Franklin James Cook

Archive for the ‘Opinion’ Category

Community, Prevention Experts Influence “Dr. Phil” Episode

In Media, Opinion, Prevention on March 14, 2010 at 12:39 pm

Three gears working together

By Franklin Cook, SPNAC Editor

I consider Friday’s episode of the Dr. Phil Show — titled “Teens Under Pressure” — a case study of sorts, for it shows that a constructive dialogue is occurring among suicide prevention experts, communities, and the media. The process that shaped the show’s content could be an indication that community-focused suicide prevention is gaining traction in America.

Here is what happened:

Enter the media. A series of suicide fatalities strikes a high school on the West Coast, and a flurry of media coverage follows. Then the double suicide of two high school girls in the East makes the news in a big way, locally and nationally. As one might expect, the Dr. Phil Show plans a television program on the topic of suicide.

Enter the community. When the show’s senior producer contacts the West Coast town to invite people to participate in the program, city officials respond enthusiastically — not about participating but about the possible causal link between media coverage of suicide and suicide contagion.

In a follow-up e-mail to Senior Producer Astra Austin, [a city official] representing “Project Safety Net,” said there are two primary concerns about the planned Dr. Phil program.

The first is that it could contribute to “suicide contagion” following the deaths of four Gunn students since last May, and the second is that the program could “perpetuate the myth” that stress and suicide are tightly connected.

“[This] is a community at high-risk for more suicides due to suicide contagion,” [he] said in the e-mail. “Our most vulnerable teens (those perhaps with previous attempts or who are under medical care) need our protection right now — and will for some time.”

“Please understand our reluctance to participate in the show should not suggest a reluctance to confront or deal with this issue. On the contrary, the … community is working together, tirelessly, publicly, and carefully on this issue.”

Enter the suicide prevention experts. The community’s communication with the TV producer amounts to a mini-workshop on suicide contagion, packed with a well-chosen array of top-quality, up-to-date information and resources, all based on the research and expertise of organizations such as the National Suicide Prevention Lifeline, the Suicide Prevention Resource Center, the American Foundation for Suicide Prevention, and the American Association of Suicidology.

The outcome: The content of Friday’s Dr. Phil Show clearly demonstrates that the producer and the others involved in creating the episode heard the community and tried to follow the guidelines provided by the suicide prevention experts. I have some concerns about several elements of the show (such as how people grieving from the fatalities are addressed), and the jury is certainly still out on the effects of national media coverage such as this on contagion. Those issues notwithstanding, I believe it is extremely important to affirm that this instance of the media’s coverage of suicide represents a rare collaboration among people working to cover an important news story, people in the field of suicide prevention, and people in a community that has been directly affected (I might say traumatized) by recent suicides.

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[Editor’s note: In a SPNAC post last year, “Iraq Vet and Teen Say ‘Thank You’ to Lifeline via Avatars,” it was mentioned that “Dr. Phil shared a suicide prevention message through his avatar on the Lifeline Gallery.]

Other related SPNAC posts:

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Please Stop Saying, “Suicide is a permanent solution …”

In Opinion, Prevention on March 5, 2010 at 10:11 am


By Franklin Cook, SPNAC Editor

I have worked in suicide prevention and suicide grief support for a little more than a decade, and for the past year and a half (since the SPNAC blog was launched), I’ve scanned hundreds of articles on this tragic subject. In the course of my encounters with what is said and written in communities across the country and on the Internet, I have been subjected about a thousand times to the declaration “suicide is a permanent solution to a temporary problem,” and I cannot hear it one more time without crying out: Please stop saying that!

I know that it must seem like a clever and even a helpful thing to say (or else why would people have kept saying it, right up to the point where it has become nothing less than a cliche but with the power, I’m afraid, of an axiom). The declaration seems clever, I suppose, because it has the pleasant sing-song rhythm of an advertising jingle, like “I am stuck on Band-Aid, ’cause a Band-Aid’s stuck on me.” And it seems helpful because, of course, it is true: Indeed, suicide is a permanent solution.

But here’s why I argue that we should stop saying it:

The statement violates the age-old principle that what we communicate ought to be designed specifically with a focus on the audience for whom the particular communication is intended. “Suicide is a permanent solution to a temporary problem” might strike someone who is not suicidal as a clever statement, and it might be a helpful thing to hear from the point of view of someone who already believes (or is likely to be convinced) that his or her problem is temporary. But the audience for this anti-suicide ditty is, of course, people who are suicidal.

As Edwin Shneidman points out in his Ten Commonalities of Suicide, “The common purpose of suicide is to seek a solution.” So emphasizing to a suicidal person that suicide is a permananet solution is as likely to be unhelpful — or even harmful or dangerous — as it is to be helpful.

The problem a suicidal person is trying to solve, according to Shneidman, is how to escape from psychache, which Shneidman defines as “intolerable emotion, unbearable pain, unacceptable anguish … [that] cannot be abated by means that were previously successful” (emphasis added). In other words, from the point of view of someone who is earnestly considering killing himself or herself, the pain from which suicide would provide escape is not temporary.

Even though the perception that the pain is permanent is not accurate, the strategy of trying to convince a suicidal person that his or her pain is temporary is as likely to be counter-productive as it is to be productive.

Read more here …

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Antidepressants Aren’t the Problem, Marketing Them Is

In Advocacy, Mental Illness, Opinion on February 26, 2010 at 1:02 pm

Pills with Dollar Signs

By Franklin Cook, SPNAC Editor

I’ve been reading a lot lately about antidepressant medications, with the idea that I was going to summarize some of the recent debate about whether they are part of the problem or part of the solution regarding suicide. But I have abandoned the idea of writing a summary such as that in this small forum because, for one thing, some of the “debate” about antidepressants and suicide is very polarized, with one camp applauding them as a miraculous intervention to alleviate the suffering of suicidal people and the other decrying them as part of a murderous conspiracy being perpetrated against us all by Big Pharma. Instead, I’ve decided for now that I need to merely try to articulate my conclusions from my reading without elaborating upon them or pointing to supporting documents (in other words, to offer my unadorned opinion, which I don’t often do in the pages of SPNAC, but which seemed an important starting place for me on this topic, while I’m waiting for the New Yorker or the Atlantic or Harper’s to commission me to write a full-fledged essay on the topic).

Here is what I think can accurately be said about antidepressant medications, depression, and suicide:

  • Depression is an illness with its source in the biological structure, content, and processes of people’s brains (internally driven phenomena) AND in the structure, content, and processes of people’s “ways of thinking” about ideas and experiences (externally driven phenomena).
  • There is a clear and direct link between depression and suicide.
  • Medicines (antidepressants) have been developed that — for some people — alleviate the biological symptoms of depression, including their tendency to attempt suicide.
  • In some people, the medicines don’t work or don’t work very well, and in others they cause negative side effects, including increasing in some cases people’s tendency to attempt suicide.
  • The effects of antidepressant medication on the brain are not understood as well as they ought to be understood relative to how widely the medicines are used.
  • The scientific inquiry about antidepressants is a dynamically evolving endeavor, and there is insufficient consensus about some of the most important questions at hand.
  • The clinical usefulness of these medicines has been negatively affected by their marketing and distribution, which has overreached the science supporting their use.

And here is what a list of remedies for the current situation might look like:

  • The use of antidepressant medication must be supported as a treatment option.
  • Clinical guidelines for safe administration of antidepressants must be strengthened, and clinicians must be trained and otherwise equipped to administer them safely.
  • Strict safeguards must be put in place — not via a “warning label” but via an improved standard of practice or even a legal mandate — to keep people who are prescribed antidepressants safe from suicide.
  • Effective patient and public education about depression and its treatment — including the role of antidepressant medication — must be instituted.
  • Effective treatments must be developed, implemented, and supported that address not only the biological sources of depression but also people’s “ways of thinking” that contribute to depression.
  • Research on depression — as well as on both biological and other interventions and treatments — must be done much more strategically, ambitiously, and independently.
  • All marketing of antidepressant medications ought to be suspended while a thorough, independent review of the scientific knowledge about and marketing practices for them is undertaken and recommendations for implementing the remedies above (or better ones) are instituted.

[The abridged URL for this post is .]

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One Man’s Death Offers Insight into Humanity and Suicide

In Grief, Intervention, Opinion, Prevention on February 19, 2010 at 12:38 pm
Powell and Market Feb 16 2010 Man who jumped

For information about this photo, please see the note below.

By Franklin Cook, SPNAC Editor

The circumstances surrounding a suicide earlier this week in San Francisco — a man jumped to his death from a building on a busy street corner as a large crowd watched — are so disturbing that I am reluctant to write about it, but I hope to extract something helpful out of the situation.

Let me begin by saying that my own description, calling it “a sucide earlier this week” and “the situation” obscures the most centrally important, viscerally real fact about it, which is that a living, breathing human being died — that a life as unique and special as your life or my life are to us right now was irrevocably extinguished. In the blink of an eye, an actual person was tranformed from an “is” into a “was,” into a man who now can be referred to only in the past tense.

But, for those closest to him, their love for him is not in the past tense.

Here is an audio recording of a news interview I did with Don Grant of KOTA Radio in January 2008 after a teenage boy died by suicide in my hometown in a scene that was very public. In the interview, I say,

When something makes front page news … when the public is very aware of a suicide death, it turns a private matter into a public matter. So I think the first thing I would say to the community is, please remember that this is a very private matter … In many ways, it is a death like any other death, and we don’t want to bring attention to a family’s private suffering … The first thing I would like the community to understand is that this suicide affected a very precious human being … He has a family and friends and loved ones who deserve our respect and our compassion and our understanding and our support. We really need to … understand that, in our hearts, the most important people in this moment are those who have lost their dear loved one. That young man just a few days ago was a very vibrant human being: We should not make judgments about him. He had the same things to be happy over or to be sad over that we have. Suicide sometimes strikes a family, and we should be very understanding of that.

Another thing about last week’s tragedy in San Francisco that merits comment is the crowd’s reaction to — or perhaps I should say participation in — the suicide. Some news coverage (and lots of social network communication) depicted people who urged the man to jump or who laughed about his death. Besides the numerous seemingly obvious and perhaps futile comments that one might make (that such behavior is barbaric, that the media-entertainment machinery has so desensitized us that we are numb to each other’s pain, etc.), I would like to assert this: It might have gone differently, had those near at hand at the time he died acted differently.

This is not merely wishful thinking on my part nor simply my desire to blame someone for something that is terribly upsetting to me. Rather, I am claiming that a very straightforward, common-sense, practical behavior might have saved a man’s life.

What if one inspired, compassionate person in the crowd had yelled — not at the man threatening to jump but at the rest of the crowd — “Chant with me! Please don’t jump. Please don’t jump. Please don’t jump”? I can imagine something like that happening: “Chant with me! Everyone chant with me! Please don’t jump. Please don’t jump.” I can imagine a few dozen people taking up the chant in unison, “Please don’t jump! Please don’t jump! Please don’t jump!” Then a few hundred people joining in, “Please don’t jump! Please don’t jump! Please don’t jump!”

Can’t you, too, imagine that happening, ? If you were there, wouldn’t you have joined in the chanting? “Please don’t jump!”

There is no way to know whether that would have prevented the man from jumping, but, as the photographer says in the quote below, “he stood [on the ledge] for 50 minutes or so,” and, according to other news coverage, “witnesses reported seeing the man start to jump twice and then stop himself at the last second, before he finally made the jump.” So there were unquestionably real moments when his ambivalence between wanting to die and wanting to live might have allowed him to step back from the abyss.

The noisy scene at Powell and Market on Tuesday suggests that ideas such as these — that people facing a suicide crisis ought to be compassionately cared for as unique human beings and that there are effective ways we can intervene to help save a life during a suicide crisis — are so fundamental that perhaps we’ve taken them for granted.

[Editor’s note: There is an inherent contradiction in my words “this is a very private matter” and in my decision to publish the photo that accompanies this post. In addition, publishing the photo is arguably an infraction of the suicide prevention field’s media guidelines, which advise against sensationalizing suicide. My decision to publish the photograph was not made lightly nor without considering those matters, but the point that the man who died was “a living, breathing human being” possessing “a life as unique and special as your life or my life are to us right now” is brought home more powerfully than it could be in any other way by including the picture with the story. The photographer who posted the photo online said of the man pictured that he wanted “to show him alive [while] he is standing there … He stood for 50 minutes or so, and I watched him look around as if he was waiting for some positive message for help … So by remembering this image, next time you see someone … thinking about taking their own life, then please talk to them. Let them know you are [there] for them and ask them what do they need. Show them love even if it is a stranger.” FJC]

[The abridged URL for this post is .]

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Primary Care Depression Screening Would Save Lives

In Mental Illness, Opinion, Prevention on February 8, 2010 at 2:46 pm

By Franklin Cook, SPNAC Editor

In a Huffington Post item today, titled “Let’s Not Get Too Depressed about Depression,” Dr. Lloyd Sederer, a psychiatrist and public health advocate, argues for a mandate that would do as much to prevent suicide as any other single action might accomplish:

One hundred percent of primary care practices .. should be screening for depression and using standardized treatment guidelines.

Dr. Sederer has a fairly straightforward plan to accomplish the nationwide screening he recommends.

Mental health has been losing in the competition for fair time and proper management without a numerical measure of a disease. How about starting with its poster child disease — depression — to remedy that?

The good news is that there is a simple, nine-item questionnaire called the PHQ-9 that someone can fill out in the waiting room, before seeing the doctor or nurse, that provides a highly reliable number that tells the doctor the likelihood (almost 90 percent sensitive) that you have a depression.

Of course, screening every visitor to a doctor’s office and then further assessing and effectively treating those who have depressive illness is a vast undertaking that would not be simple nor easy nor without cost. [Editor’s note: Please see Dr. DeQuincy Lezine’s comprehensive and insightful comment on this point.]

But we know that about 33,000 people a year die by suicide in the United States and that about half of them have a mood disorder (which implicates some type of depression in 16,000 suicides annually). So if depression is mental health’s “poster child disease” and it plays a role in 16,000 deaths every year, might not universal screening for depression in primary care be, as Dr. Sederer argues, a good starting place for prevention?

There are several models already available to move such an initiative forward. Here are two examples:

(1) The Three Component Model developed by the Macarthur Initiative on Depression and Primary Care is “a systematic approach” involving the “primary care clinician and practice, care management, and collaborating mental health specialist.”

The three components include elements shown to improve depression outcomes in recent randomized controlled trials. Telephone support for the depressed patient from a care manager is one central element as is periodic quantitative feedback about the patient’s response to treatment from the care manager to the clinician. The feedback is provided through depression severity scores based on PHQ-9. Another element is closer relationships between the primary care clinician and mental health specialists …

(2) The Suicide Prevention Toolkit for Rural Primary Care is an Internet-based resource containing “information and tools to implement state-of-the-art suicide prevention practices and overcome the significant hurdles this life-saving work faces in primary care practices.”

The Toolkit offers the support necessary to establish the primary care provider as one member of a team, fully equipped to reduce suicide risk among their patients. For instance, the tools will help you engage your patients and those around them in managing their own suicide risk. You’ll find tools for developing partnerships with mental health providers — regardless of how far away they may be — and a guide to developing telemental health services, a promising solution for many rural areas. There are also posters for display in your office, schools, and churches, and wallet cards listing warning signs for suicide and the number of the national crisis line.

[The abridged URL for this post is .]

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