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Webinar: When Sexual Assault Survivors Call: Suicidality within the Context of Sexual Assault
Webinar Description: Participants will gain a better understanding of the increased risk of suicidal thoughts and behaviors among survivors of sexual assault, and will understand the importance of discussing suicide and assessing suicide risk for the survivors we support. Participants will be able to utilize strategies gained to engage the survivor who is suicidal with increased confidence. Additionally, participants will learn about how to work and advocate with systems that respond to suicidal behavior.
Webinar agenda:
* Finding a place for risk of suicide in strength-based work
* Understanding the relationship between trauma and suicide among survivors of sexual violence
* Prevalence of suicidal ideation among survivors of sexual violence
* What to look for: Subtle and overt signs of suicidal behavior
* Tools for responding to suicidal thoughts and actions
- Respectful conversations and interventions
- Engaging other systems and resources (including rape crisis centers)
* Self care: Taking care while giving care
Webinar Duration: Approximately 101 minutes
Janice Mirabassi: Good afternoon everybody. You’re on the call, When Sexual Assault Survivors Call: Suicidality within the Context of Sexual Assault, and welcome to this webinar. My name Janice Mirabassi and I’ll be the moderator today. I’m also a Program Coordinator with the Massachusetts Department of Public Health and I work with all of the Rape Crisis Programs in the State of Massachusetts. We’ll be co-sponsoring this webinar today with the folks from our Suicide Prevention Program here at the Massachusetts Department of Public Health.
Before I introduce our presenters, Lisa Hartwick and Elisabeth Nash Wrenn, I’d like to review a few housekeeping issues. First, if you experience any technical difficulties with either the audio or the video for this webinar, please jot down this number. It’s also written up on the screen here in the chat section. This phone number for any problems that you’re having is 1-800-843-9166. Again, that’s 1-800-843-9166 and a ReadyTalk representative will be more than happy to give you a hand.
Secondly, all the phone lines have been muted except for the presenters’ and for the moderator’s so please use the chat function located in the left corner to type any questions that you may have. Given the number of participants, Lisa and Elisabeth will do their very best to answer as many questions as possible as we go along and at the end of the webinar during the question and answer period.
Before we start, I would like to ask -- let me move to the next slide -- we have a response question. You should be seeing it up on your screen and we would like to get an idea who has joined us today. I’m going to ask that you select the title that most generally represents the work that you do in your field. If you choose the option ‘something else’, if you would like to do so, you may also send us a little message through the chat function and tell us what it is that you do that’s not represented. Please feel free to choose and press the submit button and we’ll wait a second to get the results.
If more folks join in, we’ll see more results as we go along. I have a list of the participants as well and, as you can see, we have a lot of advocates who have joined us today. Registered for this program, we have many rape crisis centers, domestic violence programs and shelters, some community-based suicide prevention programs, schools, victim witness programs, family planning and Planned Parenthood programs, a sexual assault nurse examiner, someone from the Women’s Commission, health centers, tribal nations, mental health services, and therapists. I would say, looking over this list, that the majority of folks who are joining us today are focused on survivor services for people who’ve experienced sexual assault and/or intimate partner violence or sexual assault within the context of intimate partner violence. Just so you know, that’s who is with us today.
I’d like to introduce the first of our presenters, Elisabeth Nash Wrenn. Elisabeth worked as the Assistant Director for the North Shore Rape Crisis Center in Lynn, Massachusetts from 2008 to 2011. Prior to her work with the North Shore Rape Crisis Center, Elizabeth worked for the Department of Health Bureau of Substance Abuse Services for seven years.
She is on the Board of Directors for Lynn Economic Opportunity, as well as for Salem State University School of Social Work Alumni Organization. Elisabeth received her MSW from Salem State University with a focus in end-of-life care. She’s currently dedicating her life to raising her beautiful baby girl, Georgia Grace. Without further ado, I’d like to turn it over to Elisabeth.
Elisabeth Nash Wrenn: Thank you so much, Janice, and welcome everyone. It does look like we have a diverse group here on the presentation participating today, which is great. I did want to start with just giving an overview of what I’m going to be covering today. I’m going to do a quick overview of sexual assault prevalence. I wanted to be mindful of the fact that not everybody on the phone call today works in the field of sexual assault services. Then I wanted to cover the prevalence of suicidal ideations and behaviors among survivors of sexual assault. Next, we want to work on understanding the relationship between trauma and suicide among survivors of sexual assault, a little bit about what makes survivors contemplate suicide. Lastly, I wanted to talk about finding a place for risk of suicide in strength-based work; where and how does risk assessment fit into strength-based work which is the lens used by many advocates in the field, as you know. Strength-based work, of course, meaning that we focus our work on the strengths and resilience of those that we work with.
Janice gave you an overview of my background. I apologize, I skipped a slide there. It’s very sensitive. As Janice mentioned, I did use to work for the Department of Public Health for a number of years and then I went back to get my MSW, at which point I had the opportunity to intern for the North Shore Rape Crisis Center. Upon completing my MSW, I did leave the Department of Public Health to become the Assistant Director of the North Shore Rape Crisis Center.
While receiving my MSW, I had the opportunity to participate in a DPH-funded initiative that worked with social work programs to assess and increase the competency of new social workers in the areas of working with suicidal clients. Our work was ultimately presented at the NASW 2008 Symposium. I bring this up, because as a student I was approached about participating in this project because I was deemed to be working with a high-risk population. Some of the work I’m presenting today is from that.
Like I said, I wanted to do an overview of the prevalence of sexual violence in America. The first statistic is from 2010. It’s from the National Intimate Partner and Sexual Violence Survey. It found that over 18% of women and 1.4% of men self-reported being a victim of rape in his or her lifetime. Statistics vary from study to study especially, I would say, in the reporting for male survivorship. We often see numbers much higher than that.
The next two statistics come from BARCC’s website, which is the Boston Area Crisis Center, for those of you who are not familiar. They have a wonderful website with great information. I would definitely refer people to look at their website for information. This statistic says that around 1 in 6 and 1 in 33 men reports experiencing an attempted or completed rape in their lifetime. Those statistics, I think, are more in line with what we typically see.
The next statistic is for Massachusetts. It’s worded a little strange. The findings are from 2006 that over 4000 adolescents and adults were sexually assaulted in Massachusetts that year and that comes out to be 12 people a day, one every two hours.
Lastly, this statistic is for college-age women. It’s estimated to be 25% of college-age women experienced an attempted or completed rape.
I just wanted to give an overview that we can see that, obviously sexual assault is devastatingly prevalent in America. When I worked as an Assistant Director at the Rape Crisis Center, people would often say to me, “I don’t know how you do that work. I could never work with survivors of sexual assault.” My response was always, “You do work with them. We all work with survivors. It’s very prevalent. The difference is that we talk about it at a rape crisis center.” The fact that we have such a diverse group of people registered today, I wanted to commend you for being from different fields and still being open to talking about sexual assault with the individuals you work with.
Sorry. I’m just getting a little used to how sensitive the cursor is. Like I said, when I was approached to participate in the Core Competencies program at my MSW program, I was very open to joining in but my initial thinking was, “I do work with sexual assault survivors but I’m not actually encountering a lot of suicidal individuals.” Regardless, I think my lens was very black and white, that these were survivors. This is a term used in sexual assault purposes. It’s very strength-based. The definition of survive is quite counter to the thought suicide assessment; it means to remain alive or in existence, to live on; to continue to function or prosper.
We know that our clients are resilient. They survived a significant trauma and they're asking for help. It’s true; survivors of sexual assault are incredibly strong individuals. But, I think we often that the risk is behind them. ‘Survivor’ suggests that the risk is past tense. I think that part of this presentation is to challenge our thinking that someone may have survived sexual assault but they're still at risk.
I want to start out by acknowledging that there are large gaps in research around the areas of suicidality among sexual assault survivors. A lot of the research was done in the 1990’s and was often done with female survivors. I just want to put that out there in the beginning. If you wonder why some of this data is a little on the older side, that is why.
I’m sure that some of you are familiar with the ACE study, the Adverse Childhood Experience study. If you're not familiar with it, I would really encourage you to Google it, to look it up. It’s a fascinating study. It was done with adults and asked them to report experiences in their childhood and it tried to make correlations between childhood experiences and behaviors in adult life.
The study was done between 1995 and 1997. It was done with over 17,000 respondents in primary care clinics. It assessed for childhood abuse, household dysfunction, suicide attempts, and multiple other issues. The ACE study found that over 24%, and 16% of men, self-reported they had experienced childhood sexual abuse; obviously a very high number.
One of the primary researchers on the ACE study was quoted as saying, “Childhood sexual and physical abuse has been strongly associated with suicide attempts.” In fact, the risk of suicide was three times higher for those who experienced childhood sexual abuse. The study definitely found that there was a relationship.
The next study that I looked at was the National Women’s Study, again an older study, but very powerful findings. It was conducted in 1992 and it found that survivors of rape were 3 times more likely to be experiencing a major depressive episode and 3.5 times more likely to currently be experiencing a major depressive episode. I think that’s important so we’re mindful of the state of mind that a sexual assault survivor may be in.
Going further, participants in the National Women’s Study were then asked if they ever thought seriously about committing suicide. The findings were that one-third of rape victims, compared to 8% of non-victims, said ‘yes’. Survivors of sexual assault were 4.1 times more likely than non-crime survivors to have contemplated suicide. We can see there is a real increased risk of contemplation. Then, moving forward, the next bullet; they were 13 times more likely than non-crime victims to have attempted suicide. That’s a pretty significant and staggering difference.
The last study that I looked at, also from the 1990’s, had about 3,000 respondents, just under, and it assessed lifetime suicide attempt rates among sexual assault survivors versus individuals with no known history of sexual abuse. Again, it found that sexual assault history was associated with increased prevalence of lifetime suicide attempts, even after controlling for sex, age, education, post-traumatic stress symptoms, and psychiatric disorder.
I think the next bullet is really important as well. For women, the odds of attempting suicide was three to four times greater when the first reported sexual assault occurred prior to 16 years of age versus when the assault happened later in life; which is important to think back to the ACE study that I referred to and the fact that 24.7% of adult women surveyed said that they did survive childhood sexual abuse. We know that many survivors experience a sexual assault in adolescence.
The ACE study and the Women’s study clearly establish that surviving sexual abuse early in life can create long-term risks of suicidality. So, if we look at studies like the Massachusetts Youth Risk Behavior Survey, which has established that there’s also a short-term risk. It’s not just that childhood sexual abuse puts someone at risk later in life, the risk is immediate as well; very short-term risk. The YRBS in Massachusetts found that adolescents, who self-reported experiencing sexual contact against their will, were five times more likely to contemplate suicide when compared to their peers who had not experienced unwanted sexual abuse.
This slide was provided by the Massachusetts Department of Public Health. It is from the 2003 YRBS and, if you look at this slide, what it’s comparing is adolescents who self-reported attempting suicide, the black bar is those who had experienced -- to left there -- dating violence, and to the right ever experienced sexual contact against their will versus their peers who were not reporting these experiences who had attempted suicide. We can see that there’s a significant difference. It is a statistically significant difference. While the most recent YRBS data has not been released yet, the Department of Public Health has shared that it does continue to show a very strong correlation and there is still a statistically significant correlation.
We know that survivors of sexual assault contemplate suicide. The next question is; why? Once we understand that the relationship is there; this slide is from Jane Doe. Those in Massachusetts are very familiar with Jane Doe. It’s a statewide coalition for sexual assault and domestic violence providers. This is from the training handbook for volunteers, advocates, staff in the sexual assault provider world.
Suicide is seen by some as an escape from feelings of helplessness, torment, disbelief brought on by a sexual assault. Not that unlike other suicidal clients that you might encounter, a sense of helplessness, but the sexual assault experience really seems to prompt this sense of helplessness, torment that leads a survivor to contemplate.
A survivor may see suicide as the only option to end the shame, sadness, fear, guilt. I sat with countless survivors who said that they wanted to disappear. That might be literal or it might be figurative but they would rather disappear than face friends and family and their future with what they had survived.
Survivor suicidal ideations are often temporary but they should always be taken seriously. I think one of the most dangerous things in our field is cynicism. I once had someone say to me, quote-unquote, “Of course she’s suicidal, she was raped.” While that makes us kind of gasp at the thought of that quote, I think that that sentiment can linger in the field and be present, whether spoken or unspoken. While we know the correlation is there, every disclosure, every risk should be taken very seriously.
In this presentation, I was thinking that it was important to share; what are some of the challenges that are unique to a sexual assault survivor who is suicidal? What is the experience of coping post-trauma? I think we have to be present and able to fit with what it must be like for a sexual assault survivor who is contemplating suicide.
I wanted to include some information. When we think about that first bullet of isolation, a survivor might be isolated from support. This study is, like many studies, it shows that the perpetrator is often someone the survivor knows, whether it be an intimate partner, a family member, or an acquaintance. We think about sexual assault as such a violation of trust; not just body, not just mind, but trust. On top of that, the survivor may have lost their primary support system. That may be the perpetrator. People that a survivor would typically turn to for support if he or she was contemplating suicide, they may now be isolated from those supports.
Survivors may also be experiencing shame or self-blame. Shame, guilt, and embarrassment, along with fear of retaliation were found to be primary barriers in reporting sexual assault for college-age females. I think that’s important to think about because a survivor is in a position to be asking for help, not just in healing form the trauma but if they're having thoughts, feelings of suicidality; what might keep a survivor from asking for help on top of all the normal things that make a client or an individual hesitant to ask for help when suicidal? A sexual assault survivor has this added layer of depth that they might be feeling shame or self-blame and it might make them resistant to ask for help.
Now that we know survivors may be contemplating suicide; what’s the next step? I wanted to provoke some thought around why advocates might either feel ill-equipped or resistant to explore the topic of suicide when working with sexual assault survivors. I’m a true believer that in order to make change on a personal level or a professional level, we have to be willing to really ask and confront; why do we do things that way that currently do? Why are current practices in place?
I think one reason is individuals don’t want to undermine or offend the survivor, “If the survivor didn’t bring it up, I won’t bring it up.” That might be the thinking. “I don’t want to plant the thought. I don’t want to bring up the conversation if they haven’t mentioned it.” That may be one hesitation.
I really believe that asking can feel counter to the helping profession if you feel unable to help. If you're a volunteer, an advocate, or kind of macro-level, no matter why you came to this work you came to it because you wanted to help. If there is an area that an individual feels unable to help with, I think there can be a natural resistance to delve into that. We tend to stick with what we have the tools to help with, whether that be legal advocacy, whether that be medical advocacy. I think the topic of suicide is something that individuals can feel somewhat unprepared to genuinely help with so they may shy away from it.
The next one is; unclear of agency policy protocol. Many people hear about a policy for an agency or a program during initial pre-service training and then; how often is it revisited? How prepared do they really feel? I think that can bring up a lot of fear; fear of liability, especially for professionals in the field. I think most professionals do have that fear of, “What if I bring up a topic? What if it comes up and I can’t help someone? What if they ultimately commit suicide?” I think are some of the fears.
The next one, for me, was always a big fear. Feeling unsupported by the system. “Do I trust the police with this survivor that I feel protective of? Do I trust the emergency room? Do I trust that the person who is so fearful to trust individuals after trauma, to send to them to the emergency room where they may go inpatient and they may lose autonomy?” I think fear of the system can be real and very present.
And, fearful to hear, “Yes.” If we ask, we have to have all the answers, I think can be our personal feeling and I don’t think that’s a fair pressure to put on ourselves. I wanted to make this bulleted list and encourage those, especially in leadership in training, to bring these in to supervision; to really revisit, what is your advocates and all those involved, anyone who might encounter suicidal survivors and really delve in an confront; where are people with this? And be willing to open a dialogue. I think it could be powerful.
I wanted to talk about truly finding a place for risk of suicide in strength-based work. I’m encouraging you to reflect on; is risk assessment part of our or my daily practice? I emphasize practice, because practice is something that we put into action. It’s something, we do it more than once. It’s a part of what I do. It’s a part of my day-to-day work. Not just a policy on file or in a training manual that would cover checkbox, “everybody knows what to do.” “We have the confidentiality agreement. We tell them our policy and then we move on.” So, really; is it part of my daily practice? Or are we sometimes doing bare minimum? Going over the confidentiality agreement and saying, “We covered it. That’s enough.”
As far as; how do I communicate with survivors about suicide? And Lisa’s going to talk more about this, but one thing really came to mind for me is the confidentiality agreement. That’s the time that you're most likely going to use the word suicide. We kind of have this key language that we say, “The following circumstances are when I can’t keep confidentiality. If you disclose thoughts of suicide is one of those times.” I think it could be like a wink-wink, nudge-nudge, “If you tell me that, then I’ll have to tell someone.” It can be very quietly almost making a deal with a survivor, or a client in any field, “If you tell me this then you understand that I can no longer keep confidentiality.” I think that can feel a bit threatening to a client or a survivor.
It’s a very clinical term that I use, I use the term ‘hot potato’. It kind of means you throw it to me, I’m going to throw it right back to you. I’m going to give every indication I’m not going to hold this. Be mindful of what message you’re sending.
One way that I found very effective when I’m going over a confidentiality agreement is to go a little bit further then the language in the confidentiality agreement. The wording that I use is, “I want you to know the scope and limitations of confidentiality in our work together. If you disclose to me that you're suicidal or having thoughts of suicide, I will likely have to break confidentiality. That said,” -- this is I think really critical -- “this is a safe and the right place to share thoughts of suicide. I don’t want you to hold the weight of that alone and I won’t hold it alone either.” That’s the language that I use. I really think that’s less threatening and it lets them know that you’re in this together so that, “I don’t want you to hold it alone and I won’t hold it alone either.”
Again, let the survivor know that you're going to engage supports if they disclose, you’ll engage supports to try and help keep them safe. I also say, let them know that if you have a concern that you're going to talk to them. They're not going to leave and you're going to make a phone call about a concern. Let them know that, “If I have a concern, I will let you know if I have a concern and we’ll talk about it.”
I know that as I changed my language and my comfort, which I think that it’s, quote, “aggressive”, survivors began to disclose to me. At the beginning of my participation in the Core Competencies project, I remember saying, “No one’s really disclosing to me. I’ll participate. I’m working with sexual assault survivors but no one’s really disclosing to me.” As my comfort increased, as I changed my language, as I made the small changes, by the end of my work as an intern at the North Shore Rape Crisis Center, I’d had a conversation about suicidality with every survivor I worked with.
I like this quote. It says, “Listening is a magnetic and strange thing; a creative force. When we are listened to it creates us, makes us unfold, and expand.” I think that when someone feels heard, it allows them to go to that place that they might not otherwise go to.
I really encourage you to be willing to sit with it, be willing to hear it, and I think survivors really respond to that. We have to remember that survivors have countless places in their lives where they can’t talk about what they're thinking and feeling. We have to really fight any urge to create another place like that even if it’s a scary topic.
I wanted to do a quick overview of the risks and signs of suicide. Verbal indications might include, “People, or the world, would be better off without me.” “Maybe I won’t be around anymore.” Expressions of hopelessness or helplessness; giving prized possessions away; previous suicide attempts we know is a major indicator; a completed suicide of someone close to them, especially true for adolescents if a key adult in their life modeled the behavior; daring or risk-taking behavior; personality changes; depression; lack of interest in the future; increase in drug and alcohol use.
Some of these were going to see with survivors just by the nature of having survived trauma. But, still we have the responsibility to explore to see if they’re risks. If you see these things don’t assume, “Oh, of course they're experiencing depression. Oh, of course they --”, whatever it is. Assume that it’s worth checking in about. Assume that it’s worth asking the questions.
The last thing I wanted to remind us that there can be very subtle cues. I was co-facilitating a survivor group and one night it was cold, really not nice New England winter night. We were doing a check in and I asked, “If you could be anywhere but here on this cold dreary New England night, where would you be?” The first survivor said, “Hawaii.” and the next survivor said, “Florida.” Then the next survivor said, “Heaven.” I thought that was really powerful. So we went along in the group. I checked in; she really didn’t want to go further. I asked, “Could you tell us any more about that?” No, she wasn’t really interested.
After the group I checked in with her. I asked if I could speak to her for a minute and I said, “I just wanted to check in with you about your check-in response about Heaven and see; are you having thoughts about going to Heaven now? Are you thinking about ending your life?” She assured me, “Absolutely not.” She told me that she was anchored in her faith and her life with her children and her grandchildren.
She thanked me for checking in with her and what I learned in that moment is even a response of “No” is learning opportunity. Because how I responded to her and it is great to hear that, “Just so you know, if you ever did have those thoughts and feelings, this is the place that it’s safe to bring it. This is the right place to bring that. I’ll hold that with you.” The fear that maybe you’ll hear, “No” and they might be offended; it’s still a wonderful opportunity to have a conversation.
Lisa’s going to talk a little bit more about some of this but I just wanted to really emphasize; what can we do? Our comfort is critical. Again, be mindful of the subtle messages of the resistance you might have. Survivors are incredibly intuitive. They pick up on our comfort. They pick up on what we’re willing to hold. It’s part of a daily assessment after surviving. I think that’s what I’d call a cost-benefit analysis constantly. Survivors are figuring out; who can they talk to? Who can they share with? Who can they trust? Make sure that you are aligning yourself as someone that a survivor can talk to about things such as suicidality. Give yourself permission to talk about it. Talking about it will not plant the idea. Free yourself from that burden and expect the topic to arise. Be mindful that it might create anxiety but expect to arise. We know there’s a strong correlation. We know that these individuals have experienced trauma. We know that they might not have others to talk to and they are coming to talk to you.
The last slide I wanted to share is an activity that I’ve done with survivors and I’m happy to email this out. There are many tree-of-life activities out there. This one I created to do with my work with survivors. The roots of the tree, which I usually make longer with a pen because our history is little bit longer than what these roots show; that represents our past. Survivors can draw things, write words, glue things from magazines on to represent their past. The trunk is the right now and the branches are the future.
I wanted to share this because I think it’s important to remember that so much of the work that we do with sexual assault survivors tends to be focused on the past. What happened to them? Then also the right now, which is the trunk. I like to point out, right now the trunk is actually relatively small in the grand scheme of life and that the future is quite expansive.
We know that individuals who are suicidal have lost perspective. Part of our work is to help an individual have a future perspective. We have to be part of that process for them; talking about long-term future, talking about what an individual wants, helping them visualize what that might look like. I think that this activity can be really helpful in working with a survivor to think long term. To have them map out what they want themselves for a future; to remember that they do have a future beyond what happened, beyond the assault experienced.
That wraps up my presentation. Thank you so much. I hope this is helpful. I’m happy to take questions. We’ll have time for questions at the end of the presentation as well. Again, I’m happy to share any information here. I’m happy to email out this activity in a Word document form. I apologize for the technical errors. Now I will hand things over to Lisa.
Janice Mirabassi: Thanks, Elisabeth for sharing your information and, again, I want to encourage people to offer up questions or comments into the chat box and we’ll make sure that the presenters have all those. They can see the questions that you're typing in as well.
I want to introduce our second speaker for the day, Lisa Hartwick, and then we’ll have some time for questions and answers and comments and sharing at the end.
Lisa has worked as the Director for the Center for Violence Prevention and Recovery at Beth Israel Deaconess Medical Center in Boston since 2004. Previously, she was the Clinical Director for the Boston Area Rape Crisis Center, which is located in both Cambridge and in Boston, Massachusetts.
She spent nearly a decade running the clinical programs at Boston Area Rape Crisis Center, which served survivors of sexual assault, their families, and significant others. Miss Hartwick spent the earlier part of her career as the Clinical Director of several outpatient mental health programs. She is interested in multidisciplinary approaches to addressing sexual assault and domestic violence as well as the intersection of trauma and mental health.
Lisa, it’s all yours.
Lisa Hartwick: Thank you so much and I realize I probably wrote that for some grant so that should be shorter but thank you for the nice introduction.
One of the slides I didn’t put in but I wanted to just highlight, is a concept, because it dovetails so nicely with what Elisabeth said, was Judy Herman’s very famous quote that says, “The result of trauma is disconnection” and, really, recovery from trauma is making connections. Her tree exercise, I just thought that was just a lovely way of really giving people hope and connection that they might not be feeling in that moment. It wasn’t part of what I was going to talk about but it was just such a great fit in some ways.
What I want to do is talk a little bit about respectful conversations and interventions and a little bit about engaging systems and when you need more than yourself and your organization what else is out there. That will be at the tail-end of what I have to say.
The most important thing I think you have to offer a survivor is really entering into a conversation with someone who is suicidal with your humanity. I think this is the most connective tool that you have to assist the person that you want to assist. Also, they're really not going to care what you have to say, in many ways, if you don’t make that connection. I think that’s imperative. I think Elisabeth said that in many different ways.
You’ll hear some of the ideas, concepts, and thoughts that I’m going to present and what I want to do is just say, try them on. See what fits for you. All of you work within the context of an organization; so what policies, procedures, what is there in your organizations that may come to bear, regarding when you’re dealing with someone who is suicidal? There may be a lot of different things you can and cannot do, depending upon your setting.
I wanted to start with this Life of Pi quote, “When you’ve suffered a great deal in life, each additional pain is both unbearable and trifling.” I picked this up because I think that many of my clients will say what they are experiencing now is nothing to what they have experienced in the past. They're letting me know that they’ve endured quite a bit in their lifetime. At the same time, these very same folks are the ones that are extremely sensitive to any changes in my schedule, the environment, other factors that may come into our therapeutic work together.
In this case, I’m thinking of people who have experienced multiple traumas or what we’re now calling complex trauma. From the literature we know that these folks are the people who will be more often calling with suicidal intent. They may have experienced childhood abuse or neglect and a sexual assault may have happened during their adolescence or early adulthood. Again, we know that that happens more often to younger people, although as we do more research, we realize it happens across the lifespan as well. We just want to keep in mind that, basically, for folks who have experienced multiple traumas that they may be calling us with some more frequency than other folks.
Again, I want you to be mindful of that because one of the things we want to do is to provide our staff with training on complex trauma as well as just have more literature available. Again, this is thinking beyond somebody who may be, although they’ve had one incident of sexual assault, that’s a terrible thing in and of itself, but a lot of times the folks that we’re talking with who are suicidal have had multiple traumas.
Here, again, this doesn’t completely flow naturally into this talk but I just want to give this resource, Trauma-Informed Care, and they have great slides at this website so I encourage you to get to it. But, basically the idea that a lot of organizations now are looking to trauma-informed care as a standard of practice and really it’s a paradigm shift from; what’s wrong with you? When you go to a doctor, you go to a therapist, the first question may be, “Well, what’s happening? What’s wrong?” One of the things we want to do is switch that, “What’s wrong with you?” to one that asks, “What has happened to you?” So, just to keep that overlay in mind.
This is just to say, and Elisabeth has so well brought out some of the stats, just that the history of sexual assault is associated with both suicidal ideation and suicide attempts. That’s the reason for our talk here today.
I think the other thing is, again thinking about; when did people experience a sexual assault? That will have an impact on how it’s impacted them. So, if they're very young or there’s multiple traumas, obviously that will have a higher impact or most of the time it will have a higher impact on them.
What I want to do right now, switching gears a little bit, is just to show a very short clip and, while I do that -- it’s just about three minutes long -- really the idea is the partnering with a helping professional as well as I think we learn a lot from people who have attempted suicide. This is one of those opportunities to really hear from somebody who has experienced a suicide attempt. So, here it is.
Janet Mirabassi: This is Janice Mirabassi, the moderator. I just want to let folks know, you need to use your computer speakers to hear the sound from the video and both the presenters and I will be lowering our volume on our phones so that you won’t hear our feedback from that during this time period. We won’t be commenting, obviously, during the video but I just wanted to give you that instruction. So, please use your computer speakers. You need to turn up the volume on your computer if you’ve turned it down. Thanks.
(Video playing)
Lisa Hartwick: I thought that that was a good overview of how connecting with this person Terry Wise connecting with herself, helping professionals, and I love the imagery of her actually paddling around and just engaged in life in a very meaningful way.
Somebody asked if that video is available. It is included with the chat, I guess. You can download it from the National Suicide Prevention Lifeline.
What I’d like to do is not really, I think, go over exactly what Elisabeth had talked about but just to acknowledge that part of stepping into the conversation is sometimes with a lot of trepidation and other times, I’m going to say for myself and working in a mental health capacity over many years, not all of the mental health field is trauma-informed. There may be advocates or people who are reluctant to step into it and then there are other, I would say, providers who tromp into it in a way that is maybe not as helpful either.
We want to have a sensitivity that really acknowledges some of the needs that survivors have and also to be mindful that we want to have a framework in which we’re looking at the act or the need or the thought processes going through someone’s mind in being suicidal that really it’s about a sense of control, about what they need in their life. We want to be mindful of those. Sometimes the mental health professionals are not.
This is a good article that I thought, if you are working with people, therapists, you’re not one yourself but you’re working with folks, it’s a great article to kind of give to back to them. One of the things that it talked about was that really there were, again, this idea of leading with empathy and your humanity, but also that we really don’t know all the reasons why someone is thinking about harming themselves or hurting themselves. The best way to know, to some degree, is to really ask these questions and to be very clear that we want to know the answer, that what this person has to say is incredibly important and we’re not going to be able to know without having this inquiry, this very open inquiry.
The other part of our role, if we’re having this conversation with someone who is suicidal, is to really gather some information. For those of you who are mental health folks it would be, we’re gathering clinical information and looking for any risks of suicide. If your role is not as a mental health provider -- I saw that there are some attorneys on the line. There are some SA nurses -- your role might be slightly different but, again, I think the idea that you are picking up on; is this person really at risk for hurting themselves? is really important.
I’m just going to talk a little bit about -- a picture’s worth a thousand words -- so hopefully I won’t have to say a thousand words for this picture. I could have added a few other pictures to really describe all sorts of addictions. One of the vulnerabilities that is associated with trauma, and particularly people with multiple traumas, is addictions. It makes perfect sense because from the standpoint of having overwhelming feelings and what we call that in a clinical setting is disregulation. Somebody feels bad, feels very agitated, or feels depressed, any number of feelings that can be quite overwhelming; some forms of addictions really address that in a way that many other things don’t.
In some ways it’s a very resourceful thing that people grab and gravitate towards, whether it’s an eating disorder or alcohol. I could have had a picture of some pills up here or cigarettes. Again, sort of looking for something that doesn’t involve other people to help them soothe themselves. Of course, what often ends up happening is that the more that they use whatever it is that they're using; if it’s alcohol, it has less of effect of more of a tolerance and therefore it’s a bad cycle to start getting into but, in the beginning, it’s actually quite a resourceful thing for people to look towards.
Just one more thing about that is, one of the things that happens as somebody is deeper and deeper into an addiction is that it destabilizes them. Therefore, they become more vulnerable for increased suicidal thoughts or actions so helping people with addictions is often key to helping them with their trauma.
There is any number of resources out there. I was just thinking that Lisa Najavits, who’s actually a local person, has a whole curriculum called Seeking Safety. Janina Fisher who I’m quoting a few times here today, her website has a very good paper, that you can download, on addictions and trauma. I think more and more we’re realizing that these things go hand in hand and we really need to take care of that. If we’re treating people who are sexually assaulted or in other violent situations that they’ve been traumatized, then we need to look at the addictions as well.
We have to think about being non-judgmental of the behaviors and I think, as advocates, we’re probably leaning on that in a good way. You may not get the same response -- and again I’m going to point to some of the general mental health field where I’ve definitely heard at various points in my career, “The person is looking for attention” “They're being manipulative”, sort of the negativity that can go along with some of the behaviors that you will see, whether it’s self-harming or behaviors around hurting themselves as a suicide attempt. We want to combat that, obviously, with being non-judgmental but also having a lens that the self-harming behavior or suicidal thoughts are an attempt to relieve pain not cause more pain. I’m just going to read something here from Janina Fisher.
She writes, and this is actually from her paper, Self-Harm and Suicidality. “The most common mistake made by therapists is the assumption that self-harm and suicidality cause pain rather than relieve it. If we assume that self-harm induces pain, then we interpret it as masochism or self-punishment or a cry for help and, if we do that, we will miss the core issue of self-harm of mastery- and relief-seeking. Because they are unable to trust or effectively use other people for support” -- and here she’s assuming people who can’t use other people in support, so people who are more likely often suicidal --“survivors of trauma may seek relief in a variety of behaviors that share the common characteristic of not requiring reliance on anyone but themselves. So, use of drugs and alcohol to numb; some use self-starvation or binging and purging to achieve a similar state of calm or ‘non-feeling’. Still others engage in a variety of self-injurious behaviors, such as cutting, scratching, burning, etc. Relief may also be sought through high-risk behaviors; so, speeding, walking in dangerous areas, walking in front of cars which induce an adrenaline response and therefore a state of calm. Fantasies of suicide or thinking about suicidal methods can also induce the same psychobiological effects and therefore become, paradoxically, a way of coping and calming.”
Sometimes the lens that we look at is incredibly important. If we want to understand somebody’s behavior, again we’re asking them, but I like this lens of really, and certainly is borne out in my work with individual patients and clients -- I work in a hospital. Sorry for the ‘patient’ slip there -- but, work with clients who talk about how sometimes when they think about hurting themselves or when they think about suicide, it really is the ultimate form of control; that if they want to, they don’t have to be here.
In that sense, it really allows them sometimes to feel like, “I can make it another day because if I can’t, if it gets worse, I can actually do something about it.” So, kind of that, the last card that they are holding. So, we don’t want to take that away from them because, again, we don’t want to take any control away from a survivor. We want to actually say, “That’s always an option but let’s talk about some other things.”
That kind of segues us into moving further into the conversation. Some of the questions we’ll ask -- again, I just put these out here as examples -- “Are you thinking of hurting yourself?” If they say, “Yes” we want to ask “Well, how are you thinking about this?” One of the things that we look at is; is it a plan to hurt themselves? Is it a behavior that is self-harming? In terms of, “Is it a cutting behavior that has been done many times before?” The person is stressed and so now they're trying to get some relief by cutting themselves. We will do this whole conversation to find out exactly what’s going on with them.
We also want to give them options, “Are there other ways to feel better?” Again this is really the main event. We want to really provide them with other options that they might not have thought about.
Although this seems very straightforward, if somebody says, “I am distressed but I’m not going to hurt myself.” You still want to go a few measures into that song. You still want to talk with them a little bit further. Partly you want to do that because some people are very compliant or they’ll say, “Yes, yes, yes. No, I was never going to hurt myself. Absolutely not.” But when you press them a little more and, again, just kind of pursuing the conversation, they might say, “Well yes, I really am.” So, you just want to make sure you're not pulling out of the conversation before it’s actually done. That’s an important thing to continue to do a little bit further than you think might be comfortable for you.
Depending upon your role, the policies and the procedures of your organization, there may be particular aspects of this conversation that are more prescriptive. I have a good example. In the setting that I work in currently, if somebody is suicidal and, after I talk with them and decide, “You know, they're really not so safe to leave and go home.” And they agree to go to our emergency department, I actually have to call an ambulance because I work on the East Campus of our organization, our hospital, and the ED is on the West Campus. I don’t like that system but that’s the system that I’m in.
Other people may have other parameters that you have to deal with. It’s kind of good to know what those are. When I’ve ever had to hospitalize somebody, I basically say, “Yes, it’s not great. I wish it were different but this is how it is” and, frankly, they may be embarrassed. There may be a lot of things that are going on for them and I can reassure them that it happens multiple times a week and that, really, people going from East to West is not something that we get very excited about here. In fact, they can see when people come, it’s quite a matter-of-fact operation. Again, knowing what your institution does around when somebody is suicidal is important because I think you can just add some comfort by talking with the person in a way that will make sense to them.
When we look at risk, I wanted to just talk about three different types and, again, we could look at it a little bit differently but if you look at the material from suicide prevention, usually there are people who feel badly; kind of this passive intent. They wish they weren’t living. They don’t feel well but they're really not doing anything about it right now. They're not even thinking about it a lot.
I have a great example. A woman that I have seen for quite a while puts it this way, “If I died today it would be okay. I’m really done.” She’ll say that and then we’ll go on and talk about lots of other things. At various points I certainly do check in with her to make sure that she isn’t planning anything but 99.9% of the time it’s this passive intent.
Other people have more active thoughts of suicide and, if there’s a crisis, that may become all that they can think about. Usually if somebody is at that point then they are moving into the next phase, which is to actually make a plan for it.
This passive, active thoughts of suicide, and active plans of suicide sometimes coincide -- there’s a quick kind of passive to active to some plan and other times it’s really -- the client that I just mentioned; passive intent most of the time. This is a person I’ve seen for quite a while.
Interestingly enough, she came into my office this week and she always gives me gifts, usually just little trinkets but this gift that she gave me was really, unfortunately, an example. She had had a crisis at her work and basically she started to talk to me about what she had done in the last two weeks. One of the things that she was doing in the last two weeks was -- this is a person who never is actively suicidal, often depressed, is a person who has multiple traumas, childhood history, and a sexual assault in her lifetime -- and she said, “You know, I was so overwhelmed. I took out a huge bottle of pills and I just looked at them. I didn’t call anybody. I didn’t even call you. I ended up not doing it because I decided I just really was just too angry to even think about killing myself.” So, here’s a person who I would say, not confidently, but I thought, “Hmm.” I was really quite surprised that she moved into a very active phase because I’ve seen her for a very long time and usually she really is much more passive.
I use that example just to say people change. When we have these conversations, just because you’ve had the conversation once definitely doesn’t mean you're done. In fact, what we want to do is have it be part of our practice so that, even it’s somebody we know very well, like the client that I just mentioned; note to self, I will be checking in with her more regularly than I had around this because, obviously, it’s something that can change quite quickly.
The other thing that we look at is; is this a low-lethality or a higher-lethality method? If somebody says that they are going to hurt themselves and they have a plan, the next part of that conversation is; is their plan something they have access to? Is it something that will, if they complete it, hurt them, kill them, etc.? I’ve had lots of different interesting examples of this.
I remember one woman that I saw many years ago, who really seemed quite agitated. and I thought definitely she probably needs to go to a hospital because I couldn’t imagine that I would be able to calm her down in the time that we had to work together. One of the things, when I went to ask this question around; she’s thinking about hurting herself and what other things could she think about. “No, no. Can’t think about anything else.” She basically said that she would take out a knife and she would cut herself. I asked the next question which is; did she have an idea of what that knife would be? She had her purse with her and she opened up her purse and she took out the dullest knife I’ve ever seen, which was this plastic knife with not even a little serrated edge. Her lethality was low but her intention was high. I think she still ended up going to a hospital because I figured the next thing she could get her hands on, she might actually try to hurt herself also. It was interesting because the tool that she was going to use to hurt herself, or the means, was quite ineffective. I was glad about that.
Then you have people where there is high lethality. We can think about firearms, which are very quick and deadly. Or we can think about things, high volumes of medicine or ingesting things that are poisonous. Again, we want to make sure we’re aware of what the lethality is.
Kind of an interesting example, when I was working at the Rape Crisis Center, a woman had called the hotline the night before, had been quite suicidal. So, I came in in the morning and got this note basically that said, “Can you follow up with this person? They were really upset last night. They did end swallowing some things but they're okay.” This was the message that I got.
I called the person and I said, “Hmm. So what did you take?” She was very easily engaged, wanted to talk to me, really decided this was not a good plan. She really didn’t want to die. She didn’t even want to hurt herself. So, she readily told me what she had ingested and she really did not want to go to a hospital. I said, “Okay. What we can do is let me call Poison Control” Which is what I did. Basically, Poison Control said it definitely is something that could kill her. So get her to a hospital immediately.
It was interesting because the person themselves was saying, “I’m really okay. I took it six hours ago. I’m really okay.” And I was able to say, “Poison Control said these things have an effect” and I don’t remember what the actual pills were that she took but she did go to the emergency department after I talked to Poison Control. Again, the high lethality was little bit hidden in that example but I think you get the idea that she had ingested something and was pretty serious and then really regretted it pretty quickly and called the hotline.
The other thing, and I’ve already mentioned one of the most lethal forms of killing oneself is firearms. This is just a slide that I had picked up for a training I went to recently. One of the things that we can definitely do is ask about firearms. Instead of waiting for someone, if you are doing an assessment and somebody says that they're thinking about hurting themselves one of those questions should be, “Is there a firearm in the house?” or “Do you have access to a firearm?” We want to make sure that, if that’s the case, that we get some help to get the firearm out of the home.
I was seeing somebody recently and, actually, it wasn’t so much that she was suicidal but her partner wasn’t really doing well and actually had said, “If you leave me” -- I do a lot of domestic violence work -- “If you leave me I will have nothing. I will kill myself.” So, I did the assessment as I would with anybody, “Tell me what you're worried about?” She didn’t think about a firearm. She just said, “I think he would kill himself. I’m also worried that he would hurt me.” When I asked, “Is there a gun in the home?” She said -- and, again, gun in the home is one thing and access to guns is the other question -- she said that, in fact there was a gun and when I asked her, “Could we think about getting rid of the gun?” she actually had some sentimental attachment to it because it had been her fathers and it was an antique and all these other things. So, we ended up working it out that she could buy a lock for the gun that went somewhere other than her home.
These are the kinds of things you need to drill down on when you meet with somebody or have somebody else do that so what you're getting the full breadth of what might be involved in their particular situation. Usually they are very particular situations. Everybody has lots of different idiosyncratic things about their house and how everything works in their life. Again, this conversation is important.
What I want to do is -- I’m realizing I skipped one slide but I’ll go back to it because it’s important; the need for increased structure. Say you have this conversation, you realize the person is not safe, and you really need some other help. One of the things that, as mental health providers we sometimes think about, is something called a ‘contract for no suicide’. I also just included this, basically, the case against ‘no suicide’ contracts.
I don’t want to be opposing myself in this conversation but, basically, for years and years we used the ‘contract for safety’. Most of you, if you’ve been in this field or rape crisis counselors, you’ve heard that term This particular article, which we could certainly include it if that’s Janice can do, really talked about the idea of ‘contract’ being a bit of a problem in terms of the word itself.
The idea, I think, is really to say, “We want you” -- this person that you're talking to -- “We want you to be around so that you can engage in life. You're a wonderful person.” You're trying to pull for all of their strengths. The word ‘contract’ seems to have some problematic, sort of prescriptive, and taking the control out of the hands of the survivor. Also it’s basically maybe shutting down the conversation. If you, for example, say to somebody, “Can you contract with me that you’ll be safe until you see a therapist in the morning?” That would be something typical that we might do when I was at the Rape Crisis Center. The person could say, “Yes” or “No” depending upon how the conversation went.
What this article is saying is the ‘contract’ word itself is problematic. What we want to do is really ask the person, “Can you commit to just staying alive through the night so that, in the morning, if things look better you haven’t taken that option away from yourself of living?” Something like that. Just be mindful that that’s the way things are moving, I think, in the suicide prevention world. I thought it was a really well-written article and I think it made a great point to the fact that the way we had been doing it for years and years, at least the word ‘contract’ was problematic and there were some better ways to do it. That’s a good thing.
The other thing that we can use, say you tried to talk with the person about not hurting themselves and what structures do they have in their own life that will help them make it through but you don’t really have a real clear sense that that’s what they're going to do. Or they say, “No. I’m really going to hurt myself and really nobody can do anything about it.” You may end up, and again in my experience this is the very small percentage of cases. Usually people are calling you or coming in for service because they really have this sense that they want to live. But, if they really don’t and you feel like you need to intervene then, in Massachusetts anyway, we have something called Section 12, which is really sending someone to the hospital against their will.
Again, as advocates, even if you have to do that I think the thing to do is to really do it trying to stay in connection with that person. “I can hear that you can’t keep yourself alive during” -- whatever bargaining that you had done with them -- “and this is what I feel like would be the most helpful.” Sometimes I say to people, “I’m really sorry that it’s come down to this. I wish we could come to some agreement but I have to intervene.” Sometimes you're just doing it without having that conversation because of -- the slide prior -- it may be a lethal means. You maybe don’t have time to have this long conversation with somebody so you may just have to act.
Just so that you know, in Massachusetts now licensed independent clinical social workers are authorized to transport to an emergency room for evaluation. That could be important if, for example, you're part of a rape crisis center and you want to get somebody to the hospital and you're feeling like the only way to do that is through calling the police or calling an ambulance. If you do have a social worker who is a supervisor and you’ve worked this out ahead of time, it might be a less traumatic way of doing it. I know if it were in this hospital I would say, “My supervisor can do this. I know her. She’s a great person.” When you get to the hospital sometimes advocates could come in with somebody and sit with them in the waiting room or through the triage process.
One of the things that I wanted to talk about just briefly, and I realize I’m running out of some time here, is to really know that your relationship with somebody can really cross the boundaries or the threshold of the hospital. I think sometimes advocates are very reluctant to step into that and see it as a big, bad system, which I’m not saying it isn’t. But, it’s much more friendly and really much more approachable when you have somebody either with you or, if you wanted to check in with somebody. They're going to the hospital and you say something like, “Would it be okay if I call the hospital and ask for you and see how you're doing?” There are lots of things that we could potentially do to keep that connection. Also let the person know, “I’m not just sending you into a big, bad system or a big system. I’m a caring person who wants to know how you do in that system. Also, let’s talk about what can happen after you're evaluated.”
I just want to wrap up that here are some of the things that I see as really key pieces to doing the assessment and thinking about, at the end of this if you don’t come to some agreement with the survivor, that there are a few other options that you can exercise. I’d like to stress that I know in my own career that this is a very small percentage of the cases. Most of the time I’m doing safety planning with the person. I’m talking with. I’m trying to figure out with them what in their life make it worth living.
One of the things I should say that happens often in these conversations is when I ask somebody -- we ask people why they want to not live. I also ask people what they like and what would make them want to live. A lot of times it’s a relationship or a cat or, “I always wanted to learn how to do X or Y.” We want to build on their strengths and on their capacity and their desire to live.
That is also part of the conversation, which we didn’t really get to talk a lot about today, but I do want to acknowledge before we end. In that, I’m going to turn it over, I think, to Janice. That is my portion.
There are a few related links that are at the end of this talk so that you can look at those and also just realizing that one of the things that you should know is just your national and your local helplines for suicide prevention if you're a sexual assault provider and also vice versa; if you're a suicide prevention line, knowing what your rape crisis center and what your resources are in that area. Thank you.
Janice Mirabassi: Lisa, thanks so much and Elisabeth, thank you as well. That’s the end of the slide presentation so we’re going to begin fielding some of the questions that came in through the chat function. I’ll try to keep my eyes on that chat function while I’m also listening to the questions.
I just wanted to start off to let folks know that this entire presentation, an audio version of this presentation; so pretty much exactly what you heard today will be available to you and, as a participant, you will get a direct link to this particular webinar and that will happen as soon as I figure out how to do that. I actually have instructions about that.
This is my first time running the webinar. The person who usually runs it is on vacation so I was very glad I didn’t cut you all off at any point during this presentation. That was my greatest paranoia. I have instructions to upload this and you will get a direct link.
I also wanted to let folks know that this is being sponsored by our Suicide Prevention program. They sit around the corner from us here at Department of Public Health. We share space. We’re in the same division and I hardly ever have had the chance to attend their webinars live. They have everything archived and I just wanted to throw this out to you because the concept of becoming more comfortable if you are a person who works in a sexual assault or domestic violence program, becoming more comfortable with the issue of asking questions. I think, going through some of the webinars, the more you get used to it, the more you will know what you know and what you don’t know.
Some of the topics they have, the titles are; That’s so Gay, talking about gay teens and suicide; Standing in the Shadow of Love: The Role of the Black Church in Youth Suicide Prevention; Battlemind, which is this incredible presentation from a veteran on veterans’ issues and PTSD; Young Black Men and Suicide; Cyber-Bullying and Risk of Suicide; Grief after Suicide: Walking the Journey with Survivors; Combatting Social Bullying among Older Adults, that one I did participate in, it was kind of cool actually; Grief and Healing after Suicide; Suicide Prevention and Intervention; Supporting Transgender Communities; Veterans, Military Personnel, and Suicide Prevention; and a two-part webinar, Youth Suicide in the School Environment. I know there are some educators on this line as well.
I’m just putting in a little plug from Suicide Prevention free, available to everybody, webinars. Also there will be a transcribed version of this. That will take a couple of weeks but it will be accessible to people who are deaf and hard of hearing. There is a captioning option on the webinar as well.
All of those things will be available and, if you have colleagues who weren’t able to attend today that you want the pass the link along to them so that they go on and do it, thank you, please do that. That’s our commercial message.
You’ll also get links to be able to print out all of the slides. I’ll find out, Lisa, about if we can attach the article or not. I’m not sure what the copyright issue is with that but I’ll check into that and find out about that.
I wanted to go back to a couple of questions that were asked early on and I think there’s a longer question at the end. I’ll let you know that we actually can go over time on this particular webinar because we bought some extra time. So, you are welcome to discontinue listening at any point time. It officially ends at 2:30 but we do have some extra time should there be additional questions.
The first question was, Elisabeth, about your tree activity. Can people get access to that activity and maybe further description of how to run that activity?
Elisabeth Nash Wrenn: Absolutely. I’d be happy to share that. When we send the email out, Janice, I’m happy to share that in a Word document or.PDF form.
When I utilize the activity I typically -- we should go back to the activity real quick -- I typically draw the roots out further. The Word document, the text is smaller, so the tree is larger. What I do is I provide magazines and colorful markers and give the survivor -- I’ve done it in group and individually -- some time to really spend some time doing the activity. I’ve also done it with volunteers in training because I think it’s important for them to think about -- I think it builds some empathy.
When it’s done what I do is I fold the tree in half so you don’t see the future and I present the idea that, to a survivor who may be feeling suicidal, that can be what the experience is like and part of our role is unfolding the tree and helping them gain some perspective.
Another tool I like to do is to turn the tree sideways, once the roots are drawn and expanded and show that the future actually balances our past; that they're equally expansive. We tend to think of our roots, our past, as really what anchors us and we’re kind of on this borrowed time future thinking. So, really if you think about that our past is behind us but our future is equally before us. I think for a survivor, for someone who’s suicidal that’s really powerful to see the tree sideways. And really emphasize that the trunk, the right now, is very short and brief in comparison to how we see our past and future. That perspective of the anchor and how the right now is this kind of temporary state.
I’m happy to share the activity. I encourage you to use it. Feel free to change it how you see fit. I really encourage you to use it with volunteers, staff in training, as well as groups and individuals. I’m happy to share that.
Janice Mirabassi: Elisabeth, if you email that to me, I’ll get that out to folks as well that participated today. We’ll see if we can try to get it included with the webinar broadcast.
A couple of people have asked about, “Can you give me the website and all?”
I can’t get on to the web right now to get that information for you and I don’t want to give it incorrectly so I definitely will email you, everybody that participated today, with the information about to access all of those webinars. We would love to have you spread that information around and go on and take a look at what we have.
Thanks, Elisabeth. There was another question that came earlier from Wilbur and it as this. “Open-ended questions are important to survivor work when to talking to survivors about suicidal ideas. Should there more be more emphasis on yes-no questions?”
Lisa Hartwick: This is Lisa Hartwick. Do you want me to take that?
Janice Mirabassi: Sure.
Lisa Hartwick: I think there was also a question similar to that also which is, “What questions do you ask? And do you want to get to a yes or no?”
I know when I was the Clinical Director at the Boston Area Rape Crisis Center, I had this decision tree sort of algorithm-type thing that I think was helpful. What I thought it was most helpful with, too, is just to really do the training and to say to people, “Suicidal thinking comes up pretty often, particularly on the hotline.” Or some of the services that are particular to rape crisis center. Some will experience that more.
This gave a way of saying, yes, you would come down on a yes-no but I think that -- I didn’t include that one because I don’t have it any more -- but also I think it depends on what setting you're in. I think you do want to come down to a yes or no but I would also not want people to arrive there a little too quickly.
I do think it’s a good idea to really work with whatever system you're in or to look at different products that might be available around safety planning and what are the policies of that particular agency, so that when somebody says that they're going to hurt themselves, they say “Yes”, what does that mean? Does that mean you call an ambulance? Does that mean the supervisor talks to them? What does that mean? That could be written into any kind of decision tree-type, even a one-page thing that you have for your organization.
Janice Mirabassi: Thank you. If you have other questions from this question, please feel free to put that in the chat.
The next question I wanted to bring up and Casey asks this question. “I’m wondering if you can speak about effective questions volunteers on crisis helplines, who are not trained clinicians” -- and I assume who are also not rape crisis counselors -- “can ask survivors of sexual assault. For example, how do volunteers navigate through a conversation once a caller or somebody that’s chatting” -- I assume emailing or the other methods of communication -- “once somebody has identified that they're a survivor victim of sexual assault?”
So, sort of the opposite in training rape crisis folks and DV folks about being comfortable asking the questions about suicide, the flip side of that; folks who might be very comfortable with the suicide issue may not be comfortable the issue of sexual assault.
I remember this very clearly when I was a rape crisis counselor, our calls came in through a suicide hotline and actually they were transferred over to us. They literally had a red phone in the room. The rape crisis phone was a red phone and when it rang they were really happy to transfer those calls over. I felt the same way as a rape crisis counselor. I was really happy to transfer those suicidal folks over to the suicide hotline. I think that becoming comfortable with both is part of the goal of this webinar.
Elisabeth, did you want to start off with that? And, Lisa, please jump in.
Elisabeth Nash Wrenn: I think that my first thought is that visual of passing back and forth is something we do a lot and it still happens. I think we have to remember that these are the same folks. When we put the burden on an individual to kind of cafeteria-style seek support, it’s not really fair.
That doesn’t mean that we don’t need to work together and learn from each other but we really have the onus of having a skill set, of not just saying, “Oh. You know, I hear suicide and we’re referring you over to --” “I hear sexual assault. I’m referring you.” To really try to build our capacities is critical so I’m glad that question was asked.
I think really just directly asking. If you have an individual on the phone if you're a sexual assault service volunteer, if you're working with a rape crisis center, or volunteering for a rape crisis center to give yourself permission to directly ask, “Are you thinking about hurting yourself?” Make sure you go to that next step, “Are you having thoughts of ending your life?” I think it’s important to be direct, to release yourself from some of the fear.
Again, to say to an individual, “I want you to share this with me. I don’t want you to hold it alone but I’m not going to hold it alone either. I have resources I can pull in. I want to be here to help you.” If you're working on a suicide hotline and you get the call and someone is a sexual assault survivor to let them know, “We have services in this state. You are not alone in healing from this. I’m so glad you called tonight. I’m so glad you called today.”
One of the things I always opened with was, in training and when I was working on hotline, is, “Hi, this is Elisabeth. How can I help you today?” Let them tell you how they can help you. If they're asking for our help, if they're disclosing suicide; they're looking for help. Just make sure that you're feeling prepared to offer whatever you have to offer and know that, in that instance, you don’t have to have all the information to let them know that you're going to engage systems and supports to help them. You're going to engage your supervisor.
Janice Mirabassi: Lisa, did you want to jump in on that?
Lisa Hartwick: No. I think that what Elisabeth said is exactly what I would say. Also, it’s okay to say, if you have people who don’t know a lot about an area and I think you mentioned this Elisabeth, just to say, “I really don’t know a lot about that but I can find out and I’m interested in connecting you to what you need.”
Also, it would be really helpful if people do build their capacity so that, as you said and I couldn’t agree more, Elisabeth, just so that people don’t have to call five different lines because they have five different issues; that we build our capacities internally.
I think it’s okay, too, sometimes if you really don’t know something to just kind of be very honest in that moment to say you really don’t know, “but let’s see what we can find out together and I’m happy to share” what you can. So, you're kind of really embarking on this adventure together.
Elisabeth Nash Wrenn: And another thing I would add, and I know that we’re at time here, one thing to think about, at the North Shore Rape Crisis Center something we did under my encouragement was really to think about; how do we get someone engaged at this moment? On a hotline we sometimes think, “Well, it’s just hotline. It’s hotline. There’s nothing else we can do.” Always know that you can emphasize this is a confidential hotline. “You do not have to share any more information. We do not have to speak again but if you would like someone from my agency” -- if you're a volunteer and it wouldn’t be you -- “to try to call in tomorrow and check in with you. You’re welcome to call back but if you’d like, you can give me information and someone can call you tomorrow or someone can call in the morning.” Whatever it is to let them know you’re invested, to give them that option. Sometimes someone doesn’t even have the strength to call in the morning but knowing that someone’s going to call them, that a real person -- “One of these two people are going to call you in the morning.” Give them a name -- can really give a lot of hope.
Janice Mirabassi: That’s an excellent idea. I also, as the Contract Manager for all the rape crisis programs in Massachusetts, I like to volunteer all of our providers on a pretty regular basis to do lots of things. All of you who are calling from other states as well, there are rape crisis programs in every state in this country. There are coalitions organized in every state in this country that deal with domestic violence and sexual assault or there might be separate coalitions for those issues. Going through those folks, I would say that it’s a really strong possibility that you can contact your local rape crisis center or your coalition or both and say, “I am from the blank- blank organization. I’m from a mental health organization. I’m a teacher. I’m a healthcare provider. I work on a suicide prevention hotline. Could you come in and talk to us and provide us with some outreach and education and some basic training about what should we do if?”
I think that, similar to what’s called the QPR training in suicide prevention-- it’s the question, persuade, refer -- which is a one-hour training that can be provided to you and your providers and your co-workers about -- so I know the basics about suicide prevention. As rape crisis folks, they could provide that same basic.
I think a piece of it is, first of all do no harm. I think that’s a great, great fear as to why healthcare providers don’t want to ask about suicide. Healthcare providers don’t want to ask history of violence or sexual assault because, “I do not know what to do if somebody says, ‘Yes.’ If somebody gives an answer, I don’t want to say something that could potentially be harmful to them, wrong, not worded correctly. I think that therefore not asking the question feels easier for me.”
It is hard to ask the questions and it’s hard to engage in the conversations but I would say, reach out to rape crisis programs, befriend them, and provide and share your resources back and forth. Let them know what you do and they can let you know what they do.
We can certainly include, with the email for folks, a couple of national numbers because I know there are folks from out of state here but I’ll include of the rape crisis programs from Massachusetts, because we have a lot of Massachusetts people on this call as well. I strongly encourage you to get in touch with folks and find out; what can they do for you? Then, trade services; what can you do for them?
Elisabeth -- I’m going to be posting the Mass Prevents Suicide webinar website. Thank you, Elisabeth, for pulling that out for me. It’s kind of a long link but I will post that. I’m going to send that out to everybody.
Are there any other questions that people have? Or Elisabeth or Lisa, are there comments that you have?
Elisabeth Nash Wrenn: This is Elisabeth. My last comment would be that, clearly by the number of people who registered, that there’s a dialogue that needs to be happening. This is simply a starting point. Hopefully beyond 101, the next level, and we really encourage you to have an open dialogue in your organizations and keep the dialogue going.
Janice Mirabassi: Excellent. I’m not seeing any other questions coming up. Any final comments?
Lisa Hartwick: This is Lisa Hartwick. I was going to say, one of the things that Elisabeth talked about several times, which I think is worth noting and just a good way to end, which is, really, suicide prevention and talking about it is a practice and that it’s something that pick up where you are in your organization and move forward. You don’t have to be the experts to start this conversation and, in fact, the more of us who are able to feel confident and have some tools to address it, the better off everybody will be.
Janice Mirabassi: Excellent. The last thing I want to mention is that folks who are interested in becoming a trainer on QPR, there is an opportunity to do that, in Massachusetts. It’s usually a pretty expensive training but it is being offered to Massachusetts folks within the next month or so, I think, it’s going to take place; a month and a half I think. I’m not really sure. If you get in touch with Brandy and she can explain how to get connected to that. Brandy is the person that emailed you with the information. Brandy works in the Suicide Prevention Program and we’ll get you that information as well.
I am really thrilled with the folks who participated in the call today and I wanted to let you know we’ll be emailing information to all participants in today’s webinar. I’ll be posting this webinar as a podcast on our website.
In addition, be on the lookout for emails about upcoming webinars and trainings being sponsored by DPH. You’ll be added to our list of folks that receive that information. I wanted to let you know, after you log off, please take a few minutes to complete the evaluation that will magically appear on your screen. It’s a very brief SurveyMonkey and we would really appreciate the feedback.
I hope you’ve gained some knowledge today about the experience and needs of survivors of sexual assault that may exhibit suicidal thoughts and behaviors. I thank you all for participating and enjoy the rest of your day and be safe. Thanks, everybody.
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