Prevention division

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Combating Social Dis-Integration: The Need for Population Approaches to Preventing Suicide

If meaningful social connectedness is central to preventing suicides, is the increase in U.S. suicides related to a degradation in meaningful social connectedness in our culture? If this is true to some degree, how can the suicide prevention field devise more effective approaches for increasing meaningful social connectedness within and across communities in this country?

During an AAS Board dinner about a year ago, Research Chair Jie Zhang—a professor of sociology at State University of NY in Buffalo—said to me: “Suicide is a sociological issue.” When I asked him to elaborate on this, he indicated that the predominance of male suicides suggests that the issue is one related to cultural norms and patterns of social relationships, eg., “sociology.” During our conversation, we reflected on how the 120-year old shadow of Emile Durkheim--the French sociologist who was the progenitor of theories about why people kill themselves—loomed over us. Durkheim posited “social integration” as the primary factor in suicidality, that is, the degree to which people are connected to their community via work, family, friends and other roles and relationships. Perhaps if Durkheim were at that dinner table with us, he might have postulated that our growing suicide rates are the result of a pervasive form of “social disintegration” in our culture. 

Is their sufficient data to suggest that some “pervasive form of social disintegration” is occurring in our country?  In a 2017 issue of the American Psychologist, Julianne Holt-Lunstad and colleagues supplied a cogent review of the scientific evidence that provided a strong argument for a need to make advancing social connectedness a national public health priority. Among the data cited, they noted that: core social networks have decreased by a third since 1985, and are now less likely to include non-family members; marriage rates are decreasing and divorce rates remain at around 40%; census data shows an increased rate of childlessness, with fewer kids per household and more single-person homes than ever recorded; and significant reductions in volunteerism and religious affiliation suggest significant reductions in community involvement. The authors also note that as our population ages, connectedness deteriorates; the older we get, the more our social networks shrink. This trend towards longer lives with diminishing social connections—combined with smaller families and fewer related familial resources for support—means more will become lonely over time.  “More lonely” is an ominous prediction, given that a 2018 survey by Cigna of 20,000 Americans found that nearly half reported that they sometimes or always feel alone or “left out,”  with 13% stating that nobody knows them well.  It appears that we are entering a time when perhaps the most immediate way to bring American people together would be to stage a national sing-a-long to the Beatles’ Eleanor Rigby

In any case, we must do something more and different. From a public health perspective, enhanced social connection is associated with healthier heart, immune and neuroendocrine systems. We know that social connectedness is a significant mediator of depression, which also has clear implications for health and, of course, suicide.  These data indicate that our field will need to pay close attention to cultural trends that could further aggravate suicidality among persons becoming increasingly alone in communities across the country. These trends also remind us that we must embrace sociological and population-based approaches if we ever hope to reduce suicides in America.

How does Durkheim’s social integration theory relate to our contemporary views of suicide, and how might the inclusion of more sociological constructs contribute to our efforts to prevent suicide in this nationally? Until recently, we have been moving away from Durkheim’s suicide and social causes framework and concentrating on what more we can do in doctor’s offices and pharmacies to prevent suicides. As Thomas Joiner noted in his seminal work on Why People Die By Suicide, Durkheim’s theory went uncontested for decades until more individualized factors—such as genes and the role of mental illnesses—became more influential in conceptualizing suicidality. Later, scientific studies related to mental illness and genes, and psychotherapy and medication became the prominent modes for which we “treat” people who are suicidal, relegating more population-based theories and approaches to the periphery. Nevertheless, the emergence of Joiner’s Interpersonal Theory of Suicide in our 21st Century view of suicide’s etiology has opened the door for both social and individual causes to be examined in suicide prevention work. Joiner has stated that his concept of “thwarted belongingness” is consistent with Durkheim’s “egotistical suicide” (a person isolated and disconnected from others), and his concept of “perceived burdensomeness” resonates with Durkheim’s “altruistic suicides”, or a kind of self-sacrifice made for the benefit of the group (“excessive social integration”, in a sense).  Joiner’s framework reminds us that suicidality is not simply about an individual’s suffering and his/her prescribed treatment regimen; it is also heavily influenced by phenomena that is distinctly “interpersonal” and social in nature.

So what suicide prevention population approaches has our field widely embraced?  Over the past fifty years, suicide hotlines have remained the most consistent “community-level” strategy that we have deployed for reaching and serving suicidal individuals.  Some have stated that these hotline services are too downstream (“at the waterfall’s edge”) to have an impact. However, our crisis lines know that the majority of persons who contact our services are in non-suicidal emotional distress.  What undermines the potential of crisis lines the most is the failure to properly resource and promote them as the community crisis, support and outreach services that they effectively are. When the UK national health districts registered a reduction in suicides, the use of 24/7 crisis outreach services were cited as the most important contributor.

Yet, our culture’s stigma surrounding suicide is reflected in the way hotlines are regarded relative to other aspects of behavioral health care; they are relegated to the periphery and grossly underfunded, and often rely on volunteers because behavioral health care professionals fear liability and 24/7 availability. So it remains that--other than hospital emergency rooms—crisis hotlines help the most persons at the highest risk, at the most undesirable hours for a behavioral health care system that has forsaken them, with little to no compensation. At the Lifeline, we see more hotline operations closing their doors every year.  Perhaps the recent passage of the National Suicide Hotline Improvement Act and the subsequent SAMHSA/VA/FCC study regarding the impact of designating a national 3-digit number for mental health and suicidal crises will lead to greater recognition and support for crisis hotlines. If such a 3-digit number were to come to fruition, it would go far in reducing the overall cultural stigma related to mental health problems and suicidal experiences, by validating both the need for a service specific to “psychological emergencies” and a need to provide a caring response different than the indiscriminate (and usually inappropriate) dispatch of police or EMS resources.

Aside from SAMHSA’s support of the Lifeline network, a number of local, state and federally-funded initiatives continue to offer a scattering of population-based approaches. The Garret Lee Smith grants have disseminated community gatekeeper trainings which have been associated with temporary reductions in suicides in counties where they have been provided, effects which evaporate when these funded initiatives end. School-based approaches, which equip student peers and faculty with suicide prevention information and actions--such as Sources of Strength, Signs of Suicide and Lifelines--hold considerable promise for community “upstream approaches.” Overall, there are ten states that currently mandate annual suicide prevention trainings of school-based personnel, and another seventeen states that require such training without specifying how frequent the trainings must occur. Harvard’s Means Matter, Washington’s Forefront, NAMI New Hampshire, the VA and now AFSP are among the leaders in promoting community gun safety initiatives intended to reduce firearm suicides. In addition, Suicide Awareness and Voices of Education (SAVE), the Lifeline and the National Action Alliance for Suicide Prevention are now working with international partners to establish a uniform framework for positive public health messaging designed to reduce suicide.  SAVE, Lifeline and Forefront have also collaborated closely with FaceBook and other social media entities to apply prevention and public health approaches towards enhancing safety and support in online communities. In spite of this growing array of population-based initiatives in 21st Century, these efforts are fragmented and have not been coordinated as part of a comprehensive, evidence-based, unified and sustainable  strategy designed to reduce community suicide rates.

Without due fanfare, the Action Alliance and the CDC provided us with an outstanding blueprint for population-based initiatives going forward in March of 2017. The Action Alliance’s document, Transforming communities: Key elements for the comprehensive community-based suicide prevention, underscores seven essential processes to help prevention programs achieve success (unity, planning, integration, cultural fit, communication, data and sustainability). The CDC’s complementary work, Preventing Suicide: A Technical Package of Policy, Programs and Practices, determines seven objectives that—if accomplished—could effectively reduce suicides in our communities. These objectives include: strengthening economic supports; enhancing access to/delivery of suicide care; creating protective environments; promoting connectedness; teaching coping and problem-solving skills; identifying and supporting people at risk; as well as lessening harms and preventing future risk.  

Of the seven objectives, it was clear to me that most of our field’s efforts have slanted heavily towards making it harder for suicidal people to kill themselves (reducing access to lethal means), making it easier for suicidal people to access help (crisis hotlines), identifying and treating persons at risk, and to a lesser degree, reducing their harm and future risk (postvention, safe media messaging). Fewer community suicide prevention policies, programs and practices have been designed to promote connectedness, strengthen economic supports, or teach ways to better cope with and solve problems confronting us in everyday life. What new partners and approaches might our field need to scale community-wide efforts to enhance people’s relationships with others (connectedness) and the world of work (economic supports), two aspects of life central to one’s sense of value and purpose? What more can we do to broadly strengthen individual, family and community capabilities for effectively managing challenges in relationships and work (coping/problem solving skills)? Aside from safe messaging and promoting access to care, how are we proactively using the immense power of media to promote these public health and suicide prevention objectives?

In an attempt to connect disparate dots, we can now see the development of the Colorado National Collaborative (CNC), an action-learning coalition initiated together by Colorado’s Office of Suicide Prevention the Action Alliance and the CDC-funded Injury Control Research Center for Suicide Prevention (ICRC-S), begun in 2015 and now involving a multiple national partners—such as CDC, SAMHSA, AFSP, and the National Action Alliance for Suicide Prevention.  The CNC now is engaging diverse county and state-level public and private stakeholders in suicide prevention, human services, business, education and media to deploy many of the key objectives and processes listed in the aforementioned CDC and Action Alliance technical assistance documents. In a recent email, Eric Caine, PI of the ICRC-S and co-chair of the CNC with Jarrod Hindman of Colorado, noted that this ambitious initiative still is a work in progress, in search of major funding to help this collective fully realize its unified vision of reducing suicide in Colorado communities. If this project gets the funding it needs, the lessons could be among the most important we learn in our quest to reduce U.S. suicides by 20% by 2025.

In this time of stubborn (and rising) suicide rates, both individual and population-based approaches are essential. However, more efforts need to be made to expand our reach to community stakeholders within and beyond health care systems, into our lives and the social milieus where connections are breaking down and suicides are happening. In my next essay, I will explore ways in which we can (and must) address promoting connectedness within and apart from online communities to prevent suicide. But for now, I leave you with Eric Caine’s editorial message for us all in the November 2017 issue of JAMA Psychiatry:

“…it behooves us to look beyond the walls of our clinics and offices to engage vulnerable individuals and families in diverse settings such as courts and jails, social service agencies, and perhaps the streets long before they have become ‘suicidal.’ If we wait until many are considering their options to kill themselves, much like waiting to intervene until someone is in the middle of an occlusion of the anterior branch of his left coronary artery(aka, the widowmaker), it likely will be too late.”

John Draper, Ph.D., Chair, Prevention Division of AAS