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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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LINDSEY FENTON: OK, we'll go ahead and get started. I want to thank everyone for being here today for Facing Suicide Prevention and Postvention. This webinar is produced by WPSU, and is made possible by a grant from Twin Cities Public Television and the Pew Research Center as part of TPT's Facing Suicide Project. I'm Lindsey Whissel Fenton. I'm a senior producer and director at WPSU.

I am joined by Dr. Frank Campbell, Marisa Vicere, and Dr. Deepa Sekhar. Frank is the founder of the National Suicideology Training Center, former executive director of Baton Rouge Crisis Intervention Center, and the crisis Center Foundation in Louisiana. Has more than 20 years of working with those bereaved by suicide. Let him to introduce his Active Postvention Model, APM, which we will talk about a little bit more in this discussion. Marisa is the resident is the president and founder of the Jana Marie Foundation, a nonprofit organization in Central Pennsylvania that works to spark conversations, build connections, and promote mental well-being among young people and their communities. The foundation is named for Marisa's sister Jana who died by suicide in 2011. Deepa is a pediatrician at Penn State Health, and associate professor of Pediatrics at the Penn State College of Medicine, and executive director of Penn State Pro Wellness, a non-profit organization that is committed to educating and inspiring youth and their families to eat well, engage in regular physical activity, and become champions for bringing healthy choices to life.

We'll be talking about a range of topics related to suicide prevention and mental health in general. We will get to as much as we can. That includes factors contributing to thoughts of suicide and suicidal behavior, how to seek help, the concept of postvention, relationship between physical health, mental health, grieving as a suicide loss survivor, and a lot more. We want you to be part of this conversation. So we encourage you to submit questions in the chat, and we'll get to them as time allows. But before we begin, I do want to take a quiet moment to remember those who are not here with us because they died by suicide.

So to get started, I'd like to ask each of you to share one myth that you would love to bust when it comes to suicide or mental health in general. Frank, let's start with you.

FRANK CAMPBELL: Well, I think the one that I run into the most constantly is the myth that talking about suicide somehow will create an environment that produces contagion, and that people begin to think about thoughts that would not have thoughts of suicide before. I think we've got a couple of years of not talking about suicide and it hadn't really done any prevention work. We know from Cheryl King's work that talking about suicide is much safer, especially in the schools where it seems to be most prohibited while they're also doing the play this year Romeo and Juliet, which unless they've rewritten the ending is teen suicide. So it always is confusing to me that people can on one hand see Romeo and Juliet as a romance story and not take the opportunity to talk about choices, and they do that by saying, well, we can't talk about suicide here. We can put on a play about suicide, but we can't talk about suicide. So that'd be one myth I'd like to see go away.

LINDSEY FENTON: I'll just follow up with that. We made some videos for this project and we were concerned about putting them on YouTube because someone said, oh, they might flag it because it has the word suicide. And I'm like, well, all the more need for this project. Marisa, what about you? What's a myth would like to bust?

MARISA VICERE: Yeah. The first one that came to mind is also the one that Frank mentioned as well, that talking about suicide puts the idea in somebody's mind. And as Frank mentioned, that certainly is not the case. I think the other thing that's really important to think about too is, I know being a survivor of suicide loss by my sister, and my cousin, and other family members, is that sometimes there's this idea out there that if we mention their name, that is going to make us feel sad as being the one that's left. And there's not a day that goes by where I don't remember Jana, or Ben, or anybody else who has died by suicide that I knew. And so, I think it's really important that we do mention their names, and that we keep their memories alive, just like we would for any other cause of death.

LINDSEY FENTON: Thanks, Marisa. And Deepa, what about you?

DEEPA SEKHAR: So I guess I often think about depression and suicidal thoughts-- I see a lot of teenagers in my clinical practice. It's no different than any other chronic illness. I find a lot of times comparing to something like diabetes, and telling parents if your child had diabetes they would have days that their sugars were good, days that their sugars were bad, and everybody somehow can get their heads around that. But then when I say it's the same thing with mental health, that they're going to be good days, and they're going to be bad days because it fluctuates like any other chronic illness, I think that's for whatever reason harder for people to grasp.

LINDSEY FENTON: I want to start this conversation actually following up on something we were talking about right before we began the webinar, and I'm going to pose this to Frank to start with, is that we received several questions in terms of risk factors ahead of this conversation, specifically around either families or individuals who have a mental health conditions or history of them in the family, including depression, bipolar disorder, substance use disorder. And then, we also had people asked specifically about neurodivergent individuals, people on the autism spectrum, people with ADHD. Frank, what thoughts do you have on the subject of looking at some of these co-occurring mental health challenges, or disorders, or spectrum disorders in relationship to suicide? What should people understand about that link?

FRANK CAMPBELL: Well, when it comes to suicide, I think, first of all, we have to understand what the lens is that the question is coming to. So if you're a survivor and you've lost a family member to suicide and now you learn about a diagnosis, including diabetes. Depression is associated with diabetes. So you could have this chain of concern by having a physical diagnosis, a mental health diagnosis, a personality disorder, a spectrum disorder, all of these diagnoses. If you look at it through the spectrum of having lost someone to suicide, you're looking at it with a sense of anxiety, fear, hypervigilance, is something else terrible is going to happen. So it certainly will skew your information toward is there any correlation between this diagnosis and suicide? And almost always, you can find some correlation.

Suicide occurs so much across the spectrum it is so democratic method of death and manner of death that we're going to find somebody who has researched that little island in connection to suicide. What they don't share is, the vast majority of people with depression don't die by suicide, don't have thoughts of suicide. They don't talk about the number of-- the vast number of people with diabetes that will never have thoughts of suicide. What they do is isolate those who have, yes, also had this one issue identified and they die by suicide, but they don't talk about all the other multifactorial issues that may have been present in that person's life. So for the survivor of suicide, Marisa with a sibling, she's going to be wondering about those pre-existing conditions that might have been there, and should they show up in another generation, and how hypervigilant do you become when you see any type of behavior.

So I think you can find these answers and you can become anxious. Or you can learn how to just talk about suicide with someone you're concerned about. And that bypasses all of the diagnoses and all of the, yeah, but you know this, and you know this, and, no, you don't know that about that person. It's now being said, suicide is an n of 1. And that's really how we should approach it because all the numbers mean nothing unless one of your loved ones is in those numbers. So if your loved one has died in 2021 and you look at the number of deaths in America by suicide, that number becomes different for you than all the other years because your loved one is in that number.

So I hope that's not a rambling response, but I'm just suggesting that we're quite often look at suicide in one direction and don't turn around to look at it from the other direction, which is the vast majority of people that don't have these problems-- have these problems, but don't consider suicide. It's much more prevalent the other way.

LINDSEY FENTON: I think that's helpful, and we're going to certainly talk more about talking about it. I just want to clarify you said n of 1, so anyone who's not familiar with that reference, it's a study of one. You are the case study. The person in question is the case study.

Marisa, in your work with Jana Marie, you do a lot of work on education, on community education, on educating young people, on educating parents, caregivers, educators. What are some of the-- so we-- be careful, we just said not to focus too much on risk factors or predisposition, but are there certain risk factors that can make someone more vulnerable if we get out of the pathology of something someone might be living with in their life that can perhaps make them more vulnerable to a suicidal crisis?

MARISA VICERE:: Yeah. So we know that the study of risk factors is important just to be aware of what some of those could be, right? And so, we know if somebody has attempted suicide before they're more at risk, or if they have a family member or somebody close to them who have died by suicide, they're more at risk. However, we also need to spend a lot of time looking at those protective factors, so kind of along the lines of what Frank was saying, because we can get hung up on those risk factors. And if we look at any illness that we can think of, so I know diabetes was mentioned earlier, there's this a long list of risk factors for those as well. And just because somebody has one of those risk factors, or even multiple of those risk factors, doesn't mean that they're going to go on and develop diabetes, or same with our mental health, or suicide as well.

And so, while it's important to be aware of some of those, it's more important I believe to be focused on those protective factors. What can we do in our community to build those safety nets and to make sure that we're all watching out for one another? And some of those protective factors that we know of are being close. When we look at young people, especially, is being close to at least one adult. So having that trusted person that they can turn to if they are ever in need of anything going on in their life. We also know that scheduling is really important. Having academic supports is important. Really taking care of their health, so our physical health and mental health are often tied together. So getting enough sleep, making sure that we're exercising, or doing those things that help our body feel good are all really important protective factors to focus on. And as parents, educators, concerned adults, I think those are what we really want to be identifying with in neighborhoods and communities. Like what protective factors are going really, really well in our area. And where are there some gaps and what services could we maybe implement or bring to the table to help fill some of those gaps or needs that are out there.

LINDSEY FENTON: And Deepa, I want to follow up with you because in terms of larger community based intervention. I know you've done some work around universal screenings. And I know your work with Pro Wellness is about healthy well-being promoting behaviors in general, so I'm curious about your thoughts about both at an individual level and maybe a broader community-- whether it's a school level or maybe a senior living facility level, what are some of these things that can be put in place to help promote risk or protective factors?

DEEPA SEKHAR: So Lindsey I think the project you were referring to was called SHIELD, it was Screening in High Schools to Identify, Evaluate, and Lower Depression, and it was a large randomized clinical trial looking at the effectiveness of school based depression screening the same way we do vision and hearing screening to pick up kids who would have barriers to being successful in the school setting, and it worked. So the students that got universal screening were six times more likely to be identified with depressive symptoms and twice as likely to initiate treatment. We also as a secondary looked at picking up students at risk for suicide, and the numbers were even more striking. But I guess the question that you're asking me is about networks that can be set up, or how can we better support people, or get them the resources that they need.

So as part of this project we did some focus groups with students ahead of time asking their opinions about screening, asking them about coming into the medical office because that's where I see adolescents. And I think you're naive as a medical student, and you think that people are just going to tell you stuff and that's not how it works, right? Especially with teenagers, right? If you're meeting a teenager for the first time for 20 minutes after they've already seen your resident, like they don't want to talk to you. And then, I was very humbled by what they said. They were like, well, that person is for my physical health. Why would I tell them anything more?

I actually feel like when I talk to teens now, I'll go through all these questions about their mood, and we do screening, but one of the things I'll ask them is who's your go to adults. Do you have a person in your life that you can go to because a lot of these kids I see once a year, and they're otherwise out and about doing their thing, right? And if something happens to them six months later, they're not going to come to me first, right? So I'm a lot more worried about the kiddo who tells me they have nobody in their life than the kiddo who ticks off three adults right off the bat that they could go to for help. So kind of backing up what Marisa already said about these idea of making sure that teens in particular, because that's who I'm familiar with, can identify adults in their life that they would be able to go to if they were struggling with self harm.

LINDSEY FENTON: Thank you. And then, Frank, I want to follow up. We had a question then in the chat. I know we're talking about teens, but we also want to make sure we include everybody, middle aged folks, older folks. In general, can we list off-- this was a question from the chat, what are some of the other protective factors in addition to that meaningful connection with an adult or another person? What are some protective factors in general?

FRANK CAMPBELL: Well, there certainly are ones that I have relied on in all the years that I've been in this field. And the first one is self-care because it's self-defined though we don't spend enough time I think in the formative years, and I think teenagers would especially benefit from learning how to cope in a crisis situation by having some self-care tools in their bag.

But I want to pause that for a second and just ask in general this question, it's always bothered me that old white men have studied dead white men for the last 50 years, and I'm one of them, because what do we do? We study the high numbers and we get curious about the body count. The reality is if we want to know about protective factors, why haven't we studied African-American women who have historically had one of the lowest rates of suicide in our culture. And I doubt anyone is going to argue with me that they don't live in a stressful environment in the majority of situations. So when we looked at risk factors, we're almost always talking about white population. We're not always talking about people of color or different populations within that.

When we attempt to work in the African-American community because I've been doing this for three years now as an assistant coroner, the community is defined through the church, and it's very difficult for a white man to get into that environment and have any real honest conversations. When I do have honest conversations, it's described as that's a white man's problem. That's not our problem. And yet what we've seen is an increase in African-American suicide over the last 10 years. That should be noticed by everybody for both Black men and Black women. But what we haven't done in these 50 plus years is identify what are the true protective factors that Black women may have that somehow insulates them from suicide as a matter of risk. And I don't think it's just some simple answer. I think it's a very complex use of networking, talking, and a whole bunch of things. Thank goodness we have wonderful African-American suicideologists today working diligently to find answers. But for myself, the frustration is to live in a community where we see a tremendous increase in suicide by African-American males, and yet we're not able to penetrate that issue. And because it's not the high body count, we tend to still focus just on the higher numbers.

So when it comes to protective factors, having those protective factors at one age may be great, and then you may see them disappear at another age. So I think we also need to understand how do we keep putting more tools in the quiver. I had a wonderful person 40 years ago from the Osage Nation say that when we feel in our heart what we know in our mind, and what we speak when our tongue is straight like an arrow, that's mental health. Now we like to call that being congruent in psychology and psychiatry, but the reality is we are the most incongruent society for the most part on daily speech, much less mental health issues.

I love what you're saying Deepa about talking to teenagers. I find it was always important when-- and I don't have enough hair left to work with teenagers because it's a difficult population. But I like to say to them you got five questions you can ask me because they already been asked questions by everybody they talk to. So I like to give them the opportunity to ask me a question. And I found that a wonderful icebreaker because they're not going to talk about what's going on until they know what you're going to do with it. And if we teach them how to cope, how to have a supportive community, how to involve himself in activities daily living, how to do things that give their life meaning, and how to take care of themselves physically, like a four legged stool, if we can build that when they're young, that will be the most trustworthy furniture they have the rest of their life because those four legs of the stool were the most compromised during COVID, and I don't think many people have put them back in place. And that's why my unfortunate prediction is we will see people continue to increase in rates of suicide because they do not have a good foundation to sit on to struggle with life's pressures.

And the one question I'll say left off of so many assessments is the one Marisa said, have you ever lost someone to suicide? We know it's a risk factor. It's role modeling behavior. It's a public health issue for me. So what I have frustrated myself with is for 50 years I have researchers that send me instruments and say what do you think? And I say, I think it's great except for there's no question on here about have they ever lost someone or been impacted by someone's death by suicide. And they'll say, well, we want to keep it to one page. And I'm thinking, that's not the answer.

My best friend took his life when I was 12. I can still tell you the clothes I was wearing the day my teacher took us out onto the ground and told all of us about his death. We were not equipped to understand what was going on. And to this day, the ones of us that are still alive, if we have a reunion, they all look at me and say, what do you think he was thinking? I don't know any more now than I did then. So it's frustrating sometimes that we can't get to a handle, if you will, and grab it and say, this is it. This is the thing we need to do.

I think we not only have to work with each individual population that we can identify at risk, but we need to keep those at-risk features in our mind and using the parlance of the assist training by living works, see it as an invitation to explore. My problem and the reason I started the National Suicide training centers, the people we expect to know what to do when it comes to suicide haven't a clue. And I see all too often people being hospitalized for the proper diagnosis, risk to self or others, spend three to five days in a hospital and there's never one note that anybody ever talked to them about suicide or thoughts of suicide. Voluntary admissions who then go home and the vast majority take their life with the manner that they described they would use within 24 hours.

LINDSEY FENTON: I do want to get to talking more about having these conversations, and also about postvention, but I want to follow up a little bit Deepa on-- and talking about protective factors and links between physical health, mental health, and also following up on something I saw in the chat, which is somebody was saying that they would love to bust the myth that depression or suicidal thinking or behavior is a weakness of character.

And I will disclose, I'm someone who has dealt with depression throughout my adult life. And I remember having one bout where I was saying to my therapist I'm doing all the things. I'm being diligent about my sleep. I'm exercising. I'm eating well and nurturing connections. I'm getting out in nature and I still can't shake this. And the solution for me anyway was adjusting my medication. So I wanted to also touch on the idea of what role that may play and having a conversation with someone's health care providers if I guess I think there's still a little bit of a stigma, like that's a cop out, or you're giving up, or you need to try all these other things. And if in your experience is it a both and conversation, lifestyle factors. And like you said, that you had diabetes that would be a different conversation. So I guess your thoughts on the role that all of those interventions can play together.

DEEPA SEKHAR: Yeah. Sure, so I think some of it depends on age. So when I have these conversations with families and we're talking about medication and therapy, those are kind of our two big tool boxes that we talk about in primary care, I think the preference is if that we think a child would engage with a therapist to go that route first. But I will also have a very honest conversation with families because sometimes you can tell by the way the child is interacting with you that the symptoms are pretty severe, and many of us know the wait list to get in with a therapist is long in many cases. So then I'll talk about the fact that there's synergy between those pieces.

And also, I think the other big thing for parents is like this doesn't have to be a lifelong medication, right? So I think that's the other scary thing, especially when I'm talking to parents of young teenagers, that they're now going to be on this for the next 50 years. Now, maybe they will be, right? But there's also the possibility that working with a therapist will give them enough tools in their toolbox that we can talk about a year later, and I always talk to them about this. We will continue to reevaluate each time you come in do, we really still need to be on this, or are you now at a good place that you have enough strategies to manage how you're feeling when you're getting into trouble, but we don't need the medication anymore.

So it's a very individualized conversation. But then, Lindsey, I do fall back on that diabetes analogy, especially when I feel like families are struggling, and we'll literally say to them if I told you your child was diabetic and needed insulin, you wouldn't have any issue.

LINDSEY FENTON: I think that's such a helpful analogy. I want to share a comment that was emailed to us prior to this webinar, and, Marisa, I'm going to ask for your thoughts on this and some of the conversations you've had through Jana Marie's work,

"As someone who struggled with self-harm and has lost ones to suicide, I find it really hard to find the space to talk about it without all the sirens going off be it to my therapist or family. There's little place for non-emergency conversation, which is even more isolating."

So in the work you've done and your personal experience, how can we strike this balance between expressing concern, asking directly, but also holding space for just people authentically sharing what they're going through and having that sort of freedom to be open?

MARISA VICERE:: Yeah, I think having that space is just so important. When we lose a loved one in another way, we often will hold that space where somebody can share about their emotions, their grief process, and the questions that they may still have lingering. And when it comes to stigmatized death, whether it be through suicide, overdose, or other forms, we sometimes don't hold that same kind of space. That authenticity isn't there. And sometimes that lies in our own discomfort in the conversations as being that support person. We may not, as a support person, know those words to say. And in fear of saying the wrong thing, may instead shy away from those conversations. But for the person who is left grieving, that is really difficult then to have to take that all on and process those feelings, and emotions, and thoughts all by themselves.

And so, I do think that having spaces where we can be authentic and genuine in how we're really doing is so important. At Jana Marie Foundation, we're not counselors. But we all can have that listening ear. So we do have survivors of suicide loss support groups at our facility, and I think that's a space that often will allow for some of those conversations to happen where you're in a setting with individuals who have experienced something similar, and who understand a little bit about where you're coming from, and where some of those emotions may be stemming from, and allows for more open conversation.

I also think just being honest is really important too. So going into a conversation with your therapist or whoever is the support people, and letting them know how you're doing right now, and understanding that if they do ask the follow up questions that it really is coming from that genuine place of concern and making sure that you're safe, and that you have those strategies right now to get you through that hardship. And if there is worry that maybe those strategies aren't there, then that therapist or support person is really going to be working with you on helping to figure out some kind of safety plan to help you and make sure you have those resources of 988 and crisis numbers that are local to you so that next step if things become really overwhelming as you're processing.

LINDSEY FENTON: Thanks, Marisa. And just to clarify if anyone's not familiar, I saw we just put it in the chat, 988 is a free 24/7 hotline. It's essentially kind of a 9-1-1 for mental health crises. Or even to someone who might need help or resources, we want to make sure to share that resource. I'm sure we'll mention it again.

And, Marisa, I kind of want to follow up. You talked about making sure these spaces are held for people, especially people who are grieving the death of someone they care about by suicide. So, obviously, you've done so much work to create the space, but I don't know how much of this these spaces were held for you and your own experience. So as a suicide loss survivor of your sister, what were some of the things, or some of the things that have or continue to be helpful for you in your grief over Jana's death?

MARISA VICERE:: Yeah. So those spaces weren't always there, which is really what motivated me to start the Jana Marie foundation. It was a very isolating experience for me because, especially back then, even 10, 12 years ago, it wasn't really talked about when somebody died by suicide, those conversations weren't had. And so, I didn't always know how to process or what to do. I really found strength though in being able to connect with my family. We all grieved in very, very different ways. So making sure that we understood what each other needed was really important during that time, and recognizing that there were some really big differences in that journey. But I was able to lean into my family and to some of my friends to help me through that time. And then, just really tapping into my own coping strategies.

So Frank mentioned the importance of self-care earlier. We all have our own self-care strategies that have worked for us in the past. And so, somebody had once mentioned to me like, hey, you've made it through a lot of really hard things in your life before, what helped you during that time? And that helped me really think about what were those strategies that I used before, and can I still tap into those now. And a lot of those for me were getting outside in the nature. So going on hikes, being in the woods somewhere, camping. And then, also exercising, making sure I was getting plenty of rest. Those things were really what I needed during that time to allow myself that process of grieving.

LINDSEY FENTON: Thanks for sharing that, Marisa. And, Frank, I want to follow up on the idea of postventions. So for someone who has lost someone, or community that has experienced someone's death by suicide, we hear a lot about prevention, but I think postvention might not be as familiar a term for people. Can you briefly explain what that means?

FRANK CAMPBELL: Sure. When Shneidman came up with the terms, he didn't want them hyphenated, but Word Perfect will try to do that to you. So just be aware that it's one word. Pre meaning before, inter meaning during, and post meaning after. So I've added one hyphenated term, and that is post dash intervention, to acknowledge those that have had an attempt. Whether it was an internal intervention, or an external, or accidental intervention, they are after an attempt. And I wanted to do that because I didn't-- had originally put those who have had an attempt and those who bereaved by suicide together under the word postvention, but later in life agreed with me that we should have always had them separated. They deserve their own category even though there may be overlap.

Postvention though is contacts we do following a death by suicide, which is the opposite of what most communities know to do. They love to say, I don't know what to say or what to do. So I like to say, great, good idea. Why don't you say that, and add that I'll listen to anything you want to tell me about your son, daughter, brother, up to 45 different relationships we've worked with. So when I was president of AAS, one of the things you have to do is present some model or something to show that you I guess know what you're doing. And I had already been working for 20 years with families weekly that had lost someone to suicide and doing a weekly support group. What bothered me. It was almost 4 and 1/2 years on average between the death and then stumbling on to help where they already had lots of other maladaptive ways of coping going on. So I wanted folks to get help sooner. So I created the active postvention model instead of passive, which is what I think most communities have where the people have to find help on their own.

So I envisioned this idea of a team of survivors who have been able to feel, deal and, heal from their loss in order to then help, and be altruistic, and that is also very wonderful post-traumatic growth was the concept. So we saw these loss teams to stand for local outreach to suicide survivors who could be at the scene and work with the coroner or police department in a way that doesn't violate the crime scene, that has to be at first explored as a potential foul player or homicide. Suicide won't be ruled in for several weeks until after toxicology comes back. Quite often the family know they've witnessed or I've been there when the death occurred, or found, or discovered the body, so they see it as a suicide already.

Our teams go out without the statement of we're here because it's a suicide. They say we go to sudden and traumatic death as volunteers. We've all had a sudden and traumatic death. And then, if the newly bereaved say, really, what happened. So in my case, my son took his life, or my daughter took her life, or spouse, and they go, oh, then you know what I'm going through. But see at that moment in time, they believe they're the only people in the world that have ever had somebody die by suicide. So that paradox-- and the reality is that probably their neighbor on the left or right has also been impacted by suicide, but we never ask these questions.

What we found was that people who get a loss team visit come in for help within 47 days. They come in much sooner. But here's the gap. We don't have enough support for the survivors in this country or in the world. So loss teams really are only a referral program. There's no treatment going on other than the installation of hope that the newly bereaved can get help and this person standing in front of them did that already. So they can point them like a lighthouse to a safe harbor where they can get help. But the dearth of support groups in this country and groups that really help people is a major, major gap.

LINDSEY FENTON: So is it fair to say-- one thing I'm hearing is that even if maybe there isn't a loss team in someone's community, or they don't have access to formal support, one of a sort of community wide or even individual wide strategy is to at least leave open the door to communication about this.

I want to reiterate and restate something. I made a note you said of just I don't know what to say or do, but I'll listen. I feel like that even that is language or a tool that a lot of people don't have, especially around suicide, about death in general, but especially around suicide. So is it fair to say that opening conversation is kind of the first step in a more active postvention?

FRANK CAMPBELL: Absolutely. Listening is a very powerful intervention that is underappreciated by most people. Most people tend to move toward advice giving, which is almost the least helpful thing you can do at a time when nobody knows what to do.

The teams aren't there to do anything more than point people toward help. But they do a tremendous amount of listening. They're able to also be there and support the family if they need help at the time of the funeral, and they'll be able to come and meet with out-of-town family and refer them. But listening is one of the most powerful interventions.

I point to the fact that I've lived in the South my whole life and we grew up with rocking chairs on the front porch, but what we did was sit-in them and talk to each other. Today, they're all chained together so nobody will steal them and we're all inside where the nice air conditioning is. We've lost the kind of communal support that I see it almost-- when I would go to Cuba to work, I would see it. All the South American countries, they will build their homes with the port so they can communicate with each other and talk. We have Facebooked ourself away from communication. And COVID has only reinforced that I'm afraid.

I know I'm kind of meandering here, but you just generated that thought about when you don't have someone to literally listen to you, then you don't speak out loud. But when you speak thoughts of suicide out loud and you hear them back through your ears, it actually changes the power. It makes it no longer a rumination. It makes it speech. And people have said out loud on crisis lines, I can't believe I've been thinking like this because hearing it said is different. I know it sounds a little low key, but I've worked crisis lives for 30 years and I can tell you, talking works. Listening is why it works.

LINDSEY FENTON: So I know that one of the most oft cited things I hear is to ask someone directly. I've also had personal experience with friends who have lived through crises. And I know one friend in particular, I'm thinking of what they said to me is, “if you had asked me flat out do I have thoughts of killing myself, I would have said ‘no.’ But if you had asked me more passively, do you do I not want to be alive anymore, do I wish I wasn't here, I would have said, ‘yes,’ because the level of denial was so high.” So in those conversations, and Frank, Marisa, Deepa, feel free to chime in about if you or concerned about someone, I know that's kind of the first line of asking that question directly.

And I know it's hard to give too many specific scripts in a broad training like this. But what are some tools, some go-tos that you have for just opening the door to have a hard conversation like that with someone? Deepa, I'm wondering in your practice if you have a patient you're concerned with, how would you open that conversation? I know you spoke about that a little bit, or even in your personal life.

DEEPA SEKHAR: Lindsey, this may not be exactly what you're looking for. I mean, we give all of these adolescents standard screening tools, right? So that's often the place where things will come up. And it's interesting-- I also ask because I've found sometimes there's a discordance between what they marked down on that sheet of paper because there's been a lot of talk about this in the medical field, and especially in pediatrics because when the teenagers are filling out these scales and their parents are sitting right next to them, can they really be honest?

I had a kiddo this week who said to me, “I didn't fill this out honestly because my mom kept looking at all my answers.” And so, then that was the opening to a conversation between the two of us. I think one of the big pieces for me and talking with a teenager is figuring out the level of risk, right? Like do they do they have a plan right away, or do they not? And then, can we move from there into what we need to do in terms of getting them help? I think also one of the hardest pieces to negotiate in like your 30 minute office visit is if they do have a plan, then we've got to loop in their parents, and how can we do that effectively because obviously everyone is very emotional and stressed? And so, you're trying to move that situation along effectively.

LINDSEY FENTON: And I want to-- in terms of opening conversation, Marisa, when I was researching for this project, I also want to note we'll be posting links throughout the chat of our website around this. We created a series of short videos. They're 30 to 60 seconds that have just some of these tidbit takeaways.

But one of the things when I was researching for these videos as they were talking about, especially talking with teens with younger people, the sit down face to face conversation can be a little intimidating, or might not be the way to do it. And that's sort of a side-by-side activity. It might be when you see more of feelings coming out. And I know that a lot of what you do with Jana Marie Foundation is based around art, or creativity, or sort of these other activities. So I'm curious in your experience, does that hold up? That having some other sort of thing happening can actually help open that channel of conversation versus, OK, we're going to sit down, have a cup of tea and hash it out?

MARISA VICERE:: Yeah. I think it's important to recognize that each of us is different. There's no cookie cutter approach that that's going to work 100% of the time because each person is their own unique self. And so, looking at my own life, I am not a fan of having to sit the face and sitting down behind closed doors. Like it immediately makes my own anxiety really high. And so, I think it's important to recognize that we are all different, and may need to tap into a variety of different settings.

When we approach somebody, we do want to make sure though that we are limiting distractions. So things like our watch is going off continuously, or checking our emails, or having our phone ringing constantly. All of those things distract from a conversation. We also want to recognize that the way that we approach the conversation can have an effect, right?

So if I come in very judgmental and kind of have a harsh tone in my voice and those types of things, it could hinder that conversation. They're not going to want to talk to me or further that conversation in any kind of way. We also want to think about our setting. Making sure that it is in a private setting. So I just said, I don't like being behind closed doors, right? That's a private setting but might not be one that's going to get me to open up. But I do love going into little nooks and crannies and finding a spot where I can sit down and have a cup of coffee that's a little bit out of the way of the majority of people in the place. And so, just keeping all of that in mind. What's a safe environment for the person that we're communicating with, and what's going to help them along the way? We often will have our art supplies around. We'll have fidget spinners. Go for a walk-and-talks. Whatever it might be because those side-by-side activities could be really helpful for someone. I know growing up when my dad wanted to have a serious conversation about anything in life, he'd always say let's go in the car. Let's listen to this new soundtrack that just came out or whatever it was. And sure enough, it tricked me every single time we would go in to listen to music and slowly that radio would turn down to have that conversation. So really tapping into all of those different strategies are really important. And then, allowing that person that we're communicating with the space to share what's going on.

When we approach someone right off the bat, they may not be ready to open up. They might not be ready to share. We need to have that trust first. And so, sometimes that takes a couple of times for that approach, but knowing that they have somebody that they can come to and talk to is really important. So we want to leave that door open whenever we can. And then, create that space where we can listen. That thing, I don't really know what to say right now, but I'm really glad that you told me, right? We're going to figure this out together. Those types of words that really let them know that they're not alone are so important.

So, yeah, I think just recognizing too that we may try a strategy, and we might go into it with really well intentions, and it might not connect right with that person. And that's OK too. We're human, so if we're really worried about somebody, keep trying. Let them know that you really are there and that you care, and just be that person that they can come and talk to. And if you're not that person that they're going to open up to, that's OK too. Ask them who might be a better fit for them to talk with.

LINDSEY FENTON: That's great. And what I'm hearing from that as a key takeaway, is like don't always expect it to be this one and done conversation and keep it as an ongoing line of communication.

We have about 10 minutes left. There's at least two or three questions I want to try to get to, so we'll try to touch on these sort of succinctly.

This question I love that came in the chat, in today's landscape of texting, posting on social media, or just disconnected chat communication models, how can you effectively let the person you are listening to an avoid coming up as giving advice because, obviously, body language can go a long way, but if you are conveying something by text, any tips or any thoughts on anybody about, especially at a distance, how to offer that to open ended support to someone?

FRANK CAMPBELL: Texting has been a major challenge. On one hand, it draws in more youth because they use this as a primary form of communication these days. But a text and my consultation with crisis lines should be used to move a serious issue into a phone call so that you at least get the tone of voice because you are going to have folks that everything has to be an acronym in mental health.

So VQ is the term that most crisis lines use for someone where the validity is questionable. So you're not sure if they really mean what they're saying about anything or whether this is all just a prank. So by moving that text into a phone conversation, you have much more access to the truth. Because tone of voice, the music under the words, are what really help us have a better understanding. Content is such a small part of communication. And if you don't have body language and you're on a text, you really don't have much of anything. If you can't move it on to a phone call, then I think that might create some sense of our validity.

I would always encourage folks that whenever possible to say this is a really important conversation. I think we need to speak about it. And they have that phone number there in the text world, so they can call that number and see if they can reach out. But to say I'm concerned about you, and I'll need to really talk. We need to have a conversation is an important way to bridge that person who's wanting to get help and is hearing you sincerely say, we need more-- I need more information to be able to help. I think it's been a litigious issue and not one that crisis lines have been successful with by using texting as a way of determining risk. So I do think that it's in everybody's best interest to do our best to have either face-to-face or at least verbal communication of around topics, not only a suicide, we need to remember that risk to self or others. Others is an important part of that diagnosis and concern because about 80% of active shooter situations began and end of the suicides. And had we intervened on the suicide risk, we would have prevented all those homicides.

So I think with the information I've read about from the Secret Service on these active shooters, we keep forgetting that it's more at risk than the individual. And people that are difficult to work with, it's easy to minimize their risk factor because they're just hard to work with. And yet, those personalities are the ones that often die by suicide and take others with them.

LINDSEY FENTON: And I want to talk more about language in the few minutes we have left. I just wanted to follow up on the text. If we're a personal anecdote for whoever wrote that question, if we're talking not about risk assessment, this is not the same. But I know I lost my dog last year and that was an absolutely horrible time for me, and I will say texting for me was like a lifeline at that point because I didn't have it in me to physically talk to someone. It was too exhausting. But I will say that the thinking of you, I know you're not OK but are you OK, I wish I knew what to say texts meant so much to me in that very specific situation. So I'm not-- I agree. I like your language and I want to reiterate that around this is an important conversation we need to have in person if you're kind of concerned about someone. But I think in certain situations and in another project I did called Speaking Grief, I know other people have echoed, especially in this more disconnected time, don't underestimate the power of a simple, hey, thinking of you text. That can do a lot to help someone feel connected.

We are down to just a couple of final questions. I do want to follow up on the specific language. Deepa, if someone does answer, yes, I'm having thoughts of hurting myself. I'm having thoughts of suicide. Or if you are concerned even if they're not sharing that with you, what is the next step? How do you respond, and how do you move forward with getting them help because most of us are not trained to intervene in this situation?

DEEPA SEKHAR: So I will end up looping in their parents, as I mentioned before. And then, we have to decide-- I mean, unfortunately, I work in a primary care office, right? So it's often then sending them to the emergency room. We have a really great social worker who helps our practice out who's able to give us a heads up on what availability is in terms of getting teens into placement if they're going to need an inpatient stay for a period of time because I think one of the biggest pieces for my end is sort of setting the family up with what to expect. You're going to go there and this is what's going to happen. And you may end up waiting there for some time, right? And so, that's some of what we'll do.

It's tough because there's not enough resources out there. And I know many schools have described this to me, and this happens in primary care too, and Frank alluded to this. They'll go for their inpatient stay, and then all of a sudden they're discharged, and it's like they're going to see the psychiatrist in two months. But then, who's managing stuff in the meantime. And I've had school folks tell this to me too. Kids will leave for an inpatient stay, and then all of a sudden, they're back with very little information about what happened in the interim and what supports are needed. So it is a challenge.

LINDSEY FENTON: So those are kids-- I want to also follow up, Frank or Marisa, if you have thoughts on if we're not talking about a child or adolescent, if it's another adult who is in your life and you ask them and they say, yes, I'm having thoughts. Or I saw a question about if you are concerned even if they haven't said that, what can you say and do to help someone who might be in a crisis, Frank?

FRANK CAMPBELL: Well, what I would do is work on safety plan, what we can do to keep them safe. But there trainings that have been around 40 years for intervention, and for the last 10 or 12 on how to work as a clinician with a person at risk. The vast majority of people haven't taken these trainings, and that's what's frustrating to me.

We would work on keeping that person safe, and we would talk about resources for them. Hospitalization wouldn't necessarily be my first goal because they might not need that. Having thoughts, thoughts won't kill you. Behavior will. So it's more important to talk about how far can we get with a safety plan, and what resources can we bring to bear to help this person, regardless of their age. The vast majority of people that are over 65 that die-- they die by suicide, they've met physicians within 30 days before they died. And only recently, in my own community, does every regular checkup begin with if they've been having thoughts of suicide or have been depressed lately. And I've witnessed this the other day, I'm so relieved that after 40 years of preaching this I'm seeing that happen in my own community. But we all will benefit from knowing more rather than-- and I appreciate Deepa's comment.

It is so hard to watch the process of someone with thoughts of suicide in an ER because if you talk to the ER folks, many of them have a internal bias against helping people who have attempted because they see them as not the mission they came and signed up for. And so, I've had people elope from the ER and go jump off the roof of the parking garage of a hospital because they were never-- no security was with them, nobody sat with them, nobody really knew that we are stigmatizing this person's behavior and not helping them. And as a result, now there's a much bigger sentinel event at that facility. And then, we got to hear all the stuff that went wrong.

All of us need to know if we're really worried about somebody, don't leave them alone. And if I don't know what to do, pick up the phone down 988. Get a counselor on the line with you and say, look, I'm sitting here with this friend of mine. He tells me he wants to die by suicide. I'm really worried about him, and I don't know what to do. Tell me what we can do. And that 988 trained person will have ideas that you can't focus on at that moment. And it will all calm down. The vast majority of crisis lines, the vast majority never have to do any kind of search or identify the person on the other end. They just work with them and deal with it. By talking and not being afraid, they tend to be able to calm that person down and get resources. There are times when hospitalization is the only way we can keep them safe. And that's when we need to use that resource. But, boy, it would be nice if we had a short line when we needed that. But too often they sit-in chairs for hours and the whole family gets up and leaves.

LINDSEY FENTON: So I'm hearing—

FRANK CAMPBELL: It's punishing.

LINDSEY FENTON: I'm hearing, don't leave them alone, call 988, are two really great tangible things that an untrained person can do.

And just to follow up, I saw Becky shared-- we have a video that Frank actually helped develop talking about just in general what sort of things to think about in a safety plan. Things like getting lethal means out of their space, staying with them, not leaving them alone.

We are almost out of time, but we did have somebody ask about recommendations on speaking about a safety plan. Is that just something-- Google suicide safety plan and folks can find resources?

FRANK CAMPBELL: As part of training CAMS, C-A-M-S, is one for clinicians to learn how to work. Suicide to Hope is another one from Living Works that brought you ASSISTS and Safe Talk. So these programs are out there and they're part of being trained. And that's what I encourage people to recognize, anyone can get trained. Clinicians definitely need to get trained, but anyone can get-- there are gatekeeper trainings, all types of wonderful trainings have been around for decades. Just like CPR, we need suicide first aid training.

LINDSEY FENTON: That's all we have time for. This has been so great. I want to remind people if they know someone who wanted to attend but couldn't, this is recorded. We will share it. It'll be available online and on Facebook. We'll also have some additional resources we can share. Reminder, Act 48 credits are available. If you're a Pennsylvania based educator, you can complete the short survey in the chat link to get that credit. You can also complete that for general certificate of completion if you're not in Pennsylvania.

This event is part of an ongoing series of content as part of WPSU's effort around mental health grief and other difficult topics. And it was produced and made possible from a grant by Twin Cities Public Television and the Pew Research Center. The views and conversations in this don't necessarily reflect the views of Pew Charitable Trusts.

I want to thank everyone for being here, especially our panelists. I want to thank people for contributing to this conversation. And Thank you to Dr. Frank Campbell,

Marisa Vicere, and Dr. Deepa Sekhar.

And we would appreciate, even if you're not looking for credit, if you would help us hone in on topics you'd like to see on the future by completing a short survey that is in the link to this chat. Again, we so appreciate you being here. We know these are tough topics to talk about, but talking about them is what will make a difference. So thank you for being here. I'm Lindsey Whissel Fenton. On behalf of me and everyone at WPSU, thank you and be well.

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