Turning Research into Action: Suicide Prevention Insights with Dr. Jill Harkavy-Friedman

Dan is joined by Dr. Jill Harkavy-Friedman, Senior Vice President of the American Foundation for Suicide Prevention.

Join in for part two of the discussion with Dr. Harkavy-Friedman. Dr. Harkavy-Friedman discusses her role as a translator of research into actionable insights for suicide prevention. She emphasizes the importance of a conceptual model in research applications and shares advice for early career researchers seeking grants. The discussion also covers the future of suicide prevention, the role of policy advocacy, and the complexities of psychosis and its relationship to suicide. 

The American Foundation for Suicide Prevention is dedicated to saving lives and bringing hope to those affected by suicide, including those who have experienced a loss. AFSP creates a culture that’s smart about mental health through public education and community programs, develops suicide prevention through research and advocacy, and provides support for those affected by suicide.

AFSP is the largest private funder of suicide prevention research, dedicated to understanding suicide and identifying evidence-informed strategies to help save lives. Researchers can explore its priority areas and grant application process by visiting afsp.org/research.

Learn more about AFSP in its latest Annual Report and join the conversation on suicide prevention by following AFSP on Facebook, Twitter, Instagram, YouTube and

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Chapters

• 0:00 Introduction
• 4:35 Strengths and Gaps in Suicide Research
• 7:50 Practical Advice for Grant Applicants
• 14:00 Mentoring and Early Career Support Programs
• 17:00 Strategic Priorities and Vision for AFSP
• 20:30 The Role of Policy and Advocacy
• 27:10 Understanding 988 and Crisis Response
• 28:45 Exploring Psychosis and Suicide
• 32:00 Addressing Voices and Hallucinations
• 33:40 Final Reflections on Pushback and Pride
• 34:45 Resources and Final Thoughts

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 46 of psychotherapy and applied psychology, where we dive deep with the world's leading applied psychology research that's done cover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find the show useful, it would be much appreciated if you shared it with someone else who might enjoy it too. Today, it can be more excited to welcome back my guest, who's the Vice President of Research at the American Foundation for Suicide Prevention, where she leaves the research program, funding grants, offering workshops and disseminating findings to raise awareness and support advocacy. She's been a clinician researcher for over 35 years, has published over 100 peer-reviewed journal articles and trains clinicians nationwide. She joined AFSP in 2011 and is an associate professor at Columbia University while maintaining her clinical practice in Manhattan. I also want to give a quick shout out to Trish over at AFSP for helping us bring this conversation together. In this part of our conversation, we discuss translating research into action, innovative methodologies in suicide research, the role of policy advocacy, psychosis in suicide, navigating pushback, and much more. This episode begins with my guest responding to my question about what she thinks suicide researchers are good at and what they're not so good at. So without further ado, it is my pleasure to welcome back my very special guest, Dr. Jill Harkavi Friedman. I'm such a forgiving person. I have hard time saying I think obviously it varies. And by the way, I have often thought of myself as a translator because -- Right, that totally right here.--When I was a Columbia, they moved the statistics to Parvano into my hallway. And I offered my help of translating and they're, "Well, we don't need it," and so they did all this fancy statistical stuff but it was not appropriate for the clinical research they were doing. And then ultimately, I'd serve that role as a translator. And I think that's -- You know, we talk about translational research, the research that then turns into action and change. And in our case, the behavior that'll lead to suicide prevention. And so I see myself as a translator because like I am a researcher. I've done a lot of research, but I'm also a clinician and I'm also a consumer. And so I see my role as translating the research into so that people can use it. Into social media, you know, infographics and TikToks. And we also have, you know, other more traditional things like our research roundup, which you were going to be in, this coming month or two. And then we have a research newsletter which is we go in depth and one study every quarter. So I think of it that way. And I feel like we should all be translators. And that may be the area that not everybody has a talent for. And I feel like if you don't have the talent for it, then get someone in your group who does and have them. But to do it effectively and accurately. Like the person -- our person who does all our -- on my team who does this social media stuff. I probably drive him a little batty because, you know, we're very particular. Sometimes every word you say carries implications. So I think we're really good at asking questions. I think we're getting much better at including people with lived experience to incorporate that. Not just in, you know, what we understand. But in from the start, like what should we be asking? And I think it's funny. Some researchers are actually scared to talk about suicide. Like they could study it, but they're not comfortable with it. So I think it's -- I've been so impressed with the suicide researchers. What a group of dedicated, kind, funny, strong and excellent researchers, you know, group of people. I have -- it's a very unique group of people I find. I've worked with a lot of different kind of researchers. Some could be a little less open and flexible. I think it's an incredible group of people and we work really hard to grow it. So I think we're doing the best we can. If you were to give one piece of advice to folks who, you know, might be applying to a FSP for grant or something like that, researchers, what would it be? Come to our website, afsp.org/research. Look at our grants that we've already funded. Look at how we share the information. And if you have a really novel idea and a good way to do it, and eventually it's going to maybe help save a life, then apply. And you're always welcome to call me. And we'll call the administrator. If you write to research -->> Okay. You may regret it.>> Yeah, yeah. If you write to afsp.org, then it's not that it has to be me. I suggest you talk with the researchers that are around you and mentors and all of that kind of thing. But if you want to have a specific question, write to research afsp.org. If it's related to the science of it, you'll be directed to me. If it's related to the administrative and applying for a grant, you'll be directed to our senior director of research grants and researcher education. But just see what ideas people have. So if there was one thing, I'm trying to get some practical advice out of you, what you just said was very good. But also, if there was the one thing, and obviously, I'm asking you to be based on your intuition, that you see grants come in that is like, this is the thing that a lot -- I don't want to say a lot, but people get dinged on relatively more frequently than other things that people get dinged on. The thing that you think people aren't realizing the importance of this or they aren't quite, like what would be the thing that sort of jumps out to you?>> Not having a conceptual model for your study. And a conceptual model is not necessarily a theory. You could be testing several theories. But having a model for how your questions relate to your measures and your analysis and what you're going to find. And I'm going to add a caveat to all of applications. Take it seriously. Don't be cavalier. Don't think because we're a foundation. We're not rigorous. We're extremely rigorous. We have a very rigorous review process that you could read about on the website. But have -- make sure that the questions are asking, that you've chosen measures that can actually address that question and an analysis that can help you find. Are you sure about mediators or moderators or direct connections? Or if that's tight, the rest of your grant will flow from now. And so that's the biggest thing that people are missing. Like they -- oh, I'm interested in suicide. I have 25 variables I can look at. So that's going to do what I do and I'm going to see what comes out. And that's not going to fly.>> Right. So the larger picture, how does this relate to stuff? Right? There's some larger framework having it all sort of align with that larger framework. Then also the thing I'm sort of thinking as you're talking is then the implications, the practical implications, however that would be depending on the say. That sort of would flow out of that as well. >> Yes. And you're literally right. What's innovative about this study is. And you have a tight methodology. And in the first paragraph, you talk about the long-term implications for suicide prevention. That's why I keep saying innovative, impactful, and sound methodology. And you literally help your reader by telling them, this is what's innovative. This is what's going to make it different. This is the problem we're trying to solve. And just have a really tight conceptual model that you're enacting to answer those questions. So if you were -- >> And you will get -- so the -- I just want to say, every applicant gets feedback. And we allow for up to two resubmissions. So if you don't get a grant and you get feedback and it doesn't say don't do dare put this application in again, revise and resubmit. I mean, it's a long process. It's only once a year, but we can't win the lottery if you don't buy a ticket. And so don't send a different grant unless you don't want to study it anymore. But if you still want to do it, fix it. Like we've had grants that have been very poorly the first time. They use all the feedback and then they get it. They get the second or third time. Or some people actually have applied for federal grants with our feedback. So we also started an early -- what we call our mentoring immersion program for early career researchers, where if you don't get a grant, you can apply to -- for early career research grant. You can apply to us to come to this program with your mentor. It's a three-day program with applicant and mentor. And we are so far having a really good track record with people getting funding on their second submission. We'll find out. This is a bit -- we've done it twice now. So we'll see how it goes this year. But I can already see that things are coming in much better and much improved. I think that's wonderful. I mean, especially for early career folks and people haven't done that much of it. Just actually, you know, you go to these sort of general talks at your institution or whatever about a private -- but it's so big picture, right? And like when you're in the weeds of it, sometimes it can just get lost in it. And it's very -- it's very difficult. So actually having, you know, a researcher, a research mentor, and then the expertise that you all would provide to be able to actually sit down and talk in big picture, but then also get into the weeds with people, you know, help them overcome those psychological hurdles that they're struggling with, the anxiety, whatever the imposter syndrome kind of stuff. I mean, that seems like a very useful way of allocating some resources for sort of the future of the field. Yeah, so we -- well, it's not a grant writing program because you've already written a grant. I like to call it a grant getting program. So you get sort of the general, but you also have time with your mentor. And that's one of the hardest things to get, which is why we pay the mentors when they come. So -- So you talked about your strategic priorities now and strategic plan now of AFSP. If you were to sort of crystal ball it, don't worry, I promise I won't hold you to it. And sort of three to five years from now, what would you -- like, where do you think we're going? Like, where do you think the -- what might some of those priorities look like, you know, three to five years from now? So I'll take it by each area because we're probably still going to have research, education, advocacy, and support. That's -- that's like a given. But for research, we want to increase our research portfolio, increase the number of researchers who are then able to go on and do more definitive studies from their AFSP research that are the field of researchers is growing and that the ideas really integrate how we understand suicide with suicide prevention, what we can do. So it's already starting. We already have treatments now that are effective. And now we're starting to look at the inpatient setting where we never had treatments that are effective. And now we -- like, remember, the highest risk period is after hospitalization. That makes no sense. But that's because it turns out you have to address suicide head-up. And so more -- more and better interventions and a deeper understanding of how suicide works. So that's for the research standpoint. From education that we have a population that's not just comfortable about talking about suicide, but actually reaching out to people and knowing what to say and do if somebody is at risk. And then from an advocacy standpoint that we actually have things in place, the services in place and knowledgeable clinicians so that when somebody goes to the clinician, that clinician knows what to do and there's affordable and accessible care for all people and not just one small group of people, but all people that's tailored to what their needs are. And that people who lose someone to suicide or maybe they're struggling themselves knows that they're not alone, that there are things that they could do, that when they feel desperate, they know what to do and not act on that. And that we -- you know, we have some great programs for loss survivors. We have our healing conversations. We can have a conversation with somebody else who's a few years out from their loss to see that you will -- you're not going to forget you will have a healing journey and you will be in a different place. And also we have our international survivors of suicide last day and now we have a long-term loss conference. So that you're not going to be alone and not only that, but you can experience what we call post-traumatic growth and help others. So just everything a little bit bigger, a little bit brighter and a little bit more helpful. So one thing you've touched on a couple of times, advocacy and policy a little bit as well. And this is something that's way outside of my comfort zone. So I guess how do you think about the role of policy advocacy when it comes to suicide? Oh, we must be advocates. In fact, I mentioned our advocacy office and our current executive vice president of advocacy policy and advocacy is the head of the mental health liaison group. We develop relationships with legislators and different caucuses. We go and talk about suicide and suicide prevention and we advocate for legislation that's going to make things more accessible and more effective. And even things like data surveillance, which we must have because we'll never know if we have an effect if we can't count, who's had what experience. And that's on a personal level, not just at our office, but we literally have the opportunity sometimes to get wording and bills about suicide and suicide prevention. So to understand is a lot of reason for hope, especially in an area where most people are supportive. You know, most people are either side of the aisle are supportive of suicide prevention. So, you know, so many times, especially recently, people are like, it doesn't matter what I say. And I say, it absolutely does. Even if you're in a place where they agree with what you, you know, what you want, they have to be able to go to their peers and say, well, I've heard from a thousand people, it's not just me saying we want this, the people want it. So, and I don't know what happens, you know, in Canada, but for us, that is very important. And so we educate, like I said, I'm going to do a congressional briefing. We partner with other organizations. We get to educate legislators about the field in our advocacy forum. We show up with folders for every representative with their suicide data, our ass, which are very clearly outlined on our website. Like you could go to fsp.org/advocate now and see exactly on a federal and state level what we're advocating for. So, could you, could you, so you've given the example of pushing for 988, you just gave the example of data, so collecting data from the community. What are like some of the other just some examples of the types of things that you all have are advocating for, have advocated for, like, you know, to put a little bit more meat on the bones. I think for those of us at least in the ivory tower, it's kind of like, you know, I don't know how, like how, that, you know, I want to have this speak to policy, but I don't know, you know, so yeah. So veteran services and mental health valuations and access to care for veterans. We have advocate, we advocate for the National Violent Death Reporting System, which was non-existent, and we advocated and have advocated until we got it in all 50 states. Now we want it to be even better. We advocate for research dollars to specifically for suicide prevention. We advocate for, like, I did a briefing on services, community, veteran service operators who go, who are health veterans in the community, health care, education, public education about suicide prevention, funding on the state level for 988, because it's funded in part by the states and some states aren't funding it at all and others fully funded. Is that a good list? Yeah, that's great. So it sort of hit me that we've been talking about 988 without describing what it is. Could you just give it real quick? Sure. 988 is the National Suicide and Mental Health Crisis Line, and instead of having the eight digit number, I think it's 9 digit number, 1-800-273-8255. We now, you just have to dial 988. And that, by the way, I don't know, you know, 911 came around the same way. Like, when I was a kid, every precinct, you had your phone book, which nobody knows what a phone book is, but, and then you would, in the front, it would say, your police department number and your fire department number, and you were supposed to write it in the front of your phone book, because otherwise you wouldn't know where to get in an emergency. And so advocacy brought about 911 for police and emergency, and now for mental health emergencies. And what's so cool is, since they've brought it to be all mental health crises, people are calling for other kinds of problems, like substance use. And it's really helping more people, because people are struggling, you know, regardless of whether they're at risk for taking their life. They're still struggling, and the goal is to get people to help. Yeah, and so, and also, 988 just popped up here, well, not popped up here. It started, it started in Canada not too long ago. So yeah, so now there's just that nationwide number. I'm on the board at the Vancouver Crisis Center. And it is always confusing, because there are like so many different numbers and ways to get a hold of us. But 988, 988 is just the one. That's all you need. That's it. Yeah. What would, why have, why have you? And, you know, I have very little expertise, nor have I had many folks on the podcast to talk about psychosis and psychosis and suicide. Would it be okay if we sort of went down that road for a few minutes? Absolutely. Since you sort of have some expertise on it. Just to, I mean, could you give us a thumbnail of? I know this is totally unreasonable of psychosis and suicide. Yeah, I, you know, I'll do my best. I think one thing to keep in mind is people think, oh, you're psychotic. Of course, you don't want to, don't want to be here. And that's not true at all. Most people with psychosis do not think about suicide. They do not want to die. They do not take their lives. So there are some other things that people mistake, which is like, oh, it's the voices that tell them to do that. Well, of the people who have voices, about 22% of them, which is pretty high, will act on those voices, but that also means 78% will not. So, and again, it's because there are multiple risk factors. The mental health condition alone is not the only factor that contributes to suicide. It's that in the context of other factors, like substance use, like early abuse, like head trauma, like having a chronic illness. So, if for people with psychosis, it's the same thing. On top of that, one period of risk for people with psychosis is that if they're having a transition in medication, because sometimes what happens is they may start tapering back on one before they start on another. And that's a scary time. And, and that's the time where you really want to watch people closely. Maybe they will have them in a safe place during that time, because those thoughts of, oh no, here it is again. I'm never going to get better can really develop in that time. So that is a high risk period for people who've at risk for suicide. It like, you know, suicide does run in families, but not 100% just like schizophrenia. And they're separate. So you could have a family member who doesn't have schizophrenia, but may still be have risk. But the couple together, the risk is higher. More people with schizophrenia. Die by suicide. Again, often substance use is another problem in that mix. Depression. But I found was that people who have the risk may have greater risk during a depressive episode, but they are also at risk for making attempts when they're not in a depressive episode. So you can't just rely on oh, they're depressed. I should worry. You have to really understand where they are in their life, their reasons for living, their relationships, and their general functioning and how they feel about how they function and how they feel about their future. Just like anybody else, you know, just like anybody else. So you talked about how psychosis, how when it goes along with other types of things, other disorders, head trauma, I was thinking like, you know, job or food and securities, right? Like all that, that, that, so that makes a lot of sense. Are there certain sort of, are there certain experiences that someone with psychosis might have that might be uniquely like a certain aspect of the psychosis that might be have a unique contribution to the likelihood that they would attempt suicide? Yes. I mean, what I would say is when they're bothered by their symptoms and they feel like they're never going to go away and they're really uncomfortable and they feel like they're never going to go away. If they, if they learn these are my symptoms, it's not me, it's this good subrenia, and these are the things I can do to sort of put them in their place. If they don't, they're not completely treated by medication and psychosocial work. It's when people feel uncomfortable and afraid that their risk is a higher risk period. And that's what happens also, I think, when their medications are being changed and they see those symptoms coming back. Most people are uncomfortable with their psychosis. Not everybody, but most people. And so treating symptoms is not the full answer, but it goes a long way. Right. And I was also curious, and since I had you, so you talked briefly about voices, you know, hallucinations, how do you think about voices that we all have in our heads, because we all have voices in our heads? And the voices that people who are experiencing psychosis, the their, that they have. Well, it's really, it really is defined differently, which is like you may, you know, speak to yourself, but you know it's your thoughts and you know that you're not really hearing them. But for somebody who has psychosis, they're very, it's actually a perceptual experience. They literally hear the voice. And if you do brain imaging on them, you can see, or not imaging like EEG, you can, you can see it sometimes the brain waves in that auditory part of the brain stimulated and functioning, even though there's no sound being made. So it's different from a thought. And also often, first of all, it's inside their head. They, it feels like it's somebody else's thoughts. Or it could be somebody like repeating their thoughts, but then it wouldn't be them repeating their thoughts. It would be somebody else repeating their thoughts. So it's hallucinations, both auditory hearing and visual seeing things are real perceptual experiences that people have. That's pretty fascinating. That, that what you, if I, what if I heard you correctly, that like you can see the parts of their brain lighting up that are that are the same as if they were listening to another person in the room who's there, where for somebody, typically without psychosis, that when we have, you know, thoughts popping in our head or we have our own, we have our own voice or whatever that that's not activated. So that's, you're right. That's, yeah, that's fascinating. Have you gotten much, I sort of ask everyone this, I'm always curious about pushback that people have gotten for what they do. I was curious if there's any, if you get any pushback for the work that you do. I would say at this point, no, I usually get empathy, sympathy, encouragement. And maybe this is the way I present it. I hear, oh, that's so sad. It must be so hard. Sometimes if somebody who says, well, what if somebody really wants to die, isn't that they're right? And I say, it's not really about rights, it's about how your brain is functioning. And if your brain isn't functioning well, then you might think you're going to be better off that way. And a good example of that is that we hear this often, I love my family and my family loves me and I'm a burden to them and they'll be better off without me. That makes no sense because they're family and they love you. Is it hard? Sometimes it's hard, but sometimes it's easier, you know, it doesn't, we all have times when it, but that doesn't mean they want you gone. They want you to feel better. They don't want you gone. And so I think that's emblematic of the kind of decision making and logic that happens for people when they feel devastated, when they feel like their pain is never going to go away, no matter what they do. Like think about it. Think about when somebody steps on your foot accidentally, right? What's the first thing you do? Like in retrospect, you're like, oh, they just stepped on my foot. It was no big deal. But at the moment, most often you're going to, oh my god, why did you do that? You know, when you go into this state, when all they did was step on your foot. And so I'm not saying it's the same state, but it is a reaction to feeling terrible pain and that it's never going to go away. And your reward system is functioning differently. So you feel like what's happening here and now is my future. And they don't really see a long-term future. And also, you know, we just, but the shared results from what we call the life span study, which you can go to our website and see, which talks about the cognitive changes and symptom changes over the course of a lifespan and what's related to suicide and what changes with age. And it's pretty interesting. So I don't really get pushed back. You know, some people want to talk about the issue of like, when is it okay? I think I just feel like I understand why people might feel that way. And also, experience tells me when they get through that moment, they're going to be glad they're still here. They may still be in pain, but they're able to work on it. Yeah, this is when you're as you're talking, the thing I think he's popling in my head, at least Taryn Canada, one of the things is the medical assistance in dying. And, you know, I always sort of feel like I, this is outside of my wheelhouse. I don't have expertise in that. But I listen to a really compelling talk a few years ago with Canadian Association for Suicide Prevention, arguing against mental health related medical assistance in dying. And I think there are a lot of the essence of what you're saying is was echoed in that talk sort of this idea of that when it comes to mental health, that it's so dynamic, it changes so much over time that that sort of, you know, jumping to choosing to die, you know, sort of cuts off the opportunity for those changes that will happen either naturally or via intervention or that sort of thing. So it's probably something I should have somebody on who actually has some expertise in to really dig into. I know that Canada is doing a lot of thinking about this issue at AFSP. We don't, we see it as different from suicide and we don't, we don't take a stand on that. So, but it is a question that people have to ask themselves, but we're not at the point of that's not an area for us. That's or how I feel too in my own work. It's sort of like that's something in sort of, it's in the, it's kind of like in the neighborhood, but it's a few houses over and it's like, you know, it's, it's yeah, but it is something, but it gets back to what you said in terms of sometimes people's pushback, which is shouldn't people have the choice, right, which sort of gets into the, but anyway, yeah, but the, and I think about, you know, I've seen people with pretty horrible physical illnesses, fatal illnesses, who fight for every breath. So I don't, you know, I just, my experience is when people get through that, they eventually aren't glad they're still there. Right. What are you most proud of in terms of what AFSP has done, what you've been a part of AFSP doing? What sort of, oh, so you don't mean my kids and my grandchildren. You go there too. I feel that AFSP has two things really, well probably 15, but change the conversation so that we can do research, do education and advocate for suicide prevention and that it's really been fundamental to the development of suicide prevention in the world, because we fund research globally and we are not afraid to talk about it or to try and prevent it. Are there in wrapping up here? So we've mentioned a bunch of resources. I'm sure that your colleague Trisha is going to pass along a bunch and we will do and we will include absolutely everything in the show notes. Is there anything that we haven't had the opportunity to bring up in terms of resources for listeners that you think might be worth, you want to direct them to specifically? I think it really depends on what you're coming to the website with. If you've lost someone to suicide, there's a section for you that says I'm trying to process the loss of somebody. If you are thinking about it, there's a place for you. If you care about somebody, there's a place for you. If you just want to walk, first suicide prevention because you care about the cause, there's a place for you. We have tons of resources if you go to the research section AFSP.org/research our state fact sheets and our policies that we're at priorities are really important to review because if you think there's nothing you could do, really look at any part of our website. But in the advocacy space, we spell it out for you. We share lots of research information and we have ways to get involved in suicide prevention. Join a chapter. Our chapters are definitely a unique part of AFSP that allows us to make a difference. Grassroots boots on the ground. Great. There it is. AFSP, I don't want to say a one-stop shop, but in many ways, lots of stuff go there, go to there with your specific question, get it answered, and come back and go down the rabbit hole and explore the many, many pages of the website and all the resources available. I can't tell you Jill how much I appreciate this. This has been wonderful. Thank you. Ladies and gentlemen, Dr. Jill Harkavi Friedman. That's a wrap on our conversation. As I noted at the top of the show, it'd be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time. time.[Music]