Hello and welcome. I'm Shireen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services and social work expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Addressing Suicide from the Person and Environment and Social Justice Perspective. So SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Continuing Education Credit for Social Workers, and credit for participating in today's webinar will be available until November 8th, 2022. Next slide. Slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. Select the link to download the PDF. Next slide. And please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel as well. We will reserve 10 to 15 minutes at the end for the Q&A. Next slide. Now, I'd like to introduce you to the faculty for today's webinar, Dr. David Derizotis. Dr. David Derizotis is Director of the Peace and Conflict Studies Program in the College of Humanities and now part-time professor in the College of Social Work at the University of Utah, U of U. He also serves as a fellow and faculty learning community chair at the University Center for Teaching and Learning Excellence, as well as an OSHER instructor and as a MUSE professor in undergraduate studies. At the U of U, he currently is chair of the Senate Advisory Committee for Diversity and recently finished his term as co-chair of the University Anti-Racism Committee. As a professor at the U of U, over a span of a third of a century, he has received many awards in teaching, service, and scholarship. Dr. Derizotis, thank you so much for leading today's webinar and I'll turn it over to you. Thank you. Can you hear me okay? Yes. Okay. I'm excited to have this chance and it's an honor to be working with so many people. I heard this morning there was 570 humans watching. I tend to teach experientially most of the time, so it's different to not be able to see you. I've certainly done that before in some larger Zoom classes, but wish I could see you. I love questions, so like Shireen just mentioned, any kind of questions you have would be great to hear and we'll have a chance to talk about them. I am asked to just let you know I have no relationships or conflicts of interest related to this presentation. I won't read the learning objectives to you. I think one of the worst things you can do to anyone is read a PowerPoint to them. I'll try to avoid doing that during our meeting today. I just want to also mention as we go to the introduction, there's four sections to this presentation. I'll spend most of the time in the first two sections, which I think you'll be interested in the most. We're kind of talking about what do we mean by multicultural perspectives and showing you how I use them with my own clients and how I teach it in the classes that I teach. Then we'll spend some time talking about engagement assessment and intervention with folks. The third and fourth sections are on data and best practices. If we have time, we'll look at them, but I know you can review them yourselves. Over the years that I have been teaching, and a third of a century sounds like a long time, doesn't it, when you hear that? I think that dealing with suicide or threats of suicide is probably one of the hardest things for all of my students who are social work students usually to address. We get scared. We, of course, don't want to be responsible for people's lives. I like to say to students the word responsibility means ability to respond. There's only so much I can do to keep someone alive. There's a limit to our ability to respond. We also fear litigation, of course, to get in trouble because we didn't handle it right. I'm sure most of you have felt those kinds of fears. The title has person and environment and social justice in it, so maybe we could just talk about those concepts briefly. I'm sure you all have a picture of them, or at least are interested in it, or you wouldn't have taken the seminar. Some of the artwork I put on the slides I just really like, and I wanted to share it with you. When I think of person-environment, and I actually had someone who originally participated in doing the pie charts, person-environment charts in the literature, and who seemed pleased that we were talking about their theory, it just means what's the context of this story that the clients bring into me about their life and how they may not feel like life is worth living. That could include all sorts of things, of course, like the family I grew up in, the neighborhood I'm in, the community, culture. If I identify with an ethnicity, all the many, many identities that we have. Some folks from the same family will have a different person and environment because they grew up in different sibling order and so on and so forth. I figure a lot of this, and I'm telling you, most of you already know. Social justice, how about if we think about that as how can I promote equity and inclusion in particular as well as diversity in the community that I live in as well as the global community we all live in, and how can I help clients that I work with to empower themselves because I don't believe I can empower people to do the same. My favorite definition of empowerment is knowing what I think and feel and being able to express it effectively. Here's a question for you all just to think about for a moment. What is humanity's biggest challenge today? If you had to say, I happen to be teaching a class with social work students in Wuhan in the fall by Zoom, and I asked them that question, and the answer is since Wuhan, China is where the virus started, the COVID, a lot of them mentioned the pandemic as the biggest challenge. Then we got around to talking about all the things that threaten our existence on the planet. For me, I think Shakespeare said it best, and I mentioned Shakespeare to them, and some of them had heard of Shakespeare actually, some not. Shakespeare said, to be or not to be, that's the question. Do we choose as humans to stick around anymore on the planet? When I teach my social work classes or peace and conflict or any class, I happen to teach these days more classes for people who are retired because I'm getting older. I ask people, do you think that there will be humans still around 20 years from now? 100 or 500? I would say about half of my students say no. That's an important question then, isn't it? I won't be around maybe to see that. I believe, by the way, that all of us can do something about that. An important part of wanting to be alive is, for me, feeling that I can do something every day about not just in being a service now to people alive now and other living beings and the environments that support us to be alive on the planet, but also future generations. Section one, so multicultural perspectives. This is probably my favorite section in the presentation. What I'm going to do is mention some of my favorite people that I've read, had the privilege of listening to, and talk about some perspectives they have on life and death and what they've taught me, and encouraging you to maybe read more about these folks and other folks that you're interested in, and just show briefly how I use some of their insights to help people from all cultures. Some of you may be familiar with Pema Chodron. I always feel like when I read her books, I'm getting a hug, as well as good information. She talks about how basically that learning about spirituality for her is always about learning how to die. What an interesting comment. Of course, those of you that know about her, she had a really tough divorce, and she entered a Buddhist community, and later became a teacher, and she's a wonderful teacher and writer. I take seriously this idea that spiritual work is learning how to die. She uses the word spiritual instead of religious, and if we had a lot of time, we could go into the differences, but just to say that spirituality usually we think of as an individual dimension of human development. I like to bring that up with folks that I'm working with that are struggling with their desire to stay alive or not, and talk about this idea of learning how to die, and that I would not want to have to do all the work in dying at the last second that I die, if I have the choice to do that. If I go really quick, then I don't. One of the things I'm interested in is teaching spirituality and social work in that dimension, adding that to the other dimensions of being a human, like emotional and cognitive. It's been interesting to me that practically every wisdom tradition talks about how important it is to learn how to die, and even this idea of dying every day. I think this is very helpful often to people who may be struggling with thoughts of suicide. Here's another one. This has been quoted as something Crazy Horse said at the Battle of Greasy Grass, which is a white folks call Custer's last stand. We don't know for sure if he said it, and other people have also been quoted to have said this in his culture, but what did he mean by that? Did Crazy Horse mean, I'll say to my students, that he hoped he would die and all his warriors, Custer's soldiers, would shoot them down? What I've been told by Utah and Navajo people here in Utah, where I live and teach, is that what he meant was that, I have lived my life so that if today is the day that I have to die, I'm okay with that. To me, that's really a beautiful thing. Sometimes I'll ask people, is today a good day to die for you? Regardless of what their culture is. That often is a really helpful question to people, I think. Then we could reflect on, if the answer is no, why not? If the answer is yes, how come? A little bit later in our presentation, I'm going to ask you a question like that to reflect on, all of you. Here's another one. This is a photo of Rosa Parks that I like sitting in a bus, and of course, she protested having to sit in the back of the bus, and in fact, sat where she wanted to and was arrested. She was willing to be arrested or even die for promoting social justice. Are there things, here's the question maybe, or a question, that I would be willing to die for, that would be, even though life might be precious to me, and I sometimes will ask people that question. Is there something that you're willing to risk everything for? Some might think that would be a depressing question, but I've found that often that's very helpful to some folks. Of course, let's say that there's no such thing as an intervention, a question, a strategy of engagement or assessment that'll help everyone. Here's one from Carl Jung. You've probably heard of Carl Jung, European. When I'm suicidal, there's a part of me that needs to die, and I don't know if you've ever seen this quote. It's my favorite Carl Jung quote. Probably there's a lot of things that he said or wrote that I like. I use this with clients often. I think there's a lot of truth in it. Nothing maybe is true all the time, but if someone wants to die, I'll quote Jung and I'll say, would you consider for a moment, is there some part of you that you'd be better off letting go of? It's another way to say that needs to die. Jung said it in a dramatic way. I don't read this to mean that he actually thinks people need to die, but there might be something to let go. For example, I've had many clients since I've been in Utah who struggle because they identify as queer and are scared to death to tell anyone, largely because of cultural and religious pressures for them. I think you'll see people like this in other parts of our country and the world as well, not just in Utah. One could say that, and sometimes my clients will say, or students, that what needs to die is the need to try to kill that part of me that is queer, that queerness in me, or the need to hide that from other people, or the need to deny that. That's an example. I certainly know people that have killed themselves or tried to kill themselves or lived in a very self-destructive way because of how they feel about their own, who they choose to love. Here's another quote related to euthanasia. Many of you, probably most of you are familiar with the idea of euthanasia, being able to die with dignity. Mariette quotes it that way, at a moment when life is devoid of dignity. I could tell you many stories of work that I've done. Way back when I first started being a social worker in San Diego, I had a client who was much older than me in his 90s. I'll never forget him because he taught me so much more than I brought to him. He was moved out of this section of downtown San Diego when they were renovating it and turning it into a more attractive for many people place. All the low-rent locations were gone. He didn't want to have to move out. He continued to try to live in this area. He accidentally broke his hip and was in a hospital. They were going to force him into a location away from downtown, which is the area he loved and lived in. He jumped out of the second-story window of the hospital or care center he was in with a broken hip, 94 if I remember right, and ran away because that's how strongly he felt that he would rather die than not be able to live where he wanted to. Krishnamurti is one of my favorite philosophers from the country of India. He says death is letting go of what is not me. Therefore, we can and should die every day. This was very helpful to me because I wondered, as I mentioned earlier, why have so many traditions said that it's important to be able to die every day? Again, this is another concept I find very useful from another culture that we can bring to our own culture, whatever culture is our own. What does it mean to die every day? For Krishnamurti, it would be to see that the things that I strongly identify with aren't really me. For example, the roles I play, teacher, father, therapist, those will all go away when I die. What will happen after I die? I don't know. Maybe some of you do. I don't know. That's why I'm not a minister or a clergy. It's one of the reasons I do what I do as a professor and a therapist, but I do think that something changes. When I let go of what is not me every day, that doesn't mean I have to give up what I'm doing as a teacher. I don't have to live in a cave. It just means that I recognize that those things are not me. Now that I'm in my 70s, for example, my body's telling me every day that my body's not me because it can't do the stuff I used to do. I'm really grateful I can run and walk. I like to bicycle commute to work, but I can't do the same things physically, many of the things that I did when I was in my 20s. Dying every day means noticing things like that and accepting it. Here's another one from Irving Yalom. He's my favorite author of textbooks. I love his group, psychotherapy books. He says the root cause of human suffering is our fear of death. It's always present. He says my relationship with my own death is what saves me. I think that's a double wow. I like to bring up that idea as well with clients sometimes. We don't like to talk about death, do we? I'll just share with you that I've applied to do a presentation for a certain conference. I won't mention what conference. I've been doing this for almost five years in a row. I think four years, you know, that would be about this. That, you know, that most of our, you know, client issues are related somehow to death. And I've gotten feedback back. They've never accepted me yet. I'm not giving up. And they say, well, how's that relevant, you know, to the conference? And I think it's very relevant. I think Yalom's right. I love this. Let's all read this part. I'll break my own rule. My confrontation with death can result in my construction of a more authentic, engaged, connected, meaningful, fulfilling life. Grief and loss can be awakening experiences. Yalom isn't saying, let's jump up and, you know, celebrate in the first session with the client, just after they learn they have a fatal illness or something, you know, timing is always important. He's not saying people aren't suffering. What I take from this the most perhaps is this question, what's your relationship with death like right now? I might ask you all that to reflect on it. I think about that more and more. And I'll ask clients that sometimes. And they'll say, what do you mean my relationship with my death? And I'll say, you know, it's going to happen, right? So how do you feel about that? You know, do you, are you still running away from that? Or do you face that ever? And what happens when you face it? And what happens when you run away from it? Because usually, right, if I run away from things, fear grows. Because that's what fear is. Fear is running away, isn't it? So section two. Person in environment and social justice and engagement assessment and intervention. So let's take some of these things we're looking at from different cultures and maybe go a little bit deeper and apply them. So I couldn't fit a picture on here. You can only fit so much on a screen. Here's some suggestions about how, these are just practical ideas for you. You know, if you're trying to think, okay, so what does Dr. Dave mean by taking person into environment? Like practically, what would that mean? So here's some ideas. I might, when I assess, engage, and intervene, you know, consider what are the strengths and vulnerabilities of their own individual life, their, you know, the strengths and vulnerabilities of their family, of their community, and talk about that with them. You know, and certainly everybody has their own family and cultural history, even if their family died when they were very young. But that's their history, right? So, and I think every culture, don't you all think this has strengths and vulnerabilities, just like every individual does? And two would be, are there any significant trauma that may create current triggers? You know, so an example that comes up frequently is I've had many clients over the years who, they'll have suicidal thoughts when someone in their family makes them feel bad. You know, and usually, not always, that the trigger is, it activates the shame they have, you know, and that's a really hard one for them. They don't like often to admit that they have shame, and like Bradshaw said, you know, shame heals when we see it. And, you know, not just become aware of it, but accept it, you know, and just are willing to say we have limitations. So what he calls healthy shame moves from, you know, refusing that I have any limitations to saying, yeah, yeah, I messed up today a hundred times, or yes, I inadvertently offended people, or I made a mistake, and so on and so forth, because we all do, right? If you know me long enough, I like to say I'll probably offend you a thousand times, not because I want to, but because I'm human and so are you, and you'll probably offend me a thousand times too. It's just what happens, and hopefully, we'll also say kind things to each other a thousand times. And then a third idea would be, that's not only what their individual, but what their collective relationship was with life and death, meaning what they learned from their family. What were their mother and father's relationships if they knew them to death? And they usually say, I don't know, but I'll press them on that. How did they live? Did they live as if today's a good day to die, for example? And what did you learn from your community about death? Is it just something that we kind of just hide and lie about? We see the body of someone, and we see, oh, they look so great, right? Well, maybe they do for a dead person, right? And I don't mean be disrespectful, but a lot of people that I've seen that are dead, seen their bodies, they don't look that great, right? So that would be an example. Now, I'm thinking, of course, of Queen Elizabeth having just died this week, and wondering about whether people will view her body, what they'll say. Here's some suggestions about social justice that I think are practical. When addressing suicide or threats of suicide on the macro level, systemic level, consider all forms of xenophobia, which is fear of people who are different than me. I like to define xenophobia that way. It's not just fear of strangers, but people who are different than me in any way. Different in maybe things that we can't hide very easily, like characteristics of our racial identity, perhaps, but maybe also, like we were talking about earlier, who we love, or differences in ability, differences in age. Ageism is something that brings up a lot of xenophobia for people. We don't talk about it that much often. Oppression, forms of oppression that people have dealt with, and discrimination, and linking that, always paying attention to that, and remembering that. I would say that cultural competence isn't so much about how much I've read about your culture from experts, as much as it is my willingness to be a student of you and your culture, that I have an open heart and mind to learn. Tell me about what forms of oppression you've experienced, or discrimination. Tell me stories about that. There's an old Jewish proverb, the shortest distance between two people is a story. Global survival threats are also important, I think, in addressing suicide. I agree with a number of experts who have written about this idea that we sort of dismiss and minimize the impact of large-scale daily stressors in our collective trauma, how that impacts us. We think of trauma, tend to think of it as just individual experiences. There's no doubt that if I, for example, was sexually abused or physically abused, that can be very traumatic my whole life. I might be dealing with that in different ways. There's always reason to think that I can have post-traumatic growth, but that's there. I also think to notice that things like climate change, the possibility that our own activities may kill us, our species, and other species. It's killing other species right now, and there are humans that have died already because of climate change. Disproportionately, people that already have less power, as well as the threat of pandemic and future pandemics. Now, once again, we're talking about the threat of nuclear war. That war, the ability to kill each other is also enhanced by artificial intelligence. We don't really have that discussed yet, but that's happening. There's been nuclear armaments since the 1940s. That was really around when I was a kid in the early 50s. In Chicago, we used to be taught to go under our desks for a nuclear attack drill. Even in fourth grade, I knew how stupid that was that we'd all be vaporized if the bomb was closed, but it wouldn't matter if you're under your desk or not. As well as inequality of wealth and power is another systemic factor. I also like to encourage support of my clients in doing some kind of social justice work. There's a lot of evidence. Kenneth Keniston is probably the father, so to speak, the parent of that perspective. There's lots of evidence that people that not only believe that they can do something to help the world, but actually become committed to something larger than themselves. They have better physical and mental health indicators. Why should psychiatrists, psychologists, and social workers be the only ones who get to help people? Our clients should, too. I like this little idea. I find it helpful. Think of a seesaw and that resources are on one side and stressors on the other. Think about the culture. This comes from the Congressional Black Caucus in 2019. Think about what's the balance for the client or clients you're working with in terms of the resources that are available to them and the stressors they're dealing with. The caucus noted that some resources will stay minimal. Resources meaning, for example, wealth or access to good education or health care that's culturally sensitive, let's say. Then stressors may not go away as well. Some I list here that we're all aware of are income, wealth, access, and power. These all can be related to suicidal thought and behavior. Of course, if we're sitting in a circle and there's 12 of us, I look at all of you and say, does that make sense? Do you have any thoughts on that? Did you find that concept useful? I can't do that. If we look at some of the recent research, and I just added some of them here with some citations, you can look at them yourselves. These are things that make me reflect on this topic more deeply and actually have motivated me to talk about suicide prevention and care in a different way. The majority of people who died by suicide didn't have a known mental health condition. That makes you think about, like I was on a committee once for the state of Utah, and I was the only social worker. The other people were health care professionals in different areas. Long story short, they all had the mental health paradigm in mind. There's nothing wrong with that because there are people who have mental health conditions who killed themselves or tried to. For sure, there still are, but there's people who don't have known mental health conditions. I was talking to them about bullying. Bullying in school settings, bullying in workplace settings, which research shows that bullying in our workplaces may well be the number one stressor for health care professionals, either by our superiors or by our colleagues of equal status where we work. It's a big deal, and we all know what that feels like. We often don't identify people that are vulnerable to suicide. They're hard to identify unless they tell us. Sixty percent, at least, of suicide attempts happen within 30 days of a health care visit. By the way, I love my primary care physician. He's such a great guy. He's my favorite doctor ever, but I always give him a hard time because he has to ask me. I just had my annual checkup, and he always has to ask me these questions that are supposed to ascertain whether I'm depressed. The first question is always, have you been sad lately? I always say to him, Doc, to me sadness is the opposite of depression because at least I'm feeling it. To me, depression is numbness. I think updating and looking at how do we assess so-called mental illness. It's asking whether people are sad. Is that really assessing mental illness? When I worked at a hospice in San Diego, one of my colleagues who I respected a lot who was a pastor, a clergy, he said that sadness is the most healthy emotion you can have. If you can go into sadness, it's less likely to hurt myself and others as opposed, for example, to anger, resentment. He said we don't like it because it doesn't feel good at first. I think he's right. I think when I can feel sad about something that's difficult, it doesn't mess me up. It doesn't lead as likely to me causing harm to others. We don't know yet much about biomarkers. There's lots of people studying, but we don't know enough. I know this is a huge generalization, and some of you are probably like, what? You can find this in some of these citations. It's hard to use biomarkers with certainty yet. To say you have this condition, Mr. Smith, and so we're concerned about your suicide risk. There's also research more recently that suggests there's not that much evidence supporting no-harm contracts. I'm not saying let's do away with them, but if there's not much evidence, is there something else? We should spend a limited amount of time we're doing, we spend with clients to do that would help them. Then one other one I wanted to share with you is there's not as much association maybe as a lot of us thought between suicidal ideation and actual suicide. I think that's an important thing to think about too. If that's true, then should we be looking at other parts of the assessment? Of course, in this presentation to you, we're talking about cultural aspects, a person and environment aspects. This was an important slide, I think. We also know that suicide rates, and I know we're getting closer. I haven't got my warning message yet that, Dr. Dave, get done, but we're getting closer to the end of this segment. Then we'll have questions and answers, but let's note that, and I think we all know this, that suicide rates vary by all sorts of factors of characteristics that we have as humans that we identify with. It's interesting, isn't it, that now the highest suicide rates per 100,000 in the U.S. are among white males. What's up with that? We also know that those rates are high, closely followed by Native Americans or American Indian. You might want to use that term, Alaskan Natives, as well as by African American males. You can see the percentages there. What does that mean to me? That means that I don't assume that people that identify that way are suicidal, but I might pay attention to that in the assessment more. There's other groups of people in our country that have high rates of suicide in the United States. It should read other people in the United States, not Americans. They might include veterans. We know our veterans struggle. There's other occupational groups, too, that struggle. People who live in rural areas. Utah has a large rural area, and then we have this area areas called frontier. They're so rural. There's certain industries and occupations that have higher rates, like mining and construction. We know that people that identify, we could use the term queer, LGBTQ plus, to be inclusive, have a higher rate of suicidal ideation and behavior than those that identify as straight. I think you probably all know that. It's interesting that I looked at some of the stats about the pandemic because, of course, we're still in it, even though many of us are pretending we're not. People are still dying from the pandemic every day. The suicide for white folks dropped in Maryland by half, but African American suicide almost doubled. I wrote here just to consider, is the way we're helping different populations with the pandemic have something to do with that? Because we know that folks that are already disadvantaged, that don't have a voice, that are already poor, in many cases, are more likely to not get as good a care. To live, for example, in housing where they live with a lot of other people and have been more likely to get infected and get ill because they might have pre-existing illnesses as well. African American children and teens, about twice as likely as white folks to make a suicide attempt without expressing suicidal thoughts or plans. What's the cultural factor there? We could speculate on that, couldn't we? I wouldn't want to try to generalize, but I think I might pay attention, for example, knowing something like that. If I have a young person who identifies as a person of color, because there might be reasons why they are afraid or they have learned not to talk about them. They might be more at risk. I can't address that with them. I like to think that the most advanced theory is the most inclusive. What does that mean? An inclusive approach utilizes, and here's my pitch about practice that I can't help but throw in to this presentation. An inclusive approach, therefore, utilizes an eco-bio, psychosocial, spiritual lens in assessment intervention. What does that mean? I could easily talk with you for hours about this, but what it means is we consider all the developmental dimensions that make up people when we work. I am concerned that that's not happening as much as it used to. Many of my students are actually afraid to do anything other than cognitive behavioral interventions, where I think there's evidence that many of these other intervention approaches have merit. They're just simply not studied anymore as much. If you look at the percentage of studies in all of our professions around what we would call cognitive behavioral, that whole paradigm, and compare it to studies with what Maslow called the psychodynamic or the experiential or even the transpersonal models, we see that there's far fewer studies going on right now. They're not as popular. Also, to make a pitch for doing micro, meso, macro interventions, even though many of us are therapists. My favorite therapist in Salt Lake City, and I think often the most effective, not only see people individually in couples and groups, but I see them at meetings where we're talking about fair housing, or we're talking about the new industrial park that some folks want to build that's going to significantly add air and water pollution to the poorest part of Salt Lake City, for example. To me, that's just as important part of our work as seeing people at the so-called micro and meso levels. So a few questions as we near the end again. How many of us are okay with either life or death? One of the metaphors I use with my students to talk about suicide and broadening it in terms of cultural and personal environment lens is think about someone sitting on the fence, kind of like the fence in a court, like an outdoor tennis court in the picture. And on one side of the fence is life, and the other side is death. And my sense about this fence, which rhymes, is that many of us don't want to go either direction. I don't want to fully live because it's scary to know what I really want to do and go for that. It's scary to face what I really want and see if I can accomplish that. Scary to face who I am. On the other hand, it's also scary to face death because there's so many unknowns about it, I think. And so we end up sitting on a fence for many years in my life, maybe my whole life, and you know what happens to your butt? Gets really sore. And the analogy would be that I think creates a lot of what we call symptoms that are part of what we call mental illness. It's just a thought on how to expand on Yalom's idea that most of our symptoms are related to a fear of death, and I would also add to Yalom a fear of life. And here's another question for us all to consider together. At what age and under what circumstances does a person have a right to die? I'm sure all of you have had to confront that with people in your own family, as well as people that you deal with professionally. And how do you feel about it? If you knew you had a painful terminal illness ahead of you, do you want to have the right to die? And would you deny that to other people? It's just a question that we all face, I think, and we will face more. The evidence is that as the so-called baby boomers get older, more and more of us will want that right. And the evidence is that more and more people in our country support that right. So here's yet another question for you. I would like to ask you to consider why do you get up in the morning? Why'd you get up this morning? I know you're just thrilled to be in this presentation, but other than that, what gets you up every morning? Is it more fear or love? Some practitioners have written about that most of our choices could be reduced. It's reductionistic to say this, but sometimes helpful to either fear choices or love choices. So do I get up in the morning because I love myself, as Dalai Lama says, is the purpose of life and love others in the planet I live on, or do I get up because I'm afraid that I'll get in trouble if I don't show up at work, for example, or afraid about what people would think if I didn't. Not to make judgments about whether I get up in the morning or not, but another way to say this question is, can we study more people who choose to live boldly, even when they've had a tough time in life? So we understand that more, and not just study folks that want to die or choose to die every day. And now we're in the data section. So can I ask, Shereen, do we have some questions now, or should I talk some more? You can go a little bit more. Yeah, we have three questions. So I would say if you want to go five minutes more than we could do, that would be good. Okay. So I want to ask you all to please consider asking questions. I think if you have a question, it's very likely other people have that same question. There's some others that do. And like I said, I think it helps everyone learn more. So let's look at some of the data. Here's a good resource for looking at how suicide risk varies across different populations. I think these kinds of charts are helpful. You can look at, for example, the blue line shows rates of suicide for folks that identify as American Indian or Alaskan Native, and you can see differences in how these rates are changing in some cases, and the differences are even increasing between that population and some other groups over time. Here's some data around how we kill ourselves. I notice I have some passion around firearms thing. I mean, like some of my colleagues say, we have so many firearms now in our country, the greatest number proportionally per person of any country in the world. It's going to be really difficult to get rid of our firearms. On the other hand, it really helps people kill themselves, doesn't it? So the lethality of method is significant, and we notice males tend to be more likely to use guns when they want to try to kill themselves. And I certainly had clients who've shot themselves, even in the head, that didn't die, and live with that the rest of their life because they often have significant injuries and a loss of function, for example. And of course, I'm just going through these slides quickly, and like I said, there's a number of them here. So I think it's interesting for us to look at the impact of COVID on our environment and how it affects all of us. And remember, it affects us differently, right? Because it's not intentional, but what's happened, I think generally it's not intentional, is that not everyone in the United States gets treated equally, and certainly not everyone in the world, right? I mean, there's many folks, for example, in the poorest countries in the world, including Sub-Saharan Africa that have no shot at ever getting a shot, right? They're not going to get a COVID injection vaccine. So looking at the impact of all that on how people feel about their lives and how they feel about death. I put section four in here because I think it's important for us also to know what are currently still considered best practices, although there's some conflict with some of these things and some of the things we just looked at and studied, right? Here's six steps that I think are just useful to use. If you're doing an educational piece and you want to have a quick slide to use, this slide I think it's useful in organizing how to think about suicide prevention. I'd like us as a culture, and talking about the whole country now, and maybe globally, to spend more emphasis on prevention in a more culturally inclusive way around the things we've been talking about. These are interesting, right? Keys to Success from the Suicide Prevention Resource Center, which is a great resource for all of us. It's free. You can also go online, download these things. Risk Factors for Suicide. It's something just to keep in mind because people have done research on this and that these are things I can use in my own mind, and there's also formal and informal instruments that we can use. I do some consultation groups with LCSWs, licensed clinical social workers, and I'd say most of them have a favorite suicide risk inventory they use. What are some protective factors? What are characteristics of people then that are less likely to actually try to kill themselves? I won't read them to you. Also I'll note here that although the number of people proportionally that die by mass murder is small, we all are aware how common mass murder has been. And often I think it's interesting to note that it looks like people that choose to kill others usually with a rapid fire gun also seem to want to die, and they will shoot themselves or appear to set it up so that the police kill them. And I think that may be a subset of how people want to and why people want to die, but it's something worth studying, I think. And it might be that intervening earlier, because I think it's possible for us, not with 100% accuracy, but it's possible for us to identify people that are struggling in school, for example, like in high school, junior high. I think I remember when I was in high school and junior high, I knew about other kids in school who I thought were struggling, having a hard time. We could maybe be effective in reducing not only suicide, but murder. And of course, there's people that will kill just one person and then kill themselves. Something here, domestic violence. This certainly happens in our country as well and in other countries, right? I like this chart. I think it's kind of nifty as a way to think about intent, and it's something you could copy and use in a presentation or even show to a client if you wanted. This one I think is cool, too. It's a little hard to put on the slide, so it might be hard for you to read, but take a look at it if you have a chance. Like it's just a systems chart. If you're on a committee sometime trying to reduce suicide in the community you live in, I think a chart like this is really useful, so you don't have to reinvent the wheel. You can start with this and then see how it applies, if at all, to your community and build from that. Let's see. I'm at the bibliography. So, Shereen, can we try some questions, see what happens? Yep. We will. I just want to thank you first for your presentation, and before we shift into Q&A, just take a moment to let everyone know that SMI Advisor is accessible from your mobile device. So, you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. So, download the app now at smiadvisor.org slash app. All right. So, we have some great questions, and we did get a lot. So, we'll let you know after, if we don't get to all of them, how you can submit questions at a later date. Okay. But the first question I want to ask you is just about, so, if we do think of suicide as a social justice issue rather than as kind of a mental health individual issue, what would be the benefit? Do we think that we would approach it different systemically? Right. I would say, first, that the question isn't, I mean, I'm not suggesting rather than, I'm saying in addition to. That's why I put that slide in there, that the most advanced theory is the most inclusive. So, it would be, how can I also add social justice to the perspectives I already have, because they're all important. So, we don't stop thinking the way we did in the past, but we also, I might ask the question, how is this person, or how are these people sitting in front of me that I'm working with, not only impacted by things like, for example, what we call mental health, mental illness, but also how they've been impacted by injustice, which is, as we all know, it's not, it would be unjust to say that we should call it mental illness if someone that's been discriminated against and currently discriminated against or oppressed is bummed. Bummed is an old 60s word for depressed, right? And I think of an example of a good friend of mine and colleague who identifies as African American who had a prostate cancer diagnosis in his 50s, long story short, could not find a doctor for months who was willing, who was aware and or willing to look at how the literature shows that African American men need to be assessed and treated in some ways differently than white men, for example, when having that diagnosis, you know? And so, my friend does not have a mental illness, to use that as an example, that he got depressed because he couldn't get the help he wanted, but he's more a victim of injustice. I hope that helps you with that question, which I like too. How about another one? Yeah, thank you, Sheree. Yeah. So, I think we'll only have time for one more, but I will, like I said, I'll go over how we can, how you can get questions to us later, but the next question is about stigma specific to different cultures. So, some cultures have a greater stigma associated with mental health and suicide, and do you have any just thoughts about how we can work to address that? Yeah, I think that's a great question. You know, I had the privilege of, for 10 years, working with a center in Salt Lake, it was called at the time the Indian Walk-In Center, now it's the Urban Indian Center, and you know, here's this white guy, me, you know, I'm Greek and Italian, a European American who's asked to, you know, to do the clinical directing at the center, and you know, so I think it was really important to go in with a lot of modesty, right? I don't know your culture, you do, and deal with the testing in a good-natured way, because of course they're going to test me to see if I'm, and I hope this is addressing the question in an effective way, but you know, a lot of the, there's more Navajo folks than any other group, maybe a third were you identified, and they like to tease often, and they would give me a hard time, and I got it that that, what it was about was whether I could be human around them, and laugh with them, and finally kind of give them a hard time back, you know, and I'm not going to hide behind being, you know, Mr. Expert, and you know, and then running, you know, if I'm in a space, then running meetings where it's democracy, and I'm in the front, we'd sit in a circle, and it would be about us helping each other, and you know, and yes, sometimes I would say stuff, but often I would be quiet and listen, and that's just a few thoughts that come to mind, and that's common sense, but I'll say this too, you know, like, you know, one of the hardest assignments I had as an academic all these years, when I've been asked to, either for a department, or for the university, the chair, you know, an EDI, that's what we call it now, an EDI committee, equity, diversity, inclusion kind of thing, and it's because no matter what you do, people get mad at you, and you know, there's all sorts, people are all there, because they want, they all share this common goal, but we have differences of opinion about how to get there, and so I think it's really important these days, don't you all, I mean, you only have to be in a conversation typically about a minute these days, when you have somebody bringing up how terrible it is that we're polarized, and I think that we can all do something about that by spending a lot of time acknowledging that we have different theories of change, and allowing people to think differently about how to get to the goals that most of us want, and then what I would especially do is make sure that people that had the least power had the chance for voices, so both with a lot of the American Indians, not all that I know, especially the ones that I had in class up at the U, I would call on them, because they taught me that they needed that to speak, and help them with that, they weren't likely to raise their hand, not all of them, there were always exceptions, when I was running a EDI committee, I would, sometimes I would use a talking stick, you know, you pass, and people are, they're talking pencil, you know, you could use anything, and that, and I would give it first to the people with the, the person in the group that I thought had the least power, and you know, even in effective EDI committees I've sat in, usually there's one or two people that spend, that talk the most, and research shows that people think the person that talks the most is the smartest in the room, that's the most important factor they use to judge that, and I bring that up because even though it might sound like a small thing to you, I think it's huge, like how, if when I have an opportunity to be a leader, how I can get out of the way and let other people talk, but use my power to insist that folks with less power speak. Well, thank you, Dr. Dave, that's a great response, I do have to move us along, it is time, and I want to get to just the final slide, so people know how to claim their credit, but thank you so much for that powerful answer. So, is there a way for them to send questions to me, and if so, can you let them know? Yeah, so if you do have questions about this webinar, or any other topic related to evidence based care for SMI, you can get an answer within one business day from a SMI advisor or national expert, and if you have questions specifically for Dr. Dave, I would still say, why don't you submit it through the consult, and just flag that, and then our team can work with that, so submit it as a consult question, and then you can say specifically it was rated to this slide, and it will come to me then, and I'll coordinate with you. So, the service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI, and it is free and confidential, so please feel free to do that. So, SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care, so we also encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders, and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic, so to claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession, and verification of attendance can take up to five minutes. So, you'll then be able to select Next to advance and complete the program evaluation before claiming your credit, and then do please join us next week on September 15th as Dr. Margaret Hahn presents Metabolic Comorbidity and Severe Mental Illness, Treating the Brain While Minding the Body. Again, this free webinar will be September 15th from 4 to 5 p.m. Eastern, which is a Thursday. And thank you again so much, Dr. Dave, for joining us, and until next time, take care.

suicide

social justice

mental health

person

environment

culture

trauma

social inequities

holistic approach

suicide prevention