Transcript

Host: Hello, and welcome to Prevention and Protection, the United Educators risk management podcast. Today, Dr. Kurt Michael, Senior Clinical Director at The Jed Foundation, a leading nonprofit that protects emotional health and prevents suicide in teens and young adults nationwide, and Heather Salko, Manager of Risk Research at United Educators, will discuss the topic of suicide postvention. Before we begin, a quick reminder to listeners that you can find other UE podcasts, as well as UE risk management resources, on our website, www.ue.org. Our podcasts are also available on Apple Podcasts and Spotify. Now, here’s Heather.

Heather Salko: Welcome, Kurt. I’m so looking forward to our discussion about the important topic of suicide postvention. As we start, Kurt, would you please tell our listeners just a bit about your background and your role at The Jed Foundation?

Dr. Kurt Michael: Sure. And first, let me just say thanks, Heather, for having me. And so my background right now, my role is Senior Clinical Director at The Jed Foundation. I’ve been there for about three years, and my role is to direct the postvention and lethal means safety consulting for both higher education and K-12. By background, I’m a clinical child psychologist, and my focus over the past 26 years has been adolescent suicidology, meaning that I’m always interested in understanding the nature, assessment, and treatment of young people who struggle with either acute suicidality or even long-term struggles.

And so given that focus, I’m also committed to a better understanding of how crises escalate to non-lethal and lethal attempts. So by extension, I stand up JED’s efforts to provide systematic postvention support to school communities that suffer from suicide loss. So all told for the past 23 of the past 26 years, I served as a Professor of Psychology at Appalachian State [University] teaching, conducting research on these same topics, and also practicing in the surrounding communities, mentoring, and supervising grad students in clinical psych. Though I would say the location of my work has changed, my focus on reducing the risk of suicide has not.

Salko: Kurt, thanks so much for sharing your background. As we begin our conversation, I think it’s important to say that some people may not be familiar with the term “postvention.” Can you please explain what is suicide postvention, and why is it a crucial part of mental health care?

Michael: Yeah, great question. So basically in a nutshell, postvention is an organized response in a community that’s suffered from suicide loss. So it’s in some ways good that suicide is not all that common, but it’s also not rare, either. And so if we kind of think about the numbers for a typical campus of around 20,000 students, they would typically experience around two to three suicide deaths per year. So to circle back to what postvention is, there are really three big priorities.

I think the first priority is to provide that rapid and compassionate grief support, especially for those that are directly impacted by that loss, including: family, close friends, significant others, roommates, and to address for the entire community, mental health impairments such as prolonged grief. And also, I guess the third big priority is to reduce the risk of survivor suicide through systematic efforts at outreach, safe messaging when you’re communicating about the loss, and appropriate monitoring. We sometimes call that suicide risk detection and intervention as it’s deemed necessary.

And I guess what I would further add is that many campuses might have a student death protocol, but if they do, they’re not always that specific to suicide, and, unfortunately, they’re not often up to date. So it might be a single page. And it’s also possible that though those protocols might exist, people may not be broadly aware of it or necessarily properly trained or prepared to use it.

Salko: So, let’s back up a little bit and talk about how does postvention differ from prevention and how do the two complement one another?

Michael: That’s an excellent question. I think even the founding of The Jed Foundation is based on what to do in the aftermath of a suicide loss. So losing Jed, I think from the Satows’ perspective with such a major event, I think what it led to is actually the creation of our foundation. So really, I think the way I think about postvention is an opportunity for prevention. So it’s pretty much part of that comprehensive approach that we sometimes talk about at JED. It’s really an overlapping sequence of domains that progress from primary prevention to secondary prevention and last to tertiary prevention.

And so if you look at the wheel itself, what a campus does to address those tertiary elements of mental health support, and that’s kind of my main wheelhouse, is access to direct care, suicide risk surveillance, crisis management, suicide-focused treatments, including reducing access to lethal means, and, of course, addressing attempts and deaths. So, like I said before, postvention is actually prevention. And so we’re always trying to advocate for schools to create these braided systems of support that cut across and within each of the domains, through those levels of prevention.

So if you think about an example that the JED Campus program really helps guide colleges and universities through that collaborative process to create those systems, programs and policies to customize a systemic way to address mental health support, and that includes suicide prevention. So I know that we were recently listed on the SPRC’s Best Practice Registry. I think because we view this as a systemic approach up to and including what happens when adverse events like suicide death happen.

So we want to make sure that we provide targeted programming for those options across those tiers of support, if that makes sense. And we want better education, more literacy. What do we know people sort of exhibit early in the course of a mental health struggle, and how can we get them rapidly to care to prevent those adverse events? And if they do happen, we want to then still support that community as that additional opportunity to strengthen their approach to, I guess we would call it a mental health safety net.

Salko: Kurt, as we get a little more into the specifics about postvention, can you explain for our listeners what the HEMHA Postvention Guide for Higher Education is, its purpose and how it came about in its development?

Michael: Sure. So I would first say that I’ll explain what the Higher Education Mental Health Alliance is. So basically those are representatives from 10 major mental health nonprofit organizations from around the country. I’ll just list them for the, they can know what they are. So Active Minds, American Academy of Child Mental Health and Psychiatry, American College Counseling Association, American College Health Association, the College Student Educators International, American Psychiatric, American Psychological, Association for University and College Counseling Center Directors, NASPA, Student Affairs Administration and Higher Education. And last but not least, The Jed Foundation.

I know that’s a mouthful, but I just want to say the important message that it’s really such a comprehensive group of mental health folks that I think we’re in a great position, and it’s kind of important to note that we all agree when these guides are published and this postvention guide that you’re referring to was published in 2014, it’s probably one of our most accessed or downloaded guides.

And so I’m happy to report that the HEMHA Group meets monthly to discuss current issues in higher ed, such as: access to care, campus safety, town gown relationships, evidence-based mental health care, obviously political discourse and debate, tension between students and administration and upstream educational program around mental health, all in the service of trying to provide those services and those safety, that education, to make higher education or that climate in any way, much more supportive around the mental health of students, not just necessarily their education, but also their mental health.

And so I really feel blessed to be part of that group because I think anytime we come up with a new guide, the current guide is actually, the title is Promoting Resilience, Healing and Safety on Campus, a Trauma-Informed Approach. So that’s our current project. And so I think what we will ultimately do, we might get into this a little bit later in the conversation, is we plan to update the 2014 version of the Postvention Guide. But I just wanted to give you a little bit of a history of HEMHA because I really do feel like this is a very representative group of people that are there to support higher education in a broad sense.

Salko: Great. It’s nice to have that supportive community looking out for students. And so to that end, Kurt, what are some effective strategies and interventions that have been used or are currently being used in the area of suicide postvention?

Michael: Yeah, excellent question. And I want to make this as non-technical as possible. I think probably the most important thing is to basically be a human, to rely upon our instincts to provide proper grief support in a time of need. And so again, what is said exactly by postvention responders does matter, but the way you show up matters just as much. And our encouragement is to keep showing up. Sometimes there’s a gap where you might provide immediate and acute support, and then there’s kind of a drop-off. And so we want to make sure that that particular kind of support is sustained.

That is you have multiple and sustained opportunities for compassionate listeners that are skilled enough to know if there’s a need for a referral or a higher level of care, that postvention responder, even if they’re either a mental health person or even a good Samaritan, that they know where to refer that person. So basically trying to create regular opportunities for students to talk is at the cornerstone of postvention response, like things like weekly drop-in sessions. So again, it’s not super technical. We just want to make sure that there’s adequate space for people to process their grief in a very supportive way.

Now, that might be different for one person versus another. So if you’re close to the decedent, for example, we know that that risk of survivor suicide is probably higher among certain groups, and that would be one significant others, close associates, friends, etc., and family. And so because of that risk, we want to provide that ongoing support for at least six months up to a year following the death. And so in the meantime, things like monitoring, check-ins, keeping watch on people, just kind of check in with the folks, I think makes a big difference.

And where we often learn that approach is based on some studies. I might briefly describe what’s called the Caring Context Study from the late ‘60s, early ‘70s. So there’s a researcher named Jerome Motto who basically, for folks who were briefly hospitalized for a suicide attempt after they were discharged, they sent a supportive postcard to those folks that were being treated inpatient for a suicide attempt, and they continued to send these postcards. Just a very simple, “How you doing?” kind of thing. “Give me a call if you’re interested.” It wasn’t super complicated.

But if you look at the outcomes of the group of patients who received that postcard versus those that did not receive that postcard in the years following treatment, the suicide rate for the group that received the postcard was half the rate of the group that did not receive the postcard. So happy to say that both groups were relatively low, but the group that received that caring contact actually had less likely to die by suicide subsequently. So I just want to emphasize how important that is in providing that kind of direct support.

Now, the more technical part of postvention might deserve a little more sort of discussion. So that would include being systematic in the way you follow up with people, especially those who are currently in care at the time of a death. So you want to make sure you’re checking in with those folks that are currently in treatment. And again, having something that’s systematic and evidence-based would be very important. So again, how do we conduct our assessments? How do we include interventions like lethal means counseling, suicide-focused care, follow up, and finally, like I just mentioned about that study from Jerome Motto, those proper caring contacts just as a way to reach out to check in on people, if that makes sense?

Salko: Kurt, this is all really great information. And of course people want to be doing their best on campus when there is suicide to respond to. So how can some of these postvention strategies be adapted in order to be more culturally sensitive and inclusive for everyone on campus?

Michael: Yeah, also really important that you raised that question. So here’s how I would answer it. I think as much as we would like our guides to be somewhat specific and prescriptive, it’s really not that possible. I think instead what we try to do is make guides that are basically based on a set of flexible principles that we can adapt from context to context. And so its capacity or the guide’s ability to address the variability in community kind of depends on where the event happens. And so, I guess by comparison, the way we think about codes of ethics, ethical codes are generally aspirational. They’re not prescriptive, and we think that’s true for postvention guides.

So what we really want to do is know what those actual circumstances are on the ground. And those experts on the ground are the folks that I rely upon to provide that adaptations to be culturally responsive and sensitive because they know their communities. So my approach as a technical assistance provider, a consultant, would be to leverage local knowledge and implementation capacity by using those principles. So I don’t at all pretend to have the market cornered on what every community is dealing with. Rather, we want to really take advantage of what’s locally developed and preexisting and help them braid together systems that are in a position to provide that adaptational culturally sensitive and inclusive support, if that makes sense.

 Salko: Well, Kurt, we’ve been talking obviously a lot about your perspective and the perspective of mental health professionals, but what role can and do other campus professionals play in postvention? How can they, non-mental health professionals, be better equipped to handle a response if there is a suicide death?

Michael: Yeah, also a really good question. And again, if we had sufficient numbers of mental health clinicians, I think we’d probably take advantage of that. I think the reality, though, is that we don’t typically have sufficient number of postvention responders, so we have to really have a ready workforce to do the work or volunteers that are ideally prepared and sign up for that kind of role in advance and are properly trained. And so one idea would be that Residence Life could be leveraged as first responders.

Could be RAs — could be Res Life directors — that are deployed in a postvention scenario as long as they’re, again, good Samaritans, properly trained. I think you can basically compliment what you already have in terms of mental health workforce. And so we really want to provide TA for campuses that honors that expertise that’s on campus, but also involves other people who as long as they’re, again, kind of know their role and are properly overseen or supervised and trained, I think you can really have a very capable workforce for these all hands on deck situations.

So there are times when, let’s say a campus doesn’t necessarily have advanced preparation or planning, in those instances, I sometimes feel like I’m walking alongside those campuses, especially early in the course of an event, to help them think through some rapid response ideas that they can deploy quickly. But ultimately what you want is basically a very diverse, ready workforce to do this postvention responding. And it doesn’t require membership on that committee, for example, doesn’t require that you’re a mental health or licensed provider.

It just means that you have to be sufficiently trained and, for that matter, willing to serve in that role. And so we want that committee, so to speak, to be made up of a variety of folks who have various touch points with students or people impacted. I guess one example that comes to mind that we didn’t always think through is that what happens if, let’s say, a faculty or staff member dies by suicide. Some of the protocols that we’ve seen in the past don’t necessarily that as a possibility.

So we have to continue to be mindful and creative about what are we going to do if the situation emerges where we’re going to have to deploy folks that we didn’t think of in advance. And so just trying to be super planful and mindful about who could serve that role. And if it just requires a little bit more training, I think that’s another way we can supplement that workforce to really create that atmosphere, that climate of an all hands on deck, let’s do what’s necessary to provide that proper support and follow up. And that also includes providing support for responders.

Salko: Kurt, we just talked, and you just talked in your last answer, about the need to train this diverse group of people. We know that campus mental health professionals are already spread thin, and they’re probably spending a lot of time training people on the prevention side. Are there any specific training programs or resources that you recommend for postvention training to help get this diverse team up to speed?

Michael: Yeah. So yeah, we all wear many hats, and that’s why I think the phrase “Organized response” is ideally developed in advance. Or, if that’s not necessarily possible, you don’t want too many cooks in the kitchen, so to speak. So I think using frameworks as a way to train this would be a helpful idea. So not only using that HEMHA postvention guide as kind of a framework or a start point, maybe even recommending that we have assigned roles for people to coordinate that response.

Sometimes in emergency management, the phrase “Incident commander” would be appropriate for postvention.

So that is who is actually in charge of helping to manage, deploy, and sustain the processes and protocols before, during, and after a crisis. And when I explain this to campuses, I think it makes a lot of sense that we’re using this framework, and one of those elements is who basically is coordinating that process. And so the role of incident commander and maybe even have a backup would make a whole lot of sense. So that way somebody is in charge of not only kind of doing the work in the moment, but curating that framework, so to speak, that’s customized for that campus. So we often have campuses develop their own postvention protocols that look like a customized version of the HEMHA Postvention Guide.

Salko: Oh, very interesting. Great. And we keep talking about the HEMHA Postvention Guide, and you did allude earlier to the fact that it is or is slated to be updated, and I know you’re involved in that effort. When do you think that update might be coming, and are there any major changes that you think should be highlighted for people who either are new to the Postvention Guide now or already rely on it?

Michael: Of course. Yeah. Well, I mean, as you know, things going to change all the time, so we just want to stay up on things. And again, it’s still got a good shelf life, but again, it’s 10 years old now, actually going on 11 years old. So we know that all 10 organizations are committed to an update. We do have to finish the current guide, but yes, it’s next up on the docket. So I’m involved in that update, and I think our hope is that we’re going to have a ideally ready-for-primetime version by the end of 2025, hopefully sooner.

Salko: OK, great. We will of course highlight that for UE members when it does come out and because we really do think the current version is an excellent resource. But Kurt, another postvention publication that you were involved in is a guide, a Postvention Guide for housing managers. Can you tell us what prompted the creation and development of that guide and how it might differ from the current HEMHA Postvention Guide?

Michael: Yeah, let me tell you about the housing managers guide in one second. But I think, let me circle back and just mention one more thing about the HEMHA Postvention Guide. So one thing I just want to emphasize is that I’m happy to report that Erica Riba, who works with me at JED, she’s our Senior Director of Alumni Programs and Engagement, we’re actually developing some really cool features in the new guide, case studies, pedagogical features that I think will kind of enhance its capacity to be flexible, be a flexible document. And for that same reason, I think we developed that, the housing manager guide. So let me explain that a little bit and how that came to pass.

So the College Student Mental Health Wellness Advocacy Coalition, this is the national group of housing providers, actually developed a partnership with JED about two years ago to create the guide. And they also wanted us to build a webinar to train their frontline housing managers in postvention, recognizing that these communities often deal with suicide loss just like campuses do. And so we felt like it was an opportunity to provide that kind of resource support in a non-traditional community of housing providers. And so, again, it took us a while to do it. And so we conducted some focus groups. We tried to understand kind of what their needs were. And so ultimately what we up with was a customized version for a large constituency of housing providers, so that way they can work in tandem with campuses. So it’s not designed to be entirely unique. It’s actually designed to be complementary to what a campus might do.

So one of the things that we recommend very clearly is to create those advanced relationships with campus professionals, especially when there’s already postvention protocols in place, so that way they can plug in to that process rather than simply feel like they’re kind of on the outside looking in when they’ve got a lot of their residents that are also struggling. So we wanted to try to figure out a way to connect some dots in an entire sort of landscape of a campus community that would include, that would include ... in some communities the majority of students live off campus, and so we wanted to provide something specific for them so they could feel like they’re part of that discussion.

Salko: Yes. Are there, Kurt, some key differences in how an institution, obviously working with maybe housing managers, a different group who’s not part of your campus community, necessarily, but are there key differences in how people should approach handling a suicide that occurs off campus versus one that were, to say, occur on campus?

Michael: Yeah. And I think the impetus was based on the data that suggests that actually more students who are in college, actually, if they die by suicide, it’s more commonly occurring off campus. And so, yes, we want to be able to address both scenarios. But I think there’s been less attention on that reality that off-campus suicide is highly prevalent. And so we want to address those realities or given those odds, we really want those off-campus housing communities to be in a good position quickly, to be better prepared, be properly trained, and to develop those connections. Because otherwise, it feels sort of disjointed. And we sort of identified that as a gap.

Salko: UE often deals with student deaths in many different forms, and one thing we are often asked about following any student death is the best way to memorialize that person and their contributions to the campus community. Especially if there’s been a death by suicide, Kurt, are there some best practices for memorializing the deceased student and supporting the grieving process of the community — and, especially, if that might happen, a death in student housing?

Michael: Yeah, what really important questions that you’re raising. I think if you look at an area of some tension over the years around what happens after a suicide, one of those areas of tension is whether it’s OK to memorialize a decedent and how do we do that and how do we do that in a way that’s respectful but also protective? And so that’s always been a tension. At one point, there was almost this binary thinking that either you memorialized or you didn’t. And I think part of that was sort of with good intentions, that we didn’t necessarily want to unwittingly increase the risk of suicide among survivors by saying the wrong thing or doing the wrong thing. I think it also sort of flies in the face of our natural instincts and desire to grieve our loved ones.

And so I think the middle ground that I think we found is that the current thinking is to not treat suicide death differently than other types of death. And so the guidance means, can we do both? Can we respectfully honor our loved ones? I think the answer is yes. Can we do that in a protective way that the way we talk about it or the way we provide hopeful opportunities for support and referrals? I think we’re trying to find that middle ground where we are able to do both. That is remember our loved ones, honor them, and do so in ways that don’t increase the risk of survivor suicide. And so some of those guiding principles now that we follow are time-limited memorials.

It’s not to say that we shouldn’t leave flowers, but we don’t necessarily want to leave the flowers unattended for weeks or months on end. So trying to be respectful, honor spontaneous memorials, but again, in a time-limited fashion. And another thought is if it can be pre-discussed and arranged with the family, that maybe those mementos, those remembrances, those cards can be gifted to the family after the memorial.

And so that way you don’t have this memorial kind of degrading over time or due to bad weather, just trying to kind of find that middle ground, I suppose you could say. And also trying to be not so sensationalize death, not disclosed method are very key principles in this. Often providing adequate referrals and sources of support, hopeful and encouraging messages around those with lived experience. So those are the key features that we now believe to be important. It’s not to say that it’s sort of one way or the other. It’s how do we find that middle ground that’s both honoring, respectful and protective.

Salko: Very important. Along those same or similar lines, students obviously want to deal with their grief, and as we’ve been talking about this entire time, which is providing that support mechanism. But some students or faculty or others who have been impacted by a suicide on campus may not want to go to a professional. They may in fact turn to their peers to seek support. Do you see any role, or if you do, what role, for peer support programs in an institution’s postvention efforts?

Michael: Yeah, great question. Again, I think good Samaritans are a big deal. And so, again, what a person says to a close associate or a loved one after a loss can be very comforting, can be very compassionate and very important. It doesn’t have to be only delivered by a fully trained or licensed mental health person. So I think peer support is a big deal. If you look at preferences, let’s just talk about college students for a minute. If you look at college student preferences and where they would first seek support for mental health struggles, it’s actually not licensed people that they would turn to first.

It’s their own close friends, their associates, their family, their parents. And so we want to make it OK, and we want to validate that these so-called good Samaritans, first responders, however you refer to these folks, loved ones, they are fully capable of providing compassionate support in a way that often folks prefer. So I think what I would say is this is more of a layered systems of support. And even when I talk to students, I’ll often, when I’m serving campuses, I’ll end up talking to students and, again, they’ll ask me, “Well, what do I say?” Or “I’m worried about saying the wrong thing.”

Generally speaking, if you go back to a very well-known Suicidologist, Ed Shneidman, he believes that the two things, the two questions that we don’t ask each other enough of, first begins with, “How are you?” and “How can I help?” Right? Those two questions. And so really a first responder, a peer, if you will, if they’re prepared to ask those two questions. And then as a third, I guess, option, be able to provide information for people that when you ask them, “How are you doing?” and they say, “Not well.” and then you say, “How can I help?” and they say, “Well, I don’t know where to go for help.” and then that person is knowledgeable about where that person can go. That’s really the essence of grief support, of postvention responding in real time.

And so, again, is it helpful that they’re well-trained? Yes. Do the roles need to be defined? Absolutely. Does it help to have people know that bereavement support begins by answering the question to someone asking, “How are you?” “Well, I’m not doing very well.” And then you have something to say in response. Right?

So ultimately what this all suggests to me is that really at the hallmark of good postvention support is that the entire community kind of wraps their arms around people who are struggling, each other for that matter, and that’s the best way forward. In all the years I’ve been doing this, that’s probably the most active ingredient is just that willingness to be compassionate, to listen to your fellow person, your loved one, and provide that listening, that support, that referral if necessary. It’s honestly not technical.

Salko: It’s something we can all do for one another. Right? Well, I want to just say thank you for this great conversation, and you’ve obviously given us a lot to think about and then some valuable information. Is there anything before we go that you might want to add or any resources you recommend, something we didn’t talk about that you want to put a plug in for?

Michael: Yeah. I mean, I’ve talked pretty broadly about some of these guides. I think it would be helpful for listeners to check those out. And so I mentioned the 2014 HEMHA Postvention Guide. I would, if your listeners can get access to that, it’s free and available for download at a moment’s notice. And so too is the off-campus guide that kind of follows the same principles. I would definitely recommend that those resources are considered or looked at just to see what the frameworks are, would be my first recommendation.

I’d also just simply emphasize that the value of simply showing up, being willing to provide that proper support for those grieving the loss of a loved one is super important. You don’t have to provide any answers. You just have to be that listening ear and make that timely referral and then keep showing up. And so that’s what helps with prevention.

And then certainly if there’s additional questions, maybe checking out our website. We have a mental health resource center for specific content, and so the website’s chock-full of helpful resources.

Salko: Great. Thank you, Kurt. We will be sure to link on the landing page for this podcast to both The Jed Foundation’s website, but also the postvention guide so that people can find them quickly. Kurt, I just want to say this was a great conversation and I want to thank you so much for spending some time with us.

Michael: I really appreciate it. Thank you so much.

Salko: Again, I’d like to thank Dr. Kurt Michael of The Jed Foundation for joining us today and for engaging in a very enlightening conversation.

Host: From United Educators insurance, this is the Prevention and Protection Podcast. For additional episodes and other risk management resources, please visit our website at www.ue.org.