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How to Implement Best Practices in Suicide Prevention

Part II: A continuation of an important conversation with Carin Romero, LCSW.

Key points

  • Telehealth provides critical resources to rural mental health patients.
  • Mobile units can divert people in mental health crisis from arrest and possibly even the ER and still give the help they need.
  • To become a support for someone in acute mental distress, educate yourself, take care of your own needs, and watch for compassion fatigue.

This is Part II of my conversation with Carin Romero, LCSW, who is actively involved in suicide intervention in New Hampshire, on the Substance Abuse and Mental Health Services Administration (SAMHSA) ’s Best Practices Toolkit, passion, compassion burnout, and what any ordinary person can do to effectively help someone in a mental health crisis. Part I can be found here.

Mackenzie Littledale (ML): You mentioned earlier that people in rural areas have less access to the resources they need for mental stability. The pandemic forced us to do things virtually and by phone; they have access in a different way. If they’re just looking for help or social support, the conversation might lead to a video call with a licensed professional in their state.

In lockdown, I realized I could find a licensed professional anywhere from the Panhandle to Key West. I have lots of choices in my county, but if I needed to, I could search outside my immediate area. I think it’s great that you’ve given specific examples of what to look and listen for. That’s key. Instead of invalidating, just listen.

Carin Romero (CR): One of the good things to come out of the pandemic is telehealth resources. Agencies are expanding, so it’s easier for people to reach a professional when they need it. Even if we can’t be in person, we can still be connected. It’s been huge.

ML: The SAMHSA Best Practices Toolkit mentions Justice System Diversion. What does that mean, and why is it so important in a mental health crisis?

Recognizing people as patients, not prisoners

CR: There’s Justice System diversion and also emergency room diversion. Typically what happens, someone will call 9-1-1, or they’ll go to an emergency department. They’ll get a mental health evaluation and sit in the ER for hours or weeks until there’s an available inpatient psychiatric bed.

With this mobile crisis unit model, the goal is to divert that person from even going to the emergency department. We can meet people in their community and connect them to services without necessarily billing them for hospital expenses. We can get them connected to outpatient or intensive outpatient services as needed, without clogging up an ER. The Justice System Diversion piece of that is that people call 9-1-1, and police and fire go out, evaluate a situation, and it can play out in a number of ways.

The idea is to send a clinician instead of a police officer. The police are wonderful, and we partner with them. They are huge assets to our crisis situations at times, but they’re not needed for all situations.

ML: Because the police are crime fighters trained to use their guns.

CR: Yes. They can make a scene safe so that a mental health clinician can evaluate somebody. That’s extremely important, but then a clinician can give help instead of a person being brought into custody. We want to eliminate situations with police response when it’s not necessary and also get people the appropriate services and treatment they need in that crisis.

No wrong door

ML: I like that sound of that a lot. The Toolkit also mentioned “No Wrong Door.” What happens when a patient in a mental health crisis accesses services through a “wrong door”?

CR: It’s more so an idea; no matter which way you go about it, you’re going to get help. It’s resources for anyone, anytime, anywhere, whether it’s ER, calling 9-1-1, calling a crisis line or mobile crisis line, or going to a community mental health center. There’s no wrong way because all of these services are interconnected, and the one goal is getting that person safe.

ML: I imagined a bureaucratic mess labeled as a “wrong door,” or you go into a fire station when you’re psychotic and they don’t know where to send you.

CR: The goal is to eliminate those situations where a patient goes through five different people before getting the right answer. The idea is to have everybody on the same page when it comes to mental health crisis care, with mental health clinicians easily accessed anywhere, anytime, 24/7/365. It doesn’t matter where you are; we’re going to be there.

ML: Wow! That’s a big, audacious goal.

CR: But it’s reality in some of the different states. It’s being implemented.

ML: That’s through SAMHSA?

CR: Ultimately, that’s SAMHSA’s goal—to create a standard of practice that people can use as a guideline.

Defining and measuring suicide prevention success

ML: Can success be defined and measured, and how?

CR: It definitely can if you consider suicide rates nationally, state-by-state, and break it down. I think ultimately success is making sure that people are safe and that they get timely, adequate access to care, so they can get treatment and maintain that healthy baseline.

ML: Does it go beyond just the suicide prevention to improved quality of life?

CR: At the baseline, I think the first step is definitely prevention, but also in the grand scheme of things, access to more resources, more funding, more clinicians, all that “dream big” stuff. Personally, it’s about someone coming in, and they’re within an inch of going through with a suicide attempt, and that person never attempts. That’s a success because of the systems we’ve implemented. It’s a systematic approach to keeping people safe.

ML: Good, because people’s needs go beyond social support. The day after they tried, the life they go back to and their new tools, resources, phone numbers, and websites that they have access to, or maybe a new medication or just sticking with the medication they were on—all of those things help that successful day last longer.

CR: For sure, and the biggest part of it are personal and social supports.

ML: Agreed. Professionals and clinicians can’t fill in all the gaps in a person’s life.

CR: Correct, absolutely. Some of those initial feelings may be stemming from a sense of detachment, withdrawal from friends and family, feelings of being a burden. If you can come out of a situation like that, and your family says, “Listen, we love you and we’re listening,” and they’re listening, that’s just as powerful as medication and psychotherapy. If not more.

Getting involved

ML: Thank you so much for your time and tireless advocacy efforts. Where can readers find out more about what you’re doing and connect with you? If they can’t get involved, how can they support it?

CR: There are a lot of different routes people can take. For substance abuse, you can work in a recovery setting, like a sober house or rehabilitation center. You can be a peer in that regard. A lot of people who have lived through addiction and are still engaged in a recovery framework often have to go back and work in that same field as a peer.

There are peer support roles in mental healthcare. You can get a bachelor’s or a master’s. We could definitely use more clinicians who have a desire to work in mental health. You can be a provider, be a support, or be an advocate.

The most important thing is educating yourself and taking care of yourself. Compassion fatigue is real. Working with these populations can be exhausting, and if you’re not taking care of yourself, it can impact your own mental health.

We talk about self-care, setting boundaries, and supervision. We have peer support and supervisory support. At the ground level, education; understand what mental health is. You can volunteer for a suicide prevention crisis line. Know what suicidality is and the risk factors and available resources. If you’re not sure, SAMHSA has a website; National Suicide Prevention has a website. It can be a little tricky, being in a professional role; there are education requirements.