Sanford Health clinical and behavioral health workers are using the company’s new crowdsourcing platform to gather ideas on how to do a better job talking with patients and each other about suicide.
Research from a 2019 study published in the journal Preventive Medicine finds that about half the people who die from suicide have seen their primary care physician in the previous month. About 1 in 5 saw their doctor within a week of dying by suicide. And patients who went on to die by suicide had, on average, 17 health care visits in the year before their death, said Jeff Leichter, Ph.D., a psychologist and Sanford Health’s lead behavioral health integration administrator.
“So it is not something that is happening somewhere else. It’s happening at our doorstep. Primary care has historically been the doorway for behavioral health and mental health concerns,” he said.
The problem was already bad before the pandemic. It has only gotten worse, for patients and the professionals who care for them.
A recent Centers for Disease Control and Prevention report emphasizing the impact of the COVID-19 pandemic on the nation’s mental health found that 11% of American adults had strong thoughts of suicide in the previous 30 days. That number doubled for people who self-identify as an essential worker.
“If you look at an organization like ours where we have 50,000 employees, even using that more conservative number of 11%, that means that on any given day, more than 5,000 of our fellow employees have had serious thoughts about suicide in the last 30 days,” Leichter said.
“What we want to be able to do is really bring this conversation front and center. For many, many years, decades perhaps, suicide has been a stigmatized topic. People didn’t know if they should talk about it. There was the myth that if you bring it up it will push people to actually engaging in suicide. That’s completely wrong.”
‘Out of darkness’
Sanford Health formed a suicide prevention task force earlier this year to respond to what has become a crisis for adults and young people. The organization has trained about 1,500 employees in basic awareness and recognition skills through a 3-½-year-old Mental Health First Aid initiative. It’s transitioning into use of its own product that will train everyone on what to say, what not to say and how to decrease some of the stigma around mental health issues and provide foundational information on the most common behavioral health conditions.
The crowdsourcing effort is intended to gather ideas from employees to move into the next phase that “lifts (suicide) out of darkness and secrecy,” Leichter said.
“We want the folks that take care of the majority of our patients, and that’s in primary care, to be able to ask about suicide with the same ease and with the same professionalism as asking about weight or temperature or blood pressure, those kinds of things. It’s a serious health crisis not only for our patients but also for our colleagues,” he said. “This is everyone’s responsibility.”
At least one of those colleagues, a physician, died by suicide since the pandemic began.
“That drives it home. This isn’t happening to other people in other places. It’s us,” Leichter said.
“Health care providers are under pressure to take care of others and neglect taking care of themselves,” he said. “Health care providers are exhausted, they’re stressed, they’re traumatized, and they are at high risk for suicide.”
That’s largely because of what’s known as compassion fatigue.
“The thing that makes health care providers so fabulous is they have deep compassion for others. But that’s also the kryptonite for them. They’re so focused on others that they neglect their own self-care. Certainly our patients are in need of this conversation. But we also have to take care of ourselves better,” Leichter noted.
Smiling outside, something different inside
That can be difficult to do in the Upper Midwest, where talking about feelings amounts to admitting weakness, said Jon Ulven, Ph.D., a Sanford Health psychologist.
“Our folks in this part of the country, they tend keep to themselves. They’re more reluctant to share how they feel and process things with other human beings.”
Part of the blame: culture.
“We can speak in some generalities about where our farming culture started in this part of the world,” he said. “It was started by immigrants. From where? Around here, Germany and Scandinavian countries. So you look at those countries that today still have the some of the highest rates of suicide and substance use per capita. People from this part of the world tend to internalize emotion, rather than share it. We very likely still see the impact of this cultural heritage on our own.”
Tractor cab counseling
Aside from family history, farming as a profession carries with it one of the highest suicide risks, according to the CDC.
Ulven said among the contributing factors: low grain and livestock prices; uncertainty with major trading partners; social isolation made worse with smaller farmers selling to larger farms that are even more spread out; loss of rural churches and the support system they provide; lack of access to health care, especially mental health care; climate change causing less predictable weather; chronic pain and overall poor health because farming is so hard on the body.
Another big one: fear of generational failure.
“There is often a tremendous amount of pressure to keep a farm within a family. There is a common sentiment that, ‘I can’t let generations of farming end with me,’” Ulven said. Stress on the farmer puts stress on the marriage and family, which puts stress on the community.
Unfortunately in many places, a stigma of seeking help still exists. If mental health services are available in town, people are often reluctant to go because everyone will recognize their vehicle, Ulven said.
“On the positive side of things, this pandemic has brought out a proliferation of telehealth services,” he said. “The farmer or any member of the farmer’s family can be in their home and you can do care with them. I’ve had a therapy appointment with a farmer in the tractor cab. The farmer had his GPS set and the tractor was doing its thing while the farmer was talking to me through his phone.”
It’s that kind of innovation which might help ease the crisis, both for people like that farmer in the tractor and the people who care for him.
Ulven is the lead clinician for a helpline that will serve distressed health care workers called Reach for Resilience. The state of North Dakota funded the program that will offer guidance and support.
Sanford Health is also instituting a buddy system that pairs its medical professionals and requires them to check in with each other daily. If one of them senses the other person is showing signs of distress, they ask if they’re suicidal.
“We want everybody in America to learn CPR,” Leichter said. “Similarly, we want people to have the same awareness and confidence and skill to ask questions: ‘I’m worried about you. Have you had suicidal thoughts? Is there something you want to talk about?’ And to do that with ease.”
Once people know what to say and give it a try, they realize it’s not as difficult as they feared, Ulven said. “We’re all so busy and overwhelmed that we have to figure out a way to infuse this into our culture.”
Perception of control
The crowdsourcing effort itself, which uses software from the company Ideawake to gather employee ideas on how to create such a culture, can also have a positive effect, Ulven said.
One of the best psychological factors for coping with stress is called perception of control, which is actually more important than real control, he said. It’s the opposite of learned helplessness in which someone believes they can’t do anything about a bad situation, so they isolate, stop trying and often fall into depression.
Conversely, perception of control acknowledges that they don’t necessarily like their circumstances but believe they can do something about it.
“The crowdsourcing idea, it taps into some of that. It says I have a voice, there’s something I can do, and I can share an idea. Why am I sharing an idea? Because I have hope that someone’s going to hear it and do something with it,” he said.
“So instead of all of us just going through our days with multiple worries going through our minds and worrying about what we’re going to do about it, here’s an instance with crowdsourcing where you get to say, ‘Whoa, I bet we all have this shared worry. What do you think we can do about it?’ So it can have a unifying effect.”
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