Since George Floyd‘s tragic death at the hands of a Minneapolis police officer in May, entire fields have confronted — willingly or not — their track record on diversity, equity, and inclusion. That reckoning has come to , , and , and shaken industries like professional and , , and .
Something similar is happening in suicide prevention, a field whose noble cause draws academics, therapists, researchers, and public health experts determined to save lives. Those good intentions, however, can also operate like a shield against any criticism. Confronting failure is painful given what’s at stake.
That’s why conversations about race and racism, until now, have been muted. But following Floyd’s death, things shifted. Vibrant Emotional Health, which operates the National Suicide Prevention Lifeline, created tip sheets to help counselors talk about racism and civil unrest, which they distributed to the 170 crisis centers in its network. The American Foundation for Suicide Prevention, the largest private funder of research in the field, moved to make diversity a new priority for grants.
In June, the board of Crisis Text Line fired its founder and CEO when staff staged a to protest discrimination and abuse they experienced in her presence. Last month, the American Association of Suicidology (AAS), a nonprofit organization whose membership includes researchers, academics, public health professionals, and suicide attempt survivors, issued a pledging to become anti-racist.
The field finally seems willing to consider equity and inclusion as cornerstones of its work. DeQuincy Lezine, who is the sole Black board member of the AAS, is cautiously optimistic about these recent developments. For more than two decades, Lezine has thought deeply about how to stop people from taking their own lives. He is a psychologist, president and CEO of the mental health consulting firm Prevention Communities, and a suicide attempt survivor.
Lezine knows, intimately and clinically, that when a suicidal person decides to keep living, they’ve found hope. Lezine also understands something else about suicide prevention that may still be less obvious to his peers in the field: The support suicidal people receive can vary dramatically depending on their race and ethnicity.
When, for example, a suicide hotline contacts emergency services because a caller wants to die and has the means and plans to do so, a white person might be greeted by concerned police officers. A Black person, however, might be seen as threatening and approached with a firearm.
“Depending on where you are or what your background is, it may look more like help or more like punishment.”
Lezine imagines this disparity as what happens when two different people hear a siren’s howl. Some will respond viscerally with relief, confident that help is on the way. For others, the sound elicits panic, and a question: Are they going to arrest me?
“Depending on where you are or what your background is, it may look more like help or more like punishment,” says Lezine. “Even if the same help is available in both places — and I don’t think it is — the initial context it plays out in is already different.”
The example is one of countless ways that suicide prevention isn’t equipped to address the needs and unique experiences of Black, brown, or indigenous people. Hotline volunteers, who are frequently white, may be empathetic yet unaware of how to relate to people of color who are skeptical of discussing their concerns, or doubtful they’ll have access to quality mental health care. Never mind the volunteer’s capacity to talk openly about how discrimination and racial trauma play a role in suicidal feelings. Until Floyd’s murder, few national crisis services offered volunteers training to navigate such conversations.
The surge of momentum towards equity, inclusion, and anti-racism is promising, but hinges on whether leaders advocating for change are held accountable and their future actions match the new rhetoric. Squandering the chance to transform the work of suicide prevention would be more than a missed opportunity — it could leave more people of color at risk of suicide without the vital treatment and support they need to find hope and survive.
“A fundamental shift”
For suicide prevention experts, it can be agonizing to confront how the lack of diversity may inflict mental or emotional suffering on historically oppressed people. Some are defensive about this prospect, or have been trained to focus their efforts specifically on middle-aged white men because that population for more than two-thirds of suicide deaths annually.
That unnerving reality warrants an aggressive response yet also contributes to the myth that suicide is a phenomenon largely limited to white communities in the United States. In fact, the suicide rate of American Indians and Alaska Natives — 14 per 100,000 people — is a close second to that of white people. Black or African Americans, Asians and Pacific Islanders, and Hispanics die by suicide at nearly half that rate. Meanwhile, recent research shows that suicide amongst is increasing at an alarming pace, with no convincing explanation as to why.
Jonathan Singer, president of the AAS and an associate professor of social work at Loyola University Chicago, argues that the field ignores the role of race and racism.
The work of suicide prevention is “grounded in the assumption that people live in a world that believes their life matters,” says Singer, who is white. Many people of color, however, do not see that world as their own. “On a practical, daily level [society] gives explicit and implicit messages that it’s white lives that matter and not Black lives or brown or indigenous lives.”
When Singer ran for president of AAS last year, he adopted a diversity and inclusion platform. After his election, the organization’s board hired diversity and equity consultant Pata Suyemoto, chair of the Massachusetts Coalition for Suicide Prevention Alliance for Equity’s People of Color Caucus. Suyemoto co-wrote a comprehensive to help organizations work toward racial equity in suicide prevention efforts.
The first day of this year’s AAS conference featured a talk about genocide and resilience by Shelby Rowe, a suicide prevention expert and citizen of the Chickasaw Nation. Many of the organization’s 1,370 members, which includes big organizations like universities and hospital systems, welcomed Singer’s emphasis on equity at the conference, but he says others accused him of political correctness.
Singer knows his position angers some of his colleagues. He challenges the notion of objectivity because it “defaults to whiteness,” or assumptions about what experiences are neutral. Singer offers a hypothetical example of this. Imagine, he says, that he’s a white researcher studying youth suicide in a school setting where police officers are being trained to talk to suicidal kids. He might take for granted that Black and brown children’s interactions with law enforcement at school are anodyne or even positive. Instead, they may be frequently dehumanizing. If his research is challenged on those grounds, he might feel attacked or compelled to dismiss the criticism.
Singer says that by assuming all children interact with police officers in the same way, regardless of their race or ethnicity, the white researcher is building on a system of policing that of slave patrols, and often traumatizes students of color who are by law enforcement school officers in their schools. He risks unintentionally perpetuating this legacy of racism in a misguided attempt to improve the students’ mental health.
“The counter example is illustrative,” says Singer. It’s difficult to find interventions in which police are used to systematically advantage Black and Brown students inside or outside of schools.
Singer argues that researchers accustomed to controlling for race and ethnicity like any other variable that could influence the outcome of a study should change their approach. Their goal, he says, should be conducting research that doesn’t replicate or reinforce racist ideas.
“That is a fundamental shift, and it’s a shift that’s going to piss a lot of people off,” says Singer.
AAS’ recent statement on equity and anti-racism lays out specific measures, including diversifying its board, developing scholarships awarded to underrepresented researchers, and advocating for funding to understand the factors that increase suicide risk for people of color. AAS also plays an important role accrediting crisis centers across the country and pledged to evaluate its standards so that they address diversity, inclusivity, and equity.
These are ambitious goals for a nonprofit with just five full-time staff members and a $2.3 million budget. While the organization won’t fulfill each anti-racist pledge by the time he steps down in 2022, Singer is hopeful that meaningful gains during his tenure will include a more diverse board and membership and an annual conference that consistently features marginalized voices and experiences.
“We are the medicine”
Billie Jo Kipp is an enrolled member of the Blackfeet Tribe in Montana and a clinical psychologist with suicide prevention experience in tribal communities. She’d never heard of the AAS before reading its statement on equity and anti-racism. Its conviction intrigued Kipp to the point of considering membership, but she also noted its failure to make such a statement in the past. What exactly would it do to diversify its board and membership, she wondered.
For someone like Kipp, who laments the lack of culturally relevant suicide prevention efforts and research, the field’s seemingly sudden shift toward anti-racism is a welcome development that raises more questions than it answers.
Kipp says American Indian and Alaska Native communities are effectively triaging a suicide epidemic without enough money, resources, or clinicians. The Indian Health Service, which provides medical care to members of tribes, receives Congressional funding. Its annual budget for mental health — $109 million — kept pace with inflation. This year, tribes requested an additional $309 million.
Even if IHS received more money, Kipp says it would need to fund programs and interventions that reflect Native American culture.
A shortage of Native American clinicians means that if people do see a counselor or therapist, they often work with someone unfamiliar with their cultural values or experiences who may use techniques that focus on individual behavior. Youth are frequently sent to a treatment centers outside of their reservation and come home feeling unmoored, partly because their family and immediate community weren’t a part of their healing process.
Kipp is unsure whether suicide prevention hotlines are even considered a go-to resource in tribal communities because the format can feel cold and impersonal compared to their community’s emphasis on relationships.
“When you get ill, the cure should be your people. We are the medicine.”
“We’re not culturally alone,” she says. “When you get ill, the cure should be your people. We are the medicine.”
For years, Kipp says she’s been battling not just the suicide epidemic in tribal communities but also structures and systems — inadequate Congressional funding, culturally incompetent clinician training, scientific grant processes that favor certain types of research — that make it harder for her to help save lives.
The very approach of traditional suicide prevention, which revolves around a clinician’s expertise, evidence-based interventions, and changing individual behavior, can feel biased, irrelevant, or unhelpful to not just Native Americans, but also to Black people and other people of color, says Suyemoto.
The field also tends to disregard historical trauma as a factor in suicide and “culturally specific” resilience to that tragedy as a protective force. People who’ve lived through or inherited generations of trauma, such as slavery, discrimination, and poverty, may possess coping skills that aren’t measured or appreciated by clinicians singularly focused on how to get their clients to stick with a treatment plan designed for people who’ve not had those experiences.
Suyemoto believes that for suicide prevention to become fundamentally anti-racist, the interventions and treatments tested on predominantly white clinical trial participants need to be re-evaluated to see if they’re equally effective in patients who are Black, indigenous, and people of color. Similarly, she says the federal government must invest in building pipelines for people of color to become clinicians while also addressing financial and structural barriers that prevent them from entering the field. Their absence means that clients from diverse backgrounds may not receive treatment from a professional who’s likely to intuitively understand how racial or ethnic identity shapes a person’s life. Though the psychology workforce is becoming more diverse, 86 percent of clinicians were white, to 2015 figures.
While there’s no data to suggest what the lack of diversity in mental health and suicide prevention might cost us as a society, Suyemoto is frank about the consequences.
“What we do know is that suicide prevention efforts are not tailored for communities of color, so they’re not getting information they need to do prevention activities,” she says.
In 2019, the American Foundation for Suicide Prevention, set goals to increase diversity in the ranks of its national and local board leadership, provide cultural sensitivity training to staff, and expand the reach of its suicide prevention programs into more communities of color.
Christine Moutier, chief medical officer of AFSP, says Floyd’s death and the civil unrest that followed led to a “soul-searching moment,” creating fresh urgency for the organization to transform itself. The nonprofit, which raised $41 million in 2019, is known as a major grassroots advocacy organization with chapters in all 50 states. Its trademarked draw attention to suicide loss and survivor experiences.
In June, AFSP began hosting a live town hall series dedicated to “elevating” voices from underrepresented communities, with conversations about Black mental health, health disparities, and solutions. Its scientific council also voted to make diversity a new priority in its criteria for awarding research grants. Because AFSP is the largest private funder of prevention research, Moutier says the organization’s goal is to draw significant new interest from scientists and investigators from underrepresented groups as well as applicants studying mental health disparities and inequalities.
AFSP also hired a diversity, equity, and inclusion expert to lead a self-assessment of the nonprofit, and its staff will participate in a collective cultural competency training by the end of 2020. In a announcing some of these developments, CEO Bob Geddia called the changes “just the start” of a process to change the organization’s culture and “reverse the impact of systemic racism within the field of mental health.”
Some of AFSP’s goals have been easier to achieve than others. Efforts over the past year to improve board diversity led to the addition of two people of color, bringing its current composition to 81 percent white. A third Black candidate turned down an offer to join the board, citing conflicts with other commitments.
“The problem is this work is complicated,” says Suyemoto. “It’s not simple, it’s complex. It has to happen at all levels of the organization, at all times.”
“Let us be abundantly clear: Black Lives Matter”
In mid-June, as protesters marched in the street, something unexpected happened at Crisis Text Line, a well-regarded nonprofit mental health support service. Several current and former employees organized a virtual walkout under the Twitter hashtag , citing pervasive discrimination and abuse under CEO and cofounder Nancy Lublin. The board previously claims of inappropriate behavior in 2018, but little changed since then, according to staff. In June, the board swiftly terminated Lublin, who denied the charges.
At the same time, David Michael Snoberger, a volunteer counselor with hundreds of hours of experience, saw an opportunity to support those staff members by making public his own long-held concerns about Crisis Text Line’s lack of robust cultural competency training for its 37,000 volunteers, and its “active rescue” policy for aiding texters it deemed at imminent risk of attempting suicide.
Snoberger estimates he’s been involved in at least 40 active rescues. Over time, he worried that Crisis Text Line’s policy of contacting emergency services to intervene before a suicide attempt could bring harm to people of color who are often perceived by first responders and law enforcement as threatening, even when they’re not experiencing a mental health crisis.
This policy is common to suicide prevention hotlines and services, because it’s unethical to do nothing when someone is close to taking their life. Yet, he felt that supervisors and leadership embraced its active rescue approach without fully considering the unintended consequences. (Less than 1 percent of texters are involved in an active rescue per year, according to Crisis Text Line.)
Many suicidal texters he interacted with, for example, said they’d already been institutionalized and had negative experiences with emergency services and law enforcement.
“A lot of them said, ‘Please don’t do this, I don’t want this to be done.'”
“A lot of them said, ‘Please don’t do this, I don’t want this to be done,'” Snoberger recounts.
With another volunteer counselor, he drafted an open letter to the organization’s leadership that included nine demands, among them a course that “encourages and equips counselors with tools to have respectful, open-ended discussions” about injustice. Snoberger says he found it jarring when volunteer counselors posted messages on internal communications and messaging platforms that dismissed Black Lives Matter, and no one at the organization stepped in. The letter also advocated for a new active rescue policy, particularly for texters of color. Dozens of fellow counselors signed it.
In July, after a month of internal deliberation, Crisis Text Line announced that its board hired a law firm to conduct an independent investigation into the organization’s history and culture, and it began reviewing its policies and practices, among other moves. In a sent to staff and counselors, the organization said it was “taking steps to evolve Crisis Text Line’s culture and practices to center equity.”
Shawn Rodriguez, vice president and general counsel of Crisis Text Line, said in an email that the nonprofit had no knowledge of texters being harmed by the involvement of emergency services; instead, many had provided positive testimonials about their experience.
Still, staff have been trying to identify ways to make the policy safer for texters, and the organization is working with the nonprofit think tank Center for Policing Equity as part of an ongoing review of its approach. Crisis Text Line is considering providing a survey to texters involved in an active rescue 24 hours after it’s happened to learn more about their experience.
“Let us be abundantly clear: Black Lives Matter,” Rodriguez wrote in an email to Mashable. “We firmly believe this and are taking action to ensure that our words match our deeds, from the inside out … We are working on lasting change, not quick fixes. And doing that work well means taking the time to do it thoughtfully and thoroughly.”
Vibrant Emotional Health, the nonprofit organization that operates the National Suicide Prevention Lifeline, also began reassessing its imminent risk policy after Floyd’s death. The hotline is a network of 170 crisis centers across the country to which Vibrant provides some training and technical assistance. Its current policy urges counselors to “collaborate” with the caller on strategies to reduce their suicide risk, noting that emergency services interventions are a last resort.
Currently, such collaboration may include asking the caller to participate in a three-way call with a professional who’s treating them; having them choose an action or plan that ensures their personal safety; or, asking them and a significant other to agree that the loved one will intervene if necessary to safeguard the caller’s well-being.
“We’ve been saying, ‘The fundamental way you’re doing things is wrong,’ and they cannot hear it.”
Shari Sinwelski, vice president of Vibrant Emotional Health, says the organization may update the imminent risk policy to reflect recent feedback about police involvement, include details about how to successfully use the collaboration strategies, and emphasize the importance of deploying a mobile crisis team, that often includes a social worker or counselor, instead of emergency services. In addition to the technical guidance and assistance it already shares with centers in its network, the nonprofit may eventually provide them with a new, universal training for volunteers that would cover how to have difficult conversations and what it means to be culturally responsive.
Leah Harris, a suicide attempt survivor and member of the Lifeline’s lived experience committee, is skeptical that Vibrant Emotional Health — or any of the other major suicide prevention organizations — will transform themselves without radical change that includes CEOs and board members stepping down to be replaced with people from diverse backgrounds and “divergent perspectives.” New leadership must find ways to respond to and prevent suicide without resorting to police involvement or other interventions that feel punitive, says Harris. She doesn’t believe prevention organizations can train themselves out of systemic inequality and racism.
Harris, who is white, says her distrust is born of 20 years of advocacy in the field. In her experience, leaders in the field “pretend” to listen and yet nothing changes: “We’ve been saying, ‘The fundamental way you’re doing things is wrong,’ and they cannot hear it. They don’t want to give up their power.”
“I am seeing real change”
Tia Dole, a Black clinical psychologist and chief clinical operations officer at The Trevor Project, did not expect Floyd’s death to lead to a reckoning in suicide prevention. In her private practice, Dole treats young LGBTQ people of color, many of whom she considers “refugees of other therapists.” She knows firsthand how suicidal youth of color could benefit from the field’s current shift.
In many ways, The Trevor Project arrived at this moment long before its peers. Its for LGBTQ youth is designed around volunteer training that focuses on difficult conversations, different types of identity, and the minority stress model, a theory that emphasizes how discrimination and stigma can affect a marginalized person’s mental health. Counselors are taught how to help a caller feel empowered to make decisions about their well-being by using their “internal resources,” instead of offering advice or centering their own personal experiences. They’re encouraged to talk openly about the effects of racism, as it relates to the caller’s needs and concerns.
“I am seeing real change, and not just placating folks. From my perspective, this is a really exciting time.”
Dole, who frequently talks to Jonathan Singer at AAS, says she’s encouraged by the statements and commitments made by suicide prevention organizations since May.
Like every reckoning Floyd’s death unleashed, the one in suicide prevention is just beginning. No one believes actions carried out across several different organizations, each with their own unique culture and challenges, will reorient the field toward diversity, inclusivity, and equity in weeks or months.
But advocates of this change expect to slowly see noticeable differences, like more diverse boards, more funding for underrepresented researchers and topics, conferences that feature diverse voices and experiences, improved active rescue policies, and cultural competency training for hotline volunteers.
“I am seeing real change, and not just placating folks,” says Dole. “From my perspective, this is a really exciting time.”