the topics that I cover have been helpful in their own understanding of the profession. This is what I want people to get out of the podcast. It is information that will help them do their job better.

Greg Wright: Absolutely, and I think that it's working. It definitely is. Jonathan, thank you so much for being our guest on Social Work Talks.

Jonathan Singer: Oh, it is an honor and a pleasure. Thank you so much.

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