Hello, and welcome to Listen Up People, a podcast
of the USC Suzanne Dworak -Peck School of Social
Work. I'm Dr. Eric Rice, professor and associate
dean for research. Today, we're going to be talking
about suicide prevention, a subject that has
been a large focus of my own research. And so
I'm happy to have my guests with me today to
talk about this particular topic. For those of
you who are less familiar, more than half of
people who die by suicide never tell anyone about
their suicidal thoughts beforehand. So a core
challenge of suicide prevention today is how
to identify those people most at risk of falling
through the cracks and design upstream interventions
to help them. My guests today are two of the
world's leading experts on suicide and suicide
prevention. They're both listed on Stanford Elsevier's
list of the top 2 % most influential scientists
in the world. I'd like to welcome back to the
show both Dr. John Blosnich, who's an associate
professor and the director of the Center for
LGBT Health Equity at the school. And with him
is Dr. Carl Castro, professor and director of
military and veterans programs, director of the
Center for Innovation and Research on Veterans
and Military Families, and director of the Rand
USC Epstein Family Foundation Center for Veterans
Policy Research. Welcome back, guys. Yeah, happy
to be here. Happy to have you both here today
as well. for sure. Like I said at the top, I'm
excited to talk about this topic because it's
something that's very near and dear to my own
set of interests. And I've had conversations
with both of you over the years about this, but
for the benefit of our audience. Maybe we can
start with the question that I've been leading
off these shows, which is really what brought
you to do this kind of work. So maybe I'll turn
first to Carl. Carl, how did you get interested
in doing work specifically around suicide and
suicide prevention? You know, Eric, as you know,
I served in the military for over 30 years. And
when I first joined the military, suicide rates
in the military were among the lowest. in the
world, not just in the United States, they were
extremely low. For example, in the mid 1980s,
suicide rates were about eight per hundred thousand
for active duty personnel. So to put that in
context, they're now in excess of 20 per hundred
thousand. And so the military thought they had
sort of solved the suicide problem. And in fact,
I was actually in the room. where the decision
was made to end all military -related suicide
research. Wow. But then all of a sudden, when
the wars in Iraq and Afghanistan started, we
started seeing this increase in suicide rates.
So it was moving up into 12 per 100 ,000, 14
per 100 ,000, 15 per 100 ,000, given how many
people don't like change. We spent another five
or six years debating whether or not that increase
was a real increase or whether or not it represented
normal fluctuation in suicide rates. And then
all of a sudden, I got put in charge of funding
suicide research. Then I really immersed myself,
right? And then you realize that we had to kind
of relearn all of the things that we had forgotten.
Because what I found very interesting, when you
would talk to leaders in the military, like,
why do you think the suicide rates are so low?
Now, this is when they were low. They said, oh,
well, it's because we have great leadership.
We have a real world mission. They're doing things
that are meaningful in life, the camaraderie
and cohesion that exists in the military. That's
why they're low. But when they started going
up, they didn't say, well, we think they're gone
up because leadership is stumbling. morale is
down, right? They started introducing new causes.
And then you quickly realize that nobody knows
really what, there's no single cause for suicide.
So that then sort of, okay, let's step back and
start over. So that was kind of a long -winded
way of saying how I got involved in military
and veteran suicide. But it sort of started from
the beginning when we thought we had solved the
problem and then realized that we hadn't. Wow.
Wow. John, I know you've also worked with veterans,
but that's not always the main focus of your
work. How did you get interested in suicide prevention
work? Well, it actually started with veterans.
So my background in public health, I was always
interested in violence prevention and I was studying
more interpersonal violence. But then I had a
mentor, Rob Bossart, sociologist trained and
worked in suicide prevention. And he was like,
you got to come over to this side of violence.
You got to come over to this side of violence.
This is this is a tough problem. and so he recruited
me for a postdoc and I went to the University
of Rochester to work specifically in a suicide
prevention program and they put me half time
at the University of Rochester and half time
with the Center of Excellence for Suicide Prevention.
It was more than getting off the ground at that
point. It was an interesting time to be in the
VA to see how the alignment and the allocation
of resources were being devoted to suicide prevention.
There's no other, hands down, and I'll stand
by this statement, there's no other system in
the world that has put more resources, people,
and infrastructure towards suicide prevention
than the VA, hands down. People can have differing
opinions about how effective they think that
it is, but... no other healthcare system in the
world has done as much. So it was just a unique
time when I was, in a way, switching what I was
studying. But the more that I learned about it,
you know, and having personal experiences in
this field, sometimes you don't want to think
about those kinds of things, and then kind of
research becomes research. But it's really striking
to think about it as a phenomenon that we as
humans are wired to survive. Right. And somehow
we are the only species that for some people,
they override that wiring. Something happens
and that is unusual and we don't fully understand
it. And so part of it was, you know, my, my pull
into this is how do we, how do we prevent this?
Of course, not just from the individual. who's
feeling distress, who's feeling hopelessness,
but also thinking about the people who are going
to be left if or when they die. From a public
health professional standpoint, that is almost
the bigger footprint that we are left to deal
with. And my opinion is we don't deal with it
well at all of what happens after someone dies
from suicide, let alone how much we try to do
to prevent an individual from dying from suicide.
So when I tell them what I do, they're like,
oh my gosh, it must be so sad. And it is, it
can be, but. I'll keep doing it until the doors
fall off and they haven't yet. So here I am.
Yeah. No, that's that's great. I mean, I know
the two of you are so dedicated to this and it
is a challenging topic for people to talk about.
I know in I have shared this with you guys in
the past. I mean, in my own in my own life, my
father died by suicide and I for a long time
didn't want to work on suicide as a topic because
it felt too close to home to my own experiences.
And finally had a Ph .D. student. who really
wanted to do work in the topic and he convinced
me that he also had some survivorship experiences
and that it was really an important thing to
do. as somebody who was somebody who had lived
through this experience of seeing somebody that
you love go through death by suicide or suicide
attempts that. And so, yeah, it's as you like
to say, John, not to not to dim a bright room,
but it is sometimes, you know, it's a heavy topic,
but it's a really important one. And as Carl
said, you know, that when the rates go up and
up and up and up, you know, we have to do something
about it. So, Carl, you know, when you said you
wanted to sort of restart thinking how that we
conceptualize the problem. I think a lot of people
who are listening to this might be very interested
in what is a very unique set of insights that
you bring to this about what some of the root
causes of suicidal thinking for some people who
are in the military or veterans are around a
concept you call moral injury. Can you share
more about that with us, please? I'd be happy
to. And I just want to say that this linkage
to association of suicide and moral injury isn't
something that I discuss. Many, many other folks
had made this connection. In fact, this connection
was made for the first time probably 15 years
ago. But, you know, in science terms, that's
pretty new. right? Because, you know, scientists
are slow to pick up. I remember my graduate school
advisor said you have to tell people five times
something before they get it. You can't just
tell them once and then they got it. You got
to tell it again and again and again and again
to where they can tell us. At least. At least.
And, you know, one of the things when you think
about this association around moral injury, which
is a new concept in and of itself, and you try
to explain what could be going on, you know,
and then you look at all of the various risks
factors associated with someone who dies by suicide,
you know, failed relationships, mental health
issues, physical health issues, legal issues,
financial issues. I mean, it's like, what do
all of those things have in common? And in my
thinking about moral injury and the way I conceptualize
it and think about it, it's sort of an assault,
a threat to one's sense of self. And if you think
about someone who dies by suicide, as John so
eloquently put, you have to override what we
call the survival instinct. Well, what can override
that? And what can override that is a disruption
to one's sense of self, one's sense of preservation,
one's sense of wellbeing. And that's how I think
about moral injury. And I thought, well, is this
what could be happening when people decide to
take their life? And whether it's a quick decision
or impetuous decision, there's certainly lots
of other factors involved. When I think about
it, I say, well, then one way of bolstering up
people is to give them a strong sense of self.
a strong sense of control, a strong sense of
you decide how you live your life. And we say
this all the time in social work, empowerment,
but also give them control of when they explicit
control of how they end their life. And that
scares a lot of people because you don't want
to give that control to certain people. But I
think that's sort of what you have to do. you
have to acknowledge the reality. I think it was
George Orwell said, you can deny the facts as
much as you want, you can deny the reality as
much as you want, but there it is. And it's sort
of accepting the rates have gone up, and you
can try to say they haven't gone up, but they
have gone up. And it may take us two decades
to acknowledge that. I still am having flashbacks,
semi -traumatic experiences, arguments with very
senior people about why these increased were
real. And so sometimes just getting people to
agree they were going up. That took seven years
of fighting. And so you lose seven years of doing
something. And then you realize also that what
we're doing isn't working. And I'm looking at
you, Eric, and John. We have taken basically
the same approach for suicide prevention in the
military, and the Veterans Affairs uses the same
approach for the last 40 years. and it hasn't
worked. And I'm not optimistic if we do it for
another 40 years, it will all of a sudden start
working. So this got me thinking, what can we
do differently? How can we think about this differently?
So what we are doing, because as John said, the
Department of Veterans Affairs is the leader
in this area. The military, the active duty military
also has a very robust program. But I agree with
John that the VA probably has the best program.
But the military also has a very big program.
but they're not really making progress. And why
is that? So this is why, how can we apply this
concept of moral injury to this problem and perhaps
develop a different approach? So I'll stop there,
because I know that was, again, another very
long response to a very - No, no, it's great.
And I want to come back to that in a minute.
But before I do, I just want to acknowledge that
I think you and John - And myself, I think would
agree that what's been going on is great and
people are doing things as best as they can,
but there's still a gap that needs to be filled.
And trying to think about different ways of approaching
this is very much an exciting and important thing
to do. And I think, John, you know, Carl thinks
about things more from the perspective of psychology,
right? But you think about things more from the
perspective of public health. And so your take
on what needs to happen, I think, is coming from
a different place. Can you tell us a little bit
about how you conceptualize the state of the
field and what needs to be addressed? A lot of
the effort in suicide prevention is around clinical
services, which is life, that is life -saving,
that is necessary. So Zero Suicide Initiative
is probably the biggest one, focuses on training
primary care physicians, nurses, people within
healthcare to recognize warning signs, screen
people, refer them to care. You know, all of
that is necessary, but all of that requires someone
to come into a clinical center. And we need to
build that up and continue to develop resources
to doing that. Uh, but my perspective is people
have to survive to get there. And that's what
I kind of turned my attention to is. And why
coming to social work felt like from public health
and social work felt like a really fortuitous,
you know, open door, um, meeting people where
they are, which is a core tenant of social work
and being able to find people in distress wherever
they are. So really like the. You know, the tagline
for the project we've been working on is going
out and finding disruption. So Carl had alluded
to some of those sorts of social disruptions
that often precipitate suicidal crisis. You know,
a spouse files for divorce, someone loses their
job, you get an eviction notice. A lot of these
things can pile up for people that then, you
know, they begin to feel these sorts of things
that we know raise their risk, entrapment, humiliation,
sense of defeat, hopelessness, all of these things
that begin to erode. their sense of options,
their sense of self. And so the thing I started
thinking about was, so when this happens to people,
where do they go? Ideally, we would want them
to get to these clinical centers for mental health
treatment counseling. But if... you're going
through a divorce, if you're going through an
eviction, the person you might be interacting
with the most is probably an attorney, maybe
even a bank or a loan officer. And so that's
what led into this thinking about a concept of
industries of disruption. So, you know, I want
to acknowledge something that Carl said too.
This is not necessarily a new discovery. It's
just a different way of packaging this. Suicide
research has been well aware that community partners
are integral into spreading prevention and that
non -clinical sectors have been on the radar
but not necessarily in my opinion, operationalized,
not activated. It's been a, well, we know these
things exist, so these could probably be really
important places to target. So we started talking
to people. We interviewed and surveyed family
law attorneys, bankruptcy attorneys, housing
counselors, employment counselors, and even the
self -storage industry, because they all comprised
what we thought of was industries of disruption.
We've thought of industries of disruption as
three core components. One is that the folks
who work in these jobs, their daily grind, they're
not nine to five is helping someone get through
life disruption. If you're a family law attorney,
your nine to five is custody, separation, and
then asset division, right? That's what they
do constantly. That is their job. Probably not
a great way to spend your day. Some people, that's
what they love to do. That's great that they
can help people get through that, but that's
what their daily grind is. So the first part
of that definition of industries of disruption
is that that's their daily grind, helping people
through life disruptions. The second thing is
that that service or provision that these sectors
are providing is not directly over the plate
for mental health. It may be related to it, but
that end service is not counseling. That end
service is not psychotherapy. I'm an attorney.
I'm here to get you a divorce. I'm here to get
you your half or get you whatever, but that's
what my job is, which kind of leads to that third
piece of our definition, which is they have little
to no training in mental health or suicide prevention.
But here, the nature of their job every day is
that they are frequently and very closely in
contact with people navigating a really personal,
sometimes devastating thing that happens in their
life. And so we talked to them. How frequently
does it come up? A lot. So in a survey we did
with about 350 or 60, I can't remember, we're
still kind of cleaning the data. The family law
attorneys, 40 % of them had ever had a client
die from suicide. So personally presenting, died
from suicide. This number went up when you asked
them about a phenomenon in their profession called
across the table. So a divorce is two party,
two people are at least coming to that party.
And so while their client may be okay, it's the
person across the table. So that exposure to
suicide goes up even higher to about 50 % at
that point, half of them, because the person
across the table, that person died from suicide.
And that's just one example. So that was our
perspective of listening, really dusting off
this idea and approaching it in a really in a
truly intentional way of we want to hear what
they have to tell us. And they have some harrowing
things to tell us. But my job is what does this
help button look like for you? I'm not here to
make you into a counselor or therapist. They
don't want to be turned into that. Many of them
feel like they're forced into that role. What
will it take to get them to lean in when they
hear a client or a customer is in distress? And
what does that help button look like? That's
kind of what I'm envisioning my job to be. I
don't know what it's like to be an attorney.
I don't know what it's like to be a housing counselor.
I'm just here to help. So what would that help
button look like? That's what our project is
mainly about. And I think it's been really eye
-opening for me in our conversations when you've
been talking about these spaces like family law
or self -service industry, self -storage industry,
which, you know, these are probably not places
where most of us think about that you could you
could develop these sorts of prevention programs.
to come back to you again and ask about as you
were developing your thoughts around moral injury
and trying to think about suicide prevention
for veterans and folks in the active duty military
about this change. John just describes her finding
a new place to do these disruptive interventions,
but What is it that you're proposing to do to
disrupt this process as well? Well, that's a
great question. And let me just say that I'm
in a hundred percent agreement with what John
approach is and what we also should be doing.
But I take the other extreme approach. And what
I think about is in terms of dark moments, the
Stoics talk about dark moments in life. We all
go through these dark moments, these failed relationships,
these divorce. these division of assets, these
firing from your job. As a student flunking out
of college, these are all dark moments in life.
And what I think we need to do also, not instead
of what John proposed, but in addition to what
John proposed, is prepare individuals for these
dark moments. Prepare them early. In grade school,
second, third grade, fourth grade, life is filled
full of setbacks. We're sort of now bumping up
against resilience, but I'm very deliberately
not using that word. What we all suffer from
these failed relationships, but not everybody
dies from suicide who has a failed relationship.
In fact, we know suicides, even though they're
around 40 ,000 a year in the United States, they
are still fairly rare events. And we shouldn't
lose sight of a lot of people do have these setbacks,
these dark moments, and they recover from. And
what you want to give is everybody this sense
of power, this sense of confidence that no matter
what dark moments they face and it could be things
that they brought on themselves like engaging
in criminal activity and they get caught. They
can still recover from these dark moments and
suicide shouldn't be your first or second or
third or fourth or fifth or sixth or seventh
option to go to. It should be so far down on
the list of things you can do to recover from
it. It doesn't even enter your thinking. So preparing
people for dark moments, building their confidence
up that they can recover from dark moments and
go on and have a great and wonderful life. That
is what my area is pushing, but it's not instead
of what John said. It's in addition to not only
what John said, but what the the treatment folks
are doing and all of the other efforts, because
it's a very, very complex problem. And what I'm
suggesting is just one element of addressing
this very complex problem. Yeah. Complex problems
are abound in our field in social work. I think
we live in a society that likes simple solutions.
So it's nice for you to point out, Carl, that
you are not providing the silver bullet, but
another piece of the arsenal, so to speak, that
we need to be bringing in to bear on this problem.
And you also said something that really struck
me from some of our previous conversations, Carl,
when you said this about this dark moments. I
know, John, you've used the line with me a few
times that you are doing work with good people
in their worst moments. Can you expound on that
a little bit? I think it's a really useful perspective
that really mirrors what Carl's saying about
the folks that you've been studying. Yeah, so
that's saying, I don't know if it originated
with actually a family law attorney, Maurice
Kuttner. He said, criminal law attorneys see
bad people at their best and family law attorneys
see good people at their worst. And I think what
Carl is saying is very apt, you know, having
people, you know, not just reconceptualize their
sense of self whenever they have these setbacks
or these disappointments, you know, but the,
the ability to reach out for help, which is also
a huge barrier for a lot of people, especially
when we talk about veteran populations and it's
a two way street, people reaching out for help
and then making sure that we have a system and
professionals in place that are there to meet
that need when someone does reach out. You know,
these are incredibly complex problems that then,
of course, the solutions are also going to be
born out of incredibly complex systems. And when
the stakes are this high, that urgency and that
determination that we are perfect. when we do
this is we got to have more hits and strikes
on this. And but it's a lot of moving parts all
at the same time. Yeah, I'm so impressed that
the two of you are thinking about really, I suppose,
moving ahead in this work in a way that brings
solutions to people closer, closer to the moments
of crisis. Maybe that's not even the right way
of saying it. In some ways, it's earlier in the
process. So it's not quite so much at that last
minute. But I mean, Carl, you were talking about
the way in which you're trying to give people
new ways of thinking about dealing with the adversities
that they deal with in life. And I know, John,
you're really trying to reach out to people when
they're in these moments of crisis, but before
they reach that breaking point at which we may
not be able to help folks as well. And Eric,
the point that John is making is so spot on.
One of the things that we how we handle dark
moments is knowing when to reach out to folks,
when to get help. If you can't solve a problem
yourself, what are your resources, who can you
go to, who can you contact to get help? And as
John pointed out, the stigma, and this is what
we call the resilience paradox, is all of the
resilience training that happens in the military,
and really in life, works against someone raising
their hand, asking for help, or taking a knee
and taking a break. Because if you're resilient,
you should be able to solve your own problems.
You shouldn't need any help. So if you get stuck
in that phase of resilience and not understanding
that at some point we all will feel overwhelmed
where we need help from others, you know, I always
attribute people say, well, how did you become
a professor at USC with a lot of help from a
lot of other people? I'm not one of these people
who say I did it all by myself, nobody helped
me, because I know that's not true. And that's
true in life. When I was in the military, people
helping me be successful. I have teams of people
who, although I may get the credit, it's totally
unfair because I had so many people helping me
and encouraging me and supporting me. And yes,
we can point to success, but really what you
want is like, when things go really bad, who
can you call? And you see a lot of these elements
in suicide prevention efforts with the hope box,
and who would you call in a crisis? People are
building on this concept of trying to reach out
and stay connected. And Eric, I know that's your
work, social connections and the importance of
those connections to staying healthy because
we are social critters. In addition to a critter
who will take their own life, we're also people
who like to be around people. And I don't necessarily
mean you have somebody has to be around you all
the time. Some people need that. That's OK. Others,
you know, on occasion, I like to be around people.
So I was I was I was laughing because I was thinking
like, well, you know, we like to be around other
people. But as academics, there's some part of
us that likes to also sit by ourselves in a room
and write papers that an imaginary audience might
read or sort of oddballs in that respect. But
but it's true. You know, we are all fundamentally
social animals and fundamentally we have survived
as a species because we've learned how to rely
on our communities. And John, your thoughts about
bringing that reminder of those communities and
those connections to people in their dark moments
when they don't need it, I think is a beautiful
way of tying some of those thoughts in. And I
don't wanna just abruptly end a conversation
that personally I know the three of us could.
keep having for a couple of hours. I want to
give you each an opportunity to talk about something
in your own research or your own perception about
suicide and suicide prevention work that you
feel you know, our listeners who may be less
familiar with this area of work should know about.
So I'll give you a second to think that through,
but maybe Carl, I'll turn to you first and then
end with John. John, is there, Carl, is there
something that you would like our audience to
know about the work that you do or about suicide
prevention work in general that you think would
be helpful for them to know as we close out our
conversation today? I will just say this, there's
no... easy answer to this problem. If there was
an easy answer, we would have found it already,
and it wouldn't be a problem. When we find the
answer, we'll say it's an easy answer. But until
we find the answer, this is not an easy problem.
No country in the world has solved this problem.
I've traveled all over the world looking to see
what other people do. No one has solved this
problem. Now, some countries may not have a bigger
problem, but there's no solutions that are easy.
to address this issue. So I don't want anyone
thinking, oh, all you have to do is give me an
app and then I'm good to go. All right. And I
know folks have tried that. It could be part
of the solution. So I would just encourage people
don't think there's a quick fix. It's difficult,
complex problem. But we want all ideas because
these ideas can contribute to a collective solution.
Well put, Carl. Well put. John, what would you
like to say to our listeners as a parting thoughts.
You know, sometimes I start to think about what
the, you know, what the challenge to this would
be in thinking about the many different solutions
that there could be. And the thing that we arrive
at that I arrive at seems both simultaneously
simple, but also maybe the most difficult. And
it's kind of like where we are as a society is
that connection piece. You know, we're allegedly
more connected than ever because we have a phone
in our hand all the time. We're constantly allegedly
connected to everyone else's lives via Instagram
or wherever. But the rates of people reporting
loneliness are so high. And I don't fully understand
what's going on there, right? And to engage with
people and connect with people, it's not an easy
thing, as Carl was saying, it's not an easy thing.
And it's not only about the person, it's about
yourself. In suicide prevention, gatekeeper training,
it's about training people to ask the question,
are you thinking about ending your life? Are
you thinking about killing yourself? But being
ready and prepared if someone says, yes, and
that's about you and how you... You can feel
that you respond to that you can stay there for
that person You're confident in your ability
to hear them and stay with them and sit with
them in that, you know So I think that's another
component to this this world of suicide prevention
research that we don't often I don't often think
about and I have to remind myself because we're
always focused on the person who's in distress
the person who's in distress and My own work
is trying to get people around the person to
engage but that necessarily requires self -reflection
of are you going through that thought experiment
and making sure that you have that in you to
do that. And I don't know how we get more people
to come to this to just, you know, humans being
bros and just, you know, being there for one
another. It seems like an ever deeper ask for
people in an ever busier world, but I hope we
can find some way. Beautifully put. And I think
maybe I want to also say that there are resources
for those folks who are, you know, perhaps experiencing
suicidal thoughts or who are have a loved one
who is in particularly the 988 helpline is a
place that people can go. I think it's always
important for us to acknowledge that people listening
to a podcast like this. may themselves be experiencing
some suicidal distress or know somebody who is.
And so that 988 hotline is the most available
resource that we can offer that's memorable,
I think, in the context of a podcast. And I really
just want to thank both of you for the amazing
work that you do, the dedication that you have
to the communities that you serve, and what delightful
colleagues you are to talk about such a An important
topic that is so hard to talk about, but to talk
about it with both compassion and humor and all
of that. It's really lovely. So I want to thank
our listeners for tuning in today. And if you
want to learn more about upstream suicide prevention,
as well as the other research that's happening
at the USC Suzanne Dworak-Peck School of Social
Work. You can visit our school's website at
dworakpeck.usc.edu. If you have questions for our guests
on the show or you want to support our transformative
research and programs, please email us at
listenuppeople@usc.edu. And let me just say one more time
to both Carl and John, thank you both so much
for showing up and having this wonderful conversation.
And I hope we'll have more like it in the future.
My pleasure. Yep, same here.