‘In Dialogue’ Episode 19: How we talk about suicide matters

Introduction
CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Dr. Vivian Sapirman (VS):
Thank you for joining us “In Dialogue.” My name is Dr. Vivian Sapirman and I’m a psychiatrist at Women’s College Hospital and medical advisor here at the CPSO. I’m honoured to host this important episode on suicide awareness and mental health with Dr. Juveria Zaheer, a psychiatrist and researcher at the Centre for Addiction and Mental Health [CAMH], and Gina Nicoll, a dual expertise researcher at CAMH.

Before we begin, I do want to make a listener note and emphasize that the subject matter of this episode may be distressing for some listeners, especially if they are struggling or have previously experienced mental health struggles, or somebody in their family is in distress. We would like to let our listeners know that help is available for those who may need it, and we’ll be including some information and support resources on our episode page. I encourage you to make use of these and pass them along if you know someone who is struggling.

Now let’s begin. Welcome Juveria and Gina, and thank you so much for being here to discuss this important issue.

Dr. Juveria Zaheer (JZ):
Thank you so much for having us.

Gina Nicoll (GN):
Hi, thanks so much for having us.

VS: So, I know that the two of you really have a wealth of information to share with our listeners. I think the best place to begin is to maybe tell us a little bit about your research and the work that you’re doing in suicide prevention.

JZ: Our Suicide Prevention Research Program has four major areas. The first is trying to understand from a bird’s eye view how service utilization and suicide risk can present differently across different groups. And that means that we need to understand that suicide risk for people with schizophrenia may be different than people with mood disorders, or people who are ethnic minorities may be different than people who are not, or men may have different risk profiles than women. So, we do a lot of big data linked health admin work to understand how patterns of suicide and patterns of help seeking can be different in order to build targeted interventions.

The second major pillar is from the ground up. So, that’s the bird’s eye view, and this is from the ground up. Trying to understand people’s lived experiences of getting care, of having distress, how they understand suicidal thinking, what comes first, what comes next, where are the opportunities for help and support, and what works and what doesn’t for specific populations.

The third major pillar is trying to understand how we can teach suicide risk assessment in a way that is empowering, in a way that’s humane and dignified, that takes away the focus from necessarily predicting suicide — so, who is at risk; who has high, medium and low risk — but moving towards prevention. How do we understand someone’s experiences? How can we be rigorous and systematic and empathic when we collect that information? And how can we move that information from a place that’s not about predicting death, but to understanding distress and modifying distress, and eventually modifying risk?

And I think the fourth piece brings all of these pieces together. You think about the reason we all do medicine, the reason we do psychiatry, is we’re interested in people’s stories and suicide is the most tragic end to someone’s story — and it’s complicated. It’s not just about the biology or the psychology, or social determinants of health or culture — it’s about all of these things. And so, the fourth pillar brings all of these pieces together. We’re doing some work where we’re going to track people coming to emergency care over time to understand all of these different components that make them them and how these components can affect people’s suicide risk, and what are the best places and ways to intervene.

VS: That really sounds like it’s work that will have such a significant impact on how we work as psychiatrists and in terms of any physician who’s engaging in any sort of risk assessment — that shift from kind of predicting death to really focusing on distress and ameliorating distress, and thus mitigating risk — is such a nuanced difference, but so significant.

JZ: I think so, and I think one of the things that’s really difficult about being a healthcare provider is that we get two different messages about suicide, right? One is that we can’t predict suicide. And when you say, “You can’t predict suicide,” it can help in the ways that it can help us feel better if we have a tragic loss, it can help us have the context to support each other. It’s also challenging because it can lead to a sense of nihilism: what are we doing and why are we doing it? And it can make it difficult for people to accept new interventions or new approaches that may be really helpful.

And then the second story that we get is that we can always prevent suicide, which I think we know that this is unfortunately not the case on an individual level, and so it’s a huge burden. And suicide prevention takes all of us: it takes government, it takes healthcare providers, it takes family, it takes society. And to put all of that burden on one healthcare provider is also pretty problematic.

And so, we find that this third way, like let’s understand what someone is going through, let’s systematically address their risk factors and strengthen their protective factors. Having suicidal thoughts in and of itself is really distressing for people. It’s a sign that someone’s mental health isn’t where it should be, and it’s a sign that they’re deserving of hope and health and care. And if we can focus on that, I think it can be much more empowering, both as a patient and as a provider, because it gives us something to focus on that is less nebulous than living or dying.

VS: Can you expand a little bit on this idea? Bear in mind that our audience is comprised of both physicians, and the public and laypeople. But with the view to the physicians, expand on this idea of suicide being preventable or not. How we understand that, especially if we’re talking about a physician who is not a mental health specialist, who is not a psychiatrist.

JZ: I know that in speaking with family physician colleagues, other specialist colleagues and even psychiatrists, that feeling where someone discloses suicidal ideation in an interview is a scary one. It means okay, well now I have to figure out where their risk is, I have to figure out what I’m going to do. And we know that some interventions in health care can be very frightening for patients and for the provider; you know, putting someone on a form, for example, admitting them to hospital. And so, what we’re trying to do here is to demystify that process, to say that if someone tells you they’re having suicidal thoughts, that’s a symptom. It’s a normal feeling. It’s no different than having a panic attack or having difficulty falling asleep. And if we can think about that suicidal ideation then less as are they going to do it or not, and more like how we would understand pain for example. What makes it better? What makes it worse? What’s the duration? What’s the intensity? What’s the frequency? What is something that this patient has experienced before versus what is very different about it? And what’s the quality of the thought?

Gina and I talk about this a lot. This idea that when people say that they want to die by suicide — and I think this from Yvonne Bergmans, who has taught many of us in the field — it’s not often that they say, I want to end my life. They want to end something else: my pain, my suffering, my exhaustion. And I think connecting with that piece can be a very effective way to come up with a plan in terms of prediction and prevention. So, on an individual level, suicide is very difficult to predict. And even if we could predict it, there’s lots of issues with something that’s such a rare outcome. For example, are we talking about minutes or hours or days? Are interventions going to be different across each one? Are we going to only give care to people we think are at high risk, even though we know that it’s very difficult to differentiate high risk versus low risk?

At the same time though, we do know that, for example, a very good psychosocial assessment — when we talk to someone about what they’re experiencing and come up with a plan — can reduce suicide risk in people in the intervening several months by about 40 percent. We also know that really low intensity interventions, like safety planning, can reduce recurrent suicide-related behaviour by about 50 percent in three months. So, there are things out there that work. We just need to have a comprehensive approach and a comprehensive plan, and maybe remove that burden of prediction, because I think that is what gets in the way of a lot of relationships and a lot of therapeutic plans.

VS: There are some really powerful concepts in that. And this idea of likening suicidal thoughts to pain, I think really resonates and it’s so impactful and so powerful because it empowers both the physician, but also the person having that experience. It normalizes it for the person. This is a symptom. This is part and parcel of the distress you’re experiencing; part and parcel, potentially, of your diagnosis or underlying illness. And then for the physician, it gives you a bit of a roadmap. Again, to your point, that the burden doesn’t rest with you about prediction. It’s more like, okay, let me understand this, the different facets of it, the different sides of it, the same way we would look at, to your parallel about pain. So, I think that’s incredibly powerful. Can you speak to what some of the evidence-based preventions are?

JZ: Absolutely. When you think about suicide prevention, from an evidence-based perspective, we can start off with more kind of larger, broad public health interventions. So, things like means restriction, whether that’s bridge barriers, gun control, smaller packaging for pills, prescribing practices. All of this has evidence. And then we think about health care provision. So, we know that, for example, gatekeeper education or training family physicians to understand and treat depression or evidence-based interventions. When we think about patients on an individual level, we know that treating underlying mental health concerns reduces suicide risk. There are certain medications, as we know, that are associated individually with reduced suicide risk. But we also know that any kind of treatment for underlying mental health disorders can reduce suicide risk on a kind of general population level. And I think there’s an area that we focus a little bit less on, that I think is really going to come to the fore, which is suicide-specific intervention. That’s really good psychosocial risk assessment, safety planning. I think these pieces are going to be really important moving forward,

VS: You’re speaking about this idea of risk assessment — what does a comprehensive, evidence-based risk assessment look like? What does it include?

JZ: The first place to start is to always start while the iron is cold. I think sometimes when someone discloses suicidal ideation, we shouldn’t jump into risk assessment mode. But if we’re meeting someone for the first time, whether it’s in family practice, for a mental health assessment or as a psychiatrist for a specialized assessment, I think it can be really useful to get a lot of information upfront from somebody. So, if someone says, “No, I don’t have any suicidal thoughts right now,” that’s great and that’s wonderful. But I think it can be really worthwhile to understand their risk in context, so if that changes, you don’t have to get all of this information later. And it also can help mitigate risk as you move forward. So, we always suggest to people that the first thing to do is to look at historical risk factors. So, you know, asking about the things that we would ask about: do you have a family history of suicide, for example? Have you ever had suicidal ideation? If so, when was it the most intense? When was it the most recent? Have you ever had suicide related behaviour? Again, when was it at its most intense? When was it at its most recent? And then, if there is a suicide attempt, to get as many details as you can about that: so, were efforts made to seclude yourself? What was the intent? Was there any preparatory behaviour? For example, suicide-related communication, talking to people, writing notes or any kind of rehearsing behaviour or getting one’s affairs in order, that kind of thing. So, when you have this kind of rich frame, it can make it really helpful when you are assessing risk moving forward.

I think the other really important approach is “now and then.” So, compare it to how you felt then and how do you feel now? What’s different? What’s better? What’s worse? If someone then endorses suicidal ideation in your discussion with them — I think what we talked about earlier — thinking about suicide risk assessment as you’re assessing pain is really important. So, what is the quality, duration, intensity, frequency? What makes it better? What makes it worse? Sometimes people will say, “I wake up feeling okay. And then before bed, when I can’t get to sleep, that’s when it’s at its worst.” And that’s really helpful because that means we can think about plans that we can put in place in those difficult periods; always making sure that you ask about preparatory behaviour is really important and differentiating long-term.

We all learn SAD PERSONS [scale], right? But I think there’s a lot of things in SAD PERSONS you can’t modify. But thinking about acute risk factors so, what has changed recently, psychologically, socially? Asking about financial stress, asking about relationship stress, asking about work stress is really important. And then also thinking about warning signs. So, warning signs are things like increased substance use, increased agitation, increased suicide-related communication, difficulty sleeping, changes in behaviours, changes in function, because these kinds of more imminent pieces, they serve two purposes: one is they help us identify who may be at risk and who may be suffering; and they help us identify treatment targets that we can work on to get the distress down.

VS: That’s incredibly helpful and goes so far beyond this idea of this checklist of SAD PERSONS and then the standard risk factors that we’re all trained in, to so much more of a rich, nuanced framework.

JZ: And I think too, it’s been really helpful for me even as an emergency department psychiatrist, because I know it sounds like it takes a long time, but it doesn’t actually take that long at all. Because it’s a conversation and it’s part of your assessment. And I think one thing that we really shy away from, as psychiatrists or as family physicians, is it’s scary. It can feel shameful. It can feel like if we talk about it, it’s going to happen. But I think we’re really encouraging people to — Gina puts this beautifully — exploring the pain behind the plan. So, not losing sight of someone’s lived experience, what they’re actually going through. What does suicide mean to you? What would it mean to live or die? Are you dying to live? Or are you living to die? How does it feel when you’re talking about these things? Because I think if we can’t understand that pain, it makes it very difficult to connect with people.

VS: I think you raise a really important point about some of the fear that comes with opening this conversation and unpacking these things. So, it’s very, I think, reassuring and helpful to hear that it’s okay, and appropriate and important to have these conversations. At the same time, we do hear about, we do understand, we know the data on the almost viral nature of suicide. And so, how do you reconcile those two pieces? Can you kind of speak to when it’s not okay to talk about it? When it can be unhelpful or problematic versus when it’s really important and helpful and therapeutic? And maybe I’ll add to that, I know myself when I’m doing a risk assessment, especially sometimes if it’s a younger person, or where the family is very closely involved, there can be pushback and fear from the family when they hear about the screening, like you’re putting this idea into their head, or how can you be talking about this? You’re giving them ideas. You’re giving rise to these thoughts. So, can you speak to these kinds of thorny, complex issues?

JZ: When we provide people with messages about suicide in broader, immediate conversation, that is inappropriate or unsafe. So, if we suggest that suicide is related to a single cause, or that suicide is inevitable, or we trigger people by talking about specific methods, or we glamorize or glorify suicide in any kind of way, we know that these are all really inappropriate. But we do know that that evidence is not present around clinical interaction. So, there is no evidence that asking someone about suicide in a clinical setting could increase their risk of suicide. I think we can talk about suicide prevention in a hopeful way. And I think if we can say to families, “I’m so glad that you’re here. I’m so glad that your loved one is here. You’re really suffering. Sometimes when people are suffering, really dark thoughts come, but part of getting better is talking about them and knowing that you’re safe with us. And that these are things people experienced, but the vast majority of people who have suicidal thoughts don’t die by suicide.” You always want to follow someone’s lead, and you want to provide support and reassurance.

So, if someone says, “I had suicidal thoughts when I was 13, but I don’t have them now.” To say, “Well, I’m so glad to hear that you’re feeling better. Now, I wonder what’s different now? It must have been pretty scary back then. You’re so strong to have gotten through it. What helped back then?” I think that there are ways that we can have these conversations in positive, supportive and hopeful ways. But I do agree with you completely that I think we’ve come a long way as a society, where we now talk about mental health in a much more open and robust way. But there’s something about suicide that is still really frightening for people. So, I think part of that process is demystifying it a little bit, and talking about have feelings and thoughts rather than necessarily mysterious or unknowable actions.

VS: Absolutely. You also spoke earlier about this idea of suicidal behaviours, and there’s different language and different terms and words we use to describe these things. Can you speak a little bit to some of these differences? And also, potentially, how that confers risk — this idea of suicide versus suicidal behaviours versus suicidal gestures, and this different language that comes up around it?

JZ: Yeah, the nomenclature is so important. And I think it can be really tricky when people are talking about different things. I think the first thing around suicide language is to always be patient-centered, and to try to avoid words that have negative or stigmatizing connotation. So, that’s the first step. And I think most physicians are really good at this. So, not saying committed or completed. Or, as an example, I prefer the term “suicide-related behaviour,” because it encompasses a whole spectrum of experiences. And so, you have suicide-related behaviour, which is any kind of harm to oneself with undetermined or intent to die. And I think that “undetermined” piece is really important, because you’ll talk to people who, for example, have an opioid use disorder and they’ll talk about overdosing; they’ll say, “Well, I don’t know if I wanted to live or die in that moment.” And so, we can code it as an unintentional overdose. But there’s a bit of a disservice to the patient. And Gina and I’ve spoken a lot about this, and this comes up in a lot of our research: sometimes people aren’t really sure what the intent was in that moment. And so, I look at suicide-related behaviour as any kind of behaviour that harms oneself.

And then you ask the second question about intent. So, sometimes people are like, “I engage in this behaviour, but I clearly had no intent to die.” So, you can call it suicide-related behaviour without intent to die. Someone can say, “I engaged in this behaviour and I knew it could be fatal. But I didn’t care in that moment.” Or, “I’m not really sure I knew what was going to happen” or “I engage in this behaviour and I really hope to die.” And I think it takes away a little bit of that stigma that comes with it. And suicide-related behaviour can have different roles. It can be with an intent to die, it can also be with an intent to express distress. And I think we need to destigmatize that it’s okay to express distress. It doesn’t mean that you’re manipulative. I think sometimes the problem with words, like “gestures,” it’s like, “Well, if you weren’t gonna go through with it anyway,” and it kind of diminishes people’s experience. So, if we say suicide-related behaviour, then we can say, “Well, it sucked that happened to you, and that there was something that you were either trying to communicate or something that you were experiencing that is not okay. Let’s figure that out.”

VS: That’s such an important distinction. And I think your comment about stigma is so important, because I think we can so easily and inadvertently stigmatize through some of this language. I don’t know that I had really thought about the idea that using the words “suicide gestures” sends an implicit message, like, “Well, you weren’t really serious,” and how that can be really invalidating and potentially under great risk as well.

JZ: And I know that some of our colleagues, especially who work with younger folks, we know that the number of suicide-related behaviours in younger people is a lot higher — that are not fatal are a lot higher than it is in people over 65. There’s a spectrum there. And I think sometimes talking in this language can take away some of the stigma, but it can also let us talk about it in a way that doesn’t conflate necessarily suicide-related behaviour with suicide-death, and that intent piece is really important. So, you may have a person in front of you who says, “Yeah, I had like four or five episodes last month. My intent wasn’t to die, but I was really, really stressed.” And then you say, “Well, what’s our goal for this month?” And so, you have a common language that isn’t about litigating what each thing meant. It’s like, “Okay, what was going on at each time? What was tough about it? How did it help in that moment? What are some behaviours that you’d prefer to replace it with? And how do we keep moving forward?”

VS: And it’s really redefining the language and almost redefining the terms, and, hopefully, as people become more comfortable with these concepts and it gets more traction, then there becomes a more common language. Because I think right now, this isn’t the phrasing used widely, right? And it sounds like it really should be. And there’s a lot of important reasons to do that. And hopefully, with more momentum and traction and understanding and conversations like this, hopefully there becomes more consensus around how words are used and what terms are used.

GN: The discussion around suicide versus self harm. That is a topic that researchers are kind of split on as well. And in the US, a kind of dominant thinking tends to be there is a distinction between what they term “non-suicidal self-injury” and “suicide.” And those concepts are quite split. Whereas in the UK and that area, people think of it in general as “self-harm” as an umbrella term, which can include suicide with intent or suicidal behaviour with an intent, as well as self-harm in general without necessarily intent to die. And Canada kind of tends to be somewhere in the middle.

In my personal experience, I dislike the term “non-suicidal self-injury” for a couple of reasons. One is that we know that people who self-harm, regardless of intent or not, that they are at increased risk of dying by suicide later. So, even if it’s not with the intent to die in the moment, there is that longer term increase that I think is still important to recognize. And I’ve been someone who has self-harmed and I would have told you, in the moment, it’s not suicidal and that’s true. But then over the longer term, for me with my suicide attempts, my self-harm before those attempts was always increasing and something that I think helped me get to that point of making an attempt.

And there’s this concept in suicidology, there’s a theory around suicide called the “interpersonal theory of suicide” by a psychologist named [Dr. Thomas] Joiner. And one of the components of that, he says, for someone to make a near fatal suicide attempt or die by suicide, there needs to be two parts. First is the desire for suicide. And he says that’s composed of thwarted belongingness and perceived burdensomeness. But then once someone has the desire for suicide, they also need the acquired capability for suicide. And that’s based off this idea that we need to get past that evolutionary drive that we all have to survive. Like most people, when they might hear of suicide, they might think, “Oh, how can you do that to yourself?” because we have this instinct to not do something like that to ourselves, because it does mean ending our life. So, someone needs to get past that instinct. In his theory, people do that through things like exposure to violence in their life, self-harm, practicing suicide attempts, previous non-fatal attempts. So, I think we also need to think of what role self-harm without suicidal intent is playing within that larger progression towards potential death.

VS: That’s such an important lens and I think really broadens our understanding, and also how we frame it within our assessment, within our understanding of this person.

GN: Going back a bit to Juveria’s points and your discussions around moving beyond the risk assessment mode and trying to understand suicidal thoughts. We co-teach first-year residents in the psychiatry program at the University of Toronto on suicide risk assessment. One of the stories is actually with Juveria’s and my colleague, [Dr.] Yvonne Bergmans, who is a now retired social worker, who used to work at St. Michael’s Hospital. She created a group, “Skills for Safer Living,” which is a suicide intervention group therapy. And I was actually part of that group previously, first as a patient, and then I became a peer facilitator of the group, working with Yvonne.

So, one of the stories is from when I think I was going through a group, and I was in a bit of a crisis, and my suicidal thoughts had increased. And I was actually talking to Yvonne on the phone for support in between groups. And she had said, casually, “What are you thinking of?” And I knew her and maybe she was asking, “What are you thinking of doing in terms of suicide?” And I was silent for a while, didn’t say anything, and eventually was like, “I kind of don’t want to tell you and I don’t know why.” She offered, “Maybe it’s hard for you to talk about because in the past, as soon as you talked about the plan, everything became about the plan and taking that away from you, and not about the deep pain underneath.” And that really resonated for me because definitely in my experiences, it’s often been as soon as I talk about suicidal thoughts, I can see the clinician shifting into risk assessment mode: “Do you have a plan? Do you have access to means? Where are the means? Can you give those up?” Thinking of all of those things, and that kind of shifts away from understanding what I’m going through, and what is driving that pain that is often driving the plan.

So, that’s why Juveria and I talk about framing suicide not only as a risk to be managed, but a pain to be understood. And I think that understanding of the pain and where that’s coming from for people, that’s like — I guess it goes back to how I think Juveria said, we can try to think of suicide as a symptom, not a disease, if you will, the sense of understanding the pain and where that comes from. For people, that’s really going to be the treatment target. And addressing that is going to be the most effective in the long term, instead of thinking more downstream with the plan. That’s important, but doing that alone will only get you so far.

VS: I think that’s great. And I think in these conversations and in these assessments, there’s two people at the table. And so, it’s so helpful to really be able to understand that perspective and kind of have a glimpse into the way that our words and our questions and our approach impacts the person we’re speaking to. And this idea that the minute you say those things, the minute you express these thoughts or the fact that you’re feeling unsafe, you see the shift in the clinician. That’s a concept that resonates with me as well, because we right away go on high alert. And so I think that’s why this is such an important conversation because, as I said previously, not only does it I think improve the clinical experience of the patients and make it much more patient-centred and normalizing and validating and empathic and kind of helpful and more constructive, it also helps alleviate that kind of fear and that helplessness that a physician can experience faced with that, because we just want to help and we just want to make sure that we’re doing the best by our patients.

GN: Exactly. Our behaviours change, depending on if we’re talking to our best friend, or our supervisor, or our grandmother. So, really recognizing the importance of the relationship, I think, is central to the suicide risk assessment, because the relationship is the foundation that’s going to impact everything else in the suicide risk assessment.

VS: And I would imagine the prevention as well, no? Because in that moment, when the patient is forming their perceptions of the physician, it will impact what they say in the future and how forthcoming they’re going to be, and how willing they are going to be going forward to engage in this conversation and to be open and to seek help. And if we’re blind to those things and not aware of those dynamics, we could have a false sense of having the full view and of getting all the information, which then, I think, can impact prevention. Is that an accurate statement would you say?

GN: Exactly, yes, you have it right. And practically, what Juveria and I often talk about in teaching is encouraging people to build a better rapport with someone. First, on a more human level, before they get into some of the risk assessment questions. Thinking back to some of my experiences, when I was on an in-patient unit, there was a resident on my team who I had a bit of a better relationship with. And one of the things that I think helped start that was often when the treatment team would come get me in my room to talk, I would be reading a book as I was waiting, and the resident would often start by asking me what I was reading and he would tell me what he was reading. And that helped me connect with him a bit more and see him as human, like he is and like doctors are. But I had been kind of intimidated a bit by meeting with physicians. So, connecting on that more human level first helped me then connect with him more in a therapeutic context, and feel comfortable opening up to him about things that were going on and trusting him when he makes recommendations or tries to challenge some of my thoughts.

JZ: And I think Gina’s point, it’s so beautiful. One of the things and first principles that I try to remember — and it can be really tough in the middle of a busy day — is that the disclosure of suicidal thought comes with a lot for patients. They can be afraid of what can happen to them. It’s almost like coming out in a sense, but you can’t take that back. People with suicidal thoughts, they may also already feel like a burden. They may also feel like they’re hurting their families. So, saying it out loud can make all of those things real. And I think to take a moment and lead with empathy, to say, “I’m so glad that you told me. I know it’s not easy. And we’ll figure this out together.” It can just remind the patient that this is an okay thing to say and it doesn’t necessarily mean that you’re going to go to the hospital, or I’m going to ask you 100 questions all in a row. It just means that I’m going to ask you questions. We’re going to be systematic about it. But I hear you, and I’m so glad that you told me and I know this can’t be easy, and I’m so sorry you feel that way. Because fundamentally, if someone is so sad they don’t want to be alive anymore, it’s sad. And I think it’s traumatic. And I think it’s very reasonable to sometimes — I think medical training trains the humanity out of us. Like we want to get all the questions right, we want to collect the information, we want to stay boundaries. But it takes 30 seconds to say, “I’m so sorry to hear this. And this must feel really awful. And I’m so glad you told me. It was really brave. And we’ll figure this out together,” I think can go a long way.

VS: Such an important reminder.

JZ: Yeah, and I think that approach can also really help in the safety planning piece, and to make safety planning more collaborative and more helpful. Safety planning is an intervention that can be done in emergency departments, it can be done in a psychiatrist office, it can be done in a family physician’s office, and then we can include a template that is evidence-based for you. You’ll never want to jump to a safety plan when someone is still in distress. You wait, as Gina says, until the emotional bleeding has stopped and then you can work through it together. And remember, a safety plan is a living document that will change over time and that can adapt. Some people prefer paper, some people prefer an app. CAMH has a great app called the Hope app. That’s a wonderful safety planning app that’s evidence-based.

We often start with reasons for living and sometimes people may not be able to identify those. But that in itself is kind of part of the assessment. What are those early signs that I might not be safe? And is there ways that I can distract myself? What is helpful for me? Is it knitting? Is it watching a show? Is it going for a walk? Is it taking a shower? What works best for me in that moment? Then it’s people who can distract me. So, not necessarily talking about suicidality, but are there people that I can talk to, whether it’s online friends or real-life friends, or my sibling who can pull me out of this place? Then it’s people I can talk to about my feelings for help. So, identifying folks and sharing the safety plan with them can be really helpful too, so that they know what’s up and know what the steps are. Then it’s places I can go or people I can contact for help. So, it’s my care team, going to a hospital, calling a helpline.

And I think one of the key pieces to the safety plan is the last piece, which is keeping my environment safe. So, especially when we’re talking to patients, if they’re having thoughts of overdose, maybe we don’t want to prescribe in large quantities. If someone is thinking about gun violence, how do we make sure that the gun is out of the home? How do I keep my environment safe? Like, maybe I don’t keep things that I could use to self-harm in close proximity. Sometimes we talk about even putting stuff in the freezer — it reminds me of that episode of Friends where you put stuff in the freezer, under your bed if it makes you feel unsafe. There’s lots of things we can do to keep our environment safe. I know that if I use alcohol, that can be a trigger for me. So, keeping my environment safe might be keeping that stuff out of the house. Or it might be not being around people who make me feel worse. So, I think that approach can be really effective as well.

And we know that safety plans are really — in randomized control trials have shown effectiveness, both in terms of reducing suicide-related behaviour, but also in terms of increasing positive help seeking, which is awesome. And it’s something that you can do as a team. You can do it as a physician with your patient, you can do it with another member of the team who can also help a patient, a loved one can do it with a patient. I think it’s really, really effective. You just got to get the timing right. And then the cool thing about a safety plan is every time you use it, it’s reinforcing. So, every time you use a safety plan, you feel more capable to do it.

And then the last thing I’ll say is there are limits to a safety plan. A safety plan works really well for people who have increased suicidal ideation at different times in the context of distress or other symptoms, but they have a thread of hope that they’re holding on to. If someone is so hopeless and so distressed, doing a safety plan isn’t going to work for them. There are other things that we need to do on top of this to help get rid of the symptoms of severe depression and the symptoms of psychosis or the experiences of hopelessness. So, it’s not a panacea to be sure, but I think it’s something that is a really important part of every physician’s, and health care provider’s, and patient’s toolkit.

VS: You made it very clear that the concept of safety planning is actually a fairly robust, detailed intervention. But I do think it’s important to state explicitly that there’s this idea of contracted for safety, there’s this kind of note that gets put on the chart. And we know that that’s not helpful and that’s not something that really carries a lot of weight. So, can you just speak briefly to how is what we’re talking about different than this idea of kind of documenting contracted for safety?

JZ: It’s interesting you still use that expression. I think it’s fallen off a little bit. But I think all of us have trained with that expression and I think it speaks to the philosophical difficulty of this kind of work. It’s like, “Okay, well, if they can promise me, we’ll keep it together.” But it’s kind of a big burden to put on a patient. And it doesn’t consider all of the other factors that are at play, like someone may not want to be admitted to hospital, they may want to just end the conversation. They may, in that moment, feel safe and they can say that they can keep it together. I think the problem with that is that it’s this expression that nothing else comes with it. It’s like a full stop. It’s contracting for safety, but it’s not building capacity to be safe. It’s not building empathy or a relationship. It’s a way that we make ourselves feel better about something that feels fundamentally unknowable.

And I think sometimes having that conversation around contracting for safety, but are we able to do safety plan. So sometimes, if someone is unable to safety plan, that may be an indication that they need to stay in the hospital or they need extra support. It’s very different than contracting for safety, because anybody can say, “No, I’m good. That’s fine.” But it takes a little bit more work to be able to actually engage in safety planning and that safety plan is evidence-based. I think contracting for safety isn’t super helpful medicolegally and I know that’s something people think about a lot. It kind of creates this idea of this adversarial thing. It’s like, “I’m gonna tell you this, you’re gonna write it down.” I don’t know how helpful it is and there’s no great evidence for it either. So, if you can drop contracting for safety and move towards safety planning language, I think that’s a really effective way to be.

VS: That’s incredibly helpful.

JZ: Most psychiatrists and many family physicians do experience a suicide loss in their careers. That in itself can be very traumatic, and very sad, and distressing and scary. But to know that many of your colleagues have been through this and it’s not a comment on you as a clinician, and that, again, suicide prevention takes all of us. And if this does happen to you, to know to reach out for support to colleagues or to your institution I think is really important. And to know that just like we would never blame a family if someone loses someone to suicide, we would never want to blame a clinician either. And there is hope and there is help. And there are ways to do this and feel empowered by doing it, and feel like a team when you work with a patient with suicidal ideation.

VS: Thank you for highlighting that and bringing that up, because it’s such an important message to all physicians, both in terms of alleviating the fear of the “what if” or having that outcome and, also, if you’ve experienced that outcome.

Gina, Juveria, thank you so much for being here and joining us in this important conversation. I think that so many of the concepts and the messages that we’ve talked about today are so important in our moving the needle in how we understand suicide and how we engage with individuals who are struggling and how we do our work as physicians. And there’s such a wealth of information in this conversation and so many clinical pearls. So much of what you said is so impactful and so important. So, thank you.

Closing:
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