Dr. Moutier: Suicide prevention isn’t just at the moment when someone is in crisis, although that is also an important moment in time for many people, but it’s about what can we be doing to create healthy communities where we can talk about these things. This is why I love your podcast so much.

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Lily: I’m Lily Cornell Silver, and welcome to Mind Wide Open, my mental health- focused interview series. Today, I am talking to Dr. Christine Yu Moutier who is the Chief Medical Officer at the American Foundation for Suicide Prevention. Today we’re going to be talking about what to do when you or someone you know is in crisis, the stigma that exists around suicide and how it’s currently being shed, and what mental health and suicide look like in marginalized communities. Thank you so much for watching and I hope you enjoy. Hello, Dr. Moutier. Thank you so much for being here.

Dr. Moutier: Thanks so much for having me, Lily. I love your podcast and everything that you’re all about related to mental health. It is so awesome and so powerful.

Lily: Thank you so much. That means the world coming from you, especially, [laughs] but thank you. I truly appreciate you being here so much, especially it’s my second to last episode of Mind Wide Open. It feels very synchronous to have you here. I’m using Zoom class language, synchronous, asynchronous. [laughs] It feels very serendipitous to have you here. I would just love to talk to you about your experience as Chief Medical Officer at the American Foundation for Suicide Prevention. I can’t think of a more perfect guest to be talking to right now.

I would love to start just by talking about the specific focus on suicide prevention because suicide is something that I’ve talked about a lot on the series. Obviously, I have personal connection to it through friends and family. One of the main things that I’ve noticed besides suicide being one of the more highly stigmatized things within the mental health umbrella, that there can be so much more focus societally put on repairing in the aftermath versus prevention beforehand. I’m wondering if you could speak to that dichotomy and why the emphasis is on prevention.

Dr. Moutier: There’s so much to say there. What I want to say is that the topic of suicide is obviously super serious and very intense both on all sides of it if you’ve lived through the experience of suicide loss, if you struggled yourself, if a loved one has struggled and been suicidal, stigma’s going down. Now there are so many things that the science tells us that we can be doing, what we call upstream from suicide risk. Meaning suicide prevention isn’t just at the moment when someone is in crisis, although that is also an important moment in time for many people, but it’s about what can we be doing to create healthy communities where we can talk about these things.

That’s why I love your podcast so much, that when you take stigma out, we get to actually talk about the experiences that we’re having and be strengthened by each other, learn more about how you can interpret different experiences, symptoms, and signs. Sometimes there are just these very individual signs that our body or our brains might signal to us that we didn’t even know until we start really reflecting and almost looking at ourselves like scientists. There can be ways that we know it’s time to engage in various self-care activities, or to plug back into treatment, or to share that with certain important people in your life – family members, trusted mentors or therapists, mental health professionals.

Suicide is a leading cause of death. We know that it’s a health-related outcome, and that means that it’s genetics, it’s biology, but it’s also our early life, our current life. There are things we can do about that. We really do take a very, very broad approach at AFSP, it’s science-based, but prevention means a whole lot of things that we can be doing in the schools and workplaces and families, not just when you get to the doctor or with a therapist.

Lily: Where do you think that stigma comes from and why is it lightening right now? Because I agree. Just based on doing this series, that’s what I’ve heard from multiple mental health professionals, is that the stigma is being shed, but where do you think that comes from?

Dr. Moutier: I’ve had to think about this so much because the culture is changing so quickly in a positive way around both mental health and suicide. The way I look at it is if you think about other stigmatized topics that, let’s say even like cancer, certainly HIV/AIDS. When you think about what changes a culture’s view and their hearts and their minds and their attitudes about it, it oftentimes starts with science, certainly when it’s a health-related issue, but even non-health-related issues. Knowledge is power.

When you look at the history of the science around suicide risk and prevention, it’s a pretty young field. I feel like in our suicide prevention research field and that translation out into the world, that is happening, but we’re still at a relatively early point in time in the whole development of that field.

Lily: When you specify that suicide prevention comes in the medical and psychology fields, but also needs to be infused in the workplace and school, that’s something that I’ve talked about on this series. I’ve spoken about losing a close friend to suicide in high school and how much emphasis was placed on almost a PR cleanup versus actual care. Then also, I was close with many teachers at the school that we were at, and most of them said we didn’t have training necessarily. We didn’t have the training that we needed both to spot the signs beforehand and then also to help our students in the aftermath. From a professional standpoint, what would that look like? What would suicide prevention and suicide de-stigmatization look like in the workplace and look like in schools?

Dr. Moutier: I love this because you can really actually even start with very early childhood experiences in kindergarten and in first grade. What that can look like is not just building in what is happening now. Across many states, they’re required now to implement social-emotional learning curricula into schools, and that is awesome because that is a way to teach all of us about how we tick and what emotions mean and what they might signal us to be more proactive in our lives. There are other things that can happen, which are educating teachers, parents, and also building in a culture, and this is a harder thing to do, but through leadership, policy, education.

There’s a study of something called the good behavior game, which is a classroom management system for kindergarteners and first graders that helps not just reward good behavior, but actually develops a whole wraparound way in the cultural environment of the classroom for kids to learn how to manage their own emotions and behavior. That program was studied in urban Baltimore, and those kids then 15 years later had very different outcomes in terms of rates of graduation, their academic record, but also mental health experiences, suicidal thoughts, substance use, trouble with the law.

It could ideally look like building something that is both building more optimal personal development. The word coping can sound so pejorative, but really learning how you tick and making choices for yourself, learning that along the way. That’s like the utopian view, but we’re so far from that. We still have so much stigma around even just feelings and emotions that people are worried about who it’s safe to share that with. That’s how early we are in our process of building that into schools and workplaces and health systems.

Lily: It’s so interesting that you bring up even starting in kindergarten because I think there’s this idea that there is an age that’s too young to be dealing with social-emotional learning, but specifically intense and big emotions, and especially suicidal emotions. There’s this idea that it’s too young, even the school that I went to, was 6 through 12. I was in 10th grade, but there was this idea like, “Oh, the sixth graders are too young to be subjected to this. We can’t be having conversations with them around it,” That almost seemed to be more damaging.

Dr. Moutier: It’s such a tricky thing because where that is coming from is the concern about contagion. Suicide contagion is a real phenomenon, but I think it almost got misinterpreted to say we can’t talk about– I think people actually get confused, like, “Can I ask somebody if they’re having suicidal thoughts or will that be dangerous?” Those are very, very different conversations. It is so important if you’re worried about somebody to open up that supportive, safe dialog where you absolutely can and should ask if they’re having thoughts of ending their life.

That is a separate thing from contagion, which is when the topic is sensationalized, glorified, made to look like it’s a real solution, or it’s so graphically portrayed, let’s say, in entertainment that it draws people who are struggling closer to their suicidal urge. I almost feel like in the school setting, there has been a lot of conservative approaches that maybe we shouldn’t do direct topic of suicide in their face until a certain age. There is some rationale to that, but I think the main point is that most school districts are pretty early in their journey of figuring out how to implement and how to make it a priority. Teachers are stretched a million different ways, but that doesn’t mean this doesn’t warrant a high priority for them to get that learning.

Lily: You mentioned too, because we’re in the early stages of shutting the stigma, it being difficult to know both what to do if you worry that someone’s struggling or what to do when you yourself is struggling. That’s also something I’ve talked about on the series is my own experiences with suicidal ideation and even though I had access to any resource that I may have needed and I had access to a mom who was totally understanding and very supportive, I held a lot of fear and uncertainty about what do I do if I’m feeling this way?

I didn’t know that if I told my therapist that I’m experiencing suicidal ideation, am I going to get locked in a padded room? It was an interesting thing for me to experience because I come from a family situation and a home situation where there wasn’t a lot of stigma just in my own circle, but I still felt so much fear and uncertainty around being honest about my feelings. I’m wondering if there’s anyone watching this show who has similar feelings or a loved one of theirs has similar feelings, what do you recommend to do? What does it look like when you experience suicidal ideation and suicidal thoughts? What should you do?

Dr. Moutier: I’m so glad you’re bringing this up, Lily, because it’s a terrific point you’re making, which is that even when you’re the most knowledgeable, educated, you don’t have stigma, you encourage other people to talk about it, but when you’re the one in distress, I think it’s a very primitive instinct built into basically all of animal species that when you feel vulnerable, there’s an automatic pulling back and almost like putting up the shell like the roly-poly bug.

Lily: Especially when you don’t know what the reaction is going to be, you don’t know what’s going to happen. [crosstalk]

Dr. Moutier: Exactly. Add it being that you never learned about this, that it wasn’t necessarily a topic for discussion. As you’re saying, even if it was, and you’re in an environment where that is a normal topic around the dinner table, which is the ideal way mental health should be. Even in that circumstance, when you’re the one in distress, you feel that sense of pulling back – a fear, shame, what is safe. Look, the brain is a physical organ in the body. In that moment, it is not functioning at its best, so it’s not giving you the clearest pathway in terms of problem-solving and what to do, who to talk to.

I would just say to that person that there are safe people in your life because we all have them. Sometimes we don’t know who they are yet. What will happen, I think, is sometimes people who are in distress will test the waters, and they’ll put little feelers out. If you’re on the receiving end, if you’re a friend or a parent or a teacher and somebody is saying things like, “I’m just feeling a little bit overwhelmed these days. I don’t know how much more I can take.” That’s a little more obvious, but anything that’s basically a hinting at what might be a much deeper level of just feeling desperate and unsure underneath the surface.

That is something to hone in on, and to say, maybe if now’s not the time, definitely not a hallway conversation at school or in the workplace, but, “Can we talk and check in because I want to make sure that I’m hearing you and I’m understanding where you are.” That is your whole purpose in opening up that dialogue. You don’t need to solve problems, because that’s not what it’s about. It’s about you showing loving curiosity to understand what they’re going through because that means something and carries a lot of therapeutic value in and of itself.

Lily: Absolutely. Thank you so much for that answer, because as I said, even someone who has access to whatever resources I would need because we’re so early in these stages of talking about suicide and suicide intervention openly, it’s like, what are you supposed to do? Especially as you said, when you’re in that state, even if you have all the tools, there’s very little logic and rationale available to you in your own mind.

Dr. Moutier: Yes. I think if you’re the one in distress and you’re not sure what to do, let’s say you’ve identified one person in your life who’s probably trustworthy and safe, I would actually try to set them up for their best response by saying, “I want to talk to you about something that I’ve been going through or that I’m experiencing. It’s really private and I’m taking a risk connecting with you on it and I don’t need you to solve this for me. What I need you to do is to hear me and give me support and unconditional love. Maybe there will be ways and next steps forward, but what I’m really looking for in this conversation is your being present with me and being able to handle it and hear it.”

I just think so many people, it’s a foreign experience, it’s not something that they’ve necessarily had to do a lot of, so their anxiety rises. Help them out, [chuckles] giving them a little bit of framing maybe.

Lily: Something that’s been important for me in my own interpersonal relationships, especially with my mom, is specifying what support looks like if you can. In times when I’m not in crisis, being able to say, when I am feeling in crisis or feeling like I need support, this is what support looks like for me, because that can be totally different for everybody.

Dr. Moutier: Oh, that is a really amazing thing that you’re– That’s a sign of sophistication in your own journey and in your relationship with your mom, to give your loved one that gift to say, “Here’s what support would look like in that moment.” Sometimes you have to figure it out for yourself. [crosstalk] what that is, but the minute you start, and even just maybe through a conversation, sometimes it helps figure that out as well. I think that’s what I hope that many, many people, and being inspired by you and your podcast and our work at AFSP.

At AFSP we have chapters across all 50 states and they are having these dialogues with each other, peer-to-peer teaching each other exactly how it works for them. We have programs that are education for the loved ones of someone who either has had a suicide attempt or is struggling. If you’re interested in those, any of your listeners, go to afsp.org and you can find your local chapter and tap into any of these programs. Those programs are an educational experience and a tool. Then I think what can happen is your learning journey really starts when you start opening up that dialogue with trusted people in your life.

Lily: Really any conversation, it’s an intersectional issue. I’m wondering if you could speak to the experience of suicidal ideation and suicidal stigma even within marginalized communities.

Dr. Moutier: Probably no matter what family or culture you grew up in, there’s going to be stigma and opportunities for growth and learning, but what we’re seeing in the data, especially during the pandemic, is that the national US number of suicides during 2020 actually went down from 2019 to 2020 year over year, it was amazing, by 5.6%. That’s actually a decent amount for suicide numbers. But, in the states where they’ve actually taken the time now to analyze their data a little bit further – for example, in the state of Connecticut and Massachusetts – we see that non-white, so Black and other communities of color, their rate of suicide went up, in some cases doubling during 2020, during the pandemic compared to the White residents of those states where rates went down.

Advocating for policies where we increase our workforce to be representative of the actual population, where there is a requirement for training and cultural competency so that there’s a better likelihood that when you as – whatever background you’re from – encounter that health professional and you may give it one shot because you’re not sure how it’s going to go in terms of even expressing your internal experiences to a health provider, whether it’s a primary care doctor or a mental health professional, so that there’s a greater likelihood that they will be listening with an educated ear that doesn’t just make those racially-biased assumptions.

There’s tremendous research that shows that when a person of color steps into a doctor’s office with the same symptoms, let’s say of heart disease or any kind of physical or mental illness, that they’re less likely to receive the correct diagnosis and a full important treatment plan. There is just a lot of work to do that relates to structural racism as well as very specific changes that need to be made within the field so that the workforce is educated and connecting with real people with real needs.

Lily: Thank you so much for speaking to that. I think it’s something that has been left out of the forefront of the mental health conversation for a long time. To have a professional speak to it is so important. I’m wondering if you would feel comfortable speaking to your own experience around mental health. A lot of people, especially the people that I’ve had on my show, are involved in mental health advocacy or involved in psychology or whatever it may be because of their own personal experiences. I’m wondering what that looks like for you.

Dr. Moutier: What happened for me was that during medical school was my first experience when I had major mental health symptoms. I was anxious, crawling out of my skin, fear of failure. I hadn’t allowed myself, and maybe I grew up in a family– I’m half Asian. Cultural factors were a big part. I’m the firstborn in a Chinese father family. You’re always the best, there’s no question about it. Asking for help is like a foreign language. What happened for me was a very massive crisis that in a way I look back on and it sounds weird, but fortunately, I had to actually take a break and stop and get help.

That year off was transformational because I got therapy for the first time. It sounds so strange, but I developed a PTSD to the medical environment because I was just so ill when I had left. Coming back in was like a big deal. Then once you’ve experienced that amount of suffering and also getting help and realizing that this is a whole world of reality, you become sensitized to the cultural environment, in my case, in academic medicine, where there was not even, not a language for it, but you dare not talk about those real experiences.

I was in it by then, I finished medical school, residency training. By the time I was chief resident, I had probably given off a vibe or maybe was talking a little bit about my experience enough so that anyone who was gravitating towards that topic was sharing with me, was getting advice. I started learning that these are human issues. It does not cut across. Doctors are not protected from this. We are human too. Then later by the time, fast forward a few years later, I was a dean in the medical school that I had struggled in, which was a wild full-circle experience, there were a number of physicians who died by suicide.

This was at University of California, San Diego School of Medicine. More than a dozen over a period of 15 years. I got put in charge of doing something about it, in my boss’ words, and had the experience of really figuring out what constitutes effective suicide prevention. Forget about, I’m not my colleague’s or my student’s doctor, but just in a community, in a school environment that happened to be a medical school. My family has some genetic loading for mental illness. It’s very much a lived experience on a number of different fronts for me.

Sometimes I wish it weren’t quite so lived in an ongoing way, but it certainly has opened up my mind to the fact that there is a science that’s growing, that is shedding light, but so much of the world is still– the light has not been fully illuminating things. There’s still so much darkness and so much work to do. I think that’s the beauty of an organization that I’m fortunate to work for as Chief Medical Officer at the American Foundation for Suicide Prevention because these are tens of thousands of people across all 50 states who have all been personally touched, like you Lily, and are speaking out and realizing that there’s so much that it can be done education-wise, community strengthening-wise, building that safety net, and importantly, again, advocacy and policy-wise.

Lily: I think it’s so important, you sharing your experience coming from family where mental health wasn’t necessarily talked about to having to inundate yourself really intensely in that experience, not only through your own struggles but through being in the field professionally. I’m wondering also what your experiences look like, especially in this last year as an Asian-American woman and what your mental health has been and how you’ve been taking care of yourself.

Dr. Moutier: Walking my own personal journey of self-care and learning about how I tick and how to prevent crisis and keep my own resilience reservoir full for so long. Since 30 years ago when I had that first crisis, if I’m looking ahead and I see that I have a super stressful several weeks coming up, I will actually make some changes to what time I’m going to bed, what I’m putting into my body, how I alert my spouse and my family members, “Hey, this is coming. I’m going to try my best, not to put that on you, but just give me a little extra compassion.”

I think even just having that mindset almost you give yourself a reset a little bit and you’re just more ready for it in a way. It’s weird, but probably lots of years of therapy and little tools along the way just get built in a little bit more innately.

Lily: What is something that is giving you hope right now?

Dr. Moutier: Oh gosh, I think I feel the most hope around what I feel like is a tipping point that’s happening in the world around mental health. I’ve been feeling it for some time, but then during the pandemic, oh my goodness. In a way, who wasn’t struggling with something because of what it did to all of our lives? What that’s done, the unanticipated or unintended consequence is people are talking about it so much more. I think normalizing that dialogue, especially for people like us with lived experience or loss, it’s almost like, whoa, the world suddenly is speaking our language.

Maybe it opens up new opportunities to take the next step to be authentic, to take a risk, to step out and try something new. Maybe to get treatment for the first time. That’s definitely been happening during the pandemic where rates of help-seeking and accessing mental health services are higher than ever before. I think there is so much reason to hope about the culture changing around this topic and around suicide prevention. I think that’s what is the most exciting for me.

Lily: Thank you so much for being here. It’s been such a pleasure to talk with you.

Dr. Moutier: Thank you so, so much, Lily, for having me on and for doing what you do. I just really wish you all the best. I know you’re going to keep on shining that light.

Lily: Thank you.

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