A Culture of Caring

Natalie’s Light:  A Culture of Caring


In a stunning essay published in the January 11, 2017 edition of the New England Journal of Medicine,  Rana L. A. Awdish, M.D.  described her own agonizing near death story. This is a personal “Perspective” article titled “A View from the Edge—Creating a Culture of Caring.”  While describing her own multisystem organ failure, stroke, hemodynamic collapse and loss of the baby of her 7 month pregnancy, her astonishing primary message was the change now occurring in her home medical center; the transformation to a Culture of Caring.  She writes,  “My experience changed me. It changed my vision of what I wanted our organization to be, to embody. I wanted the value of empathetic, coordinated care to spread through our system. I shared my story openly. I wanted the system leaders and every employee to know that everything matters, always. Every person, every time.” 


In its own way this model of change is the core mission of Natalie’s Light, though our task may well be more challenging. It is more difficult because we seek to not just alter the culture of a medical center, but to spiritually change the culture of our entire community. It is not just a system or organizational transformation, it is a change of how each individual cares and treats others.  To paraphrase Dr. Awdish, we must learn to recognize different forms of suffering and to find ways to diminish pain and anguish, and avoid inflicting or exacerbating suffering. To do this we must come together as a community and create a Culture of Caring.  She concluded her essay with the following statement: “ In the wake of painful experience, we all seek meaning. It is the human thing to do…The stories we tell do more than restore our faith in ourselves. They have the power to transform.”


Our transformation to a Culture of Change will require redefining or reframing the very idea of suicide; in fact all manner of selfharm. It is not an individual problem; it is OUR problem. The solution involves a change in how we all recognize our connection to others. To paraphrase the poet John Donne (1631), any person’s death diminishes me, because I am involved in all Mankind.  


Suicide is a unique challenge because it is such a paradox.  It is born in the indescribable pain of an anguished soul, causing unspeakable pain in those who survive such an event. And yet, we hide from this horrible event and fail to recognize how it is slowly wringing the life out of our community. It is becoming more common, and we have become inured or numb to its creeping presence within our community and country.  For many reasons, the number of people committing suicide has increased dramatically in the last decade.  It is shocking to read some of the statistics, but we must face the facts.   


A report in the October 2016 Journal of the American Medical Association (JAMA) indicated for all age groups suicide is the 10th leading cause of death in our country with the overall rate of suicide increasing by 28.2% since 1999.  The number of suicide deaths shot past the number of deaths by traffic accidents in 2009; the 42,773 suicides reported in 2014 are more than double the number of homicides at 16,324.  Of interest, compare this with decreasing death rates over the same period for cardiovascular diseases, cancers and human immunodeficiency virus (HIV/AIDS). The JAMA article was titled, “Are There Still Too Few Suicides to Generate Public Outrage?”  I speculate, if there were 43,000 deaths per year from an infectious disease, would it not be considered a plague, a public health disaster, and Congress would declare a national emergency?  However, suicide is just a shadow on the wall we choose to ignore.  Our prevailing culture is obviously not ready to talk about such unpleasant facts.  


Or, we can talk about suicide among younger age groups, where suicide is the second leading cause of death.  For instance, in 2014 the highest percent increase in suicides was 200% in females age 10 to 14.  In 2014, in the United Sates there were 425 suicides in the age group 10 to 14; 5,079 suicides for the ages 15-24, and 6,589 suicides for the ages 25 to 34. In these age categories, suicide was the second leading cause of death.  For age group 35 to 44 there were 6,706 suicides, and for 45 to 55 the suicides numbered 8,767.  These later two groups were the fourth leading cause of death for the age groups.  As we get older more people die of “natural causes” and thus the suicide percentage drops, though the overall rate of suicides continues to climb for all ages. 


We can parse the numbers even more, with ever more discouraging, mind numbing conclusions. In another JAMA article in May of 2016 Christensen et al. concluded the following: “Preventing suicide is not easy…our current approach to the epidemiologic risk factors has failed because prediction studies have no clinical utility—even the highest odds ratio is not informative at the individual level. Decades of research on predicting suicides failed to identify any new predictors, despite the large numbers of studies. A previous suicide attempt is our best marker of a future attempt, but 60% of suicides are by persons who had made no previous attempts.”


Christine Holland, a behavioral scientist at the Center for Disease Control summed up the state of the medical concern with the following words: “We do not have enough resources directed at suicide prevention, especially compared to funding behind other leading causes of death…If this was a finding of some other problem that results in death, it would be on the front page of every newspaper. People would be pressuring the politicians to come up with solutions.”  In fact there is no public outcry, and seemingly no public concern.  Politicians currently are more concerned with enabling the means or cause of the highest rate of suicide in men: through the use of firearms. Millions, if not billions of dollars are spent extending our right to collect firearms while the rate of suicides continues to climb.


While I am a strong advocate for more research into the causes and prevention of suicide; for more mental health professionals who are trained in suicide detection and prevention; for more education in medical schools and all branches of medicine, I do not think the answer to the problem of suicide will be solved by the medical professionals or organizations or even government. This problem is not a failure of the professional providers. It is OUR failure, as a community, to create a Culture of Caring.  I accept, as a psychiatrist, this is my business to help those who are lost souls and I want to play an important role, as do all those providers I know in mental health. But it is clearly not enough.  At Natalie’s Light, we are asking for your help, whoever you are.  There is clear evidence that you can help.


In a “Viewpoint” article in November JAMA, Michael Hogan, PhD, sounded an optimistic note, “Better Suicide Screening and Prevention Are Possible.”  While acknowledging more research, education and training are desperately needed, he feels we can make progress now. He does site the need for screening, such as seeking out risk factors and having more intensive assessment tools. He notes the need for better safety planning with reduction of lethal means and restriction (i.e. of firearms) at a community level is a valuable measure; more direct treatment of suicidality with more available treatment facilities; and a public health systematic implementation of screening and prevention measures.  But there is more, much more. This is where Natalie’s Light will be a game changer in this community.


Dr. Hogan describes this additional measure as “Supportive Contacts.”  He admits “One of the most effective and widely studied interventions with suicidal patients is simply contacting them with messages of support and encouragement.”   However, he does not go nearly far enough with this idea. He limits the nature of “contacts” to those who have been identified in emergency department visits and following up with interventions. Unfortunately he ignores the vast numbers of people in distress who never get to the ER or a mental health provider, or reach any provider who is sensitive to the problem and is not too busy to ask the right questions. But I give him credit for being in the ballpark. 


The answer is much, much more powerful and all encompassing. And the answer is not grandiose or delusional; it is just so self-evident we take it for granted: the power of our caring.  The scope of connecting, caring relationships is everywhere and overwhelming, when we all begin the process of reaching out, making contacts throughout the entire community; in schools, churches, community support groups of all types; one on one and in groups of all sizes. The answer is in making a Culture of Caring. We can do that.


Finally, to bring this concept home, I ask everyone who reads this post to seek out and watch a movie called “Pay It Forward,” or at least log on Google and watch the trailer.  This drama is based on a novel of the same name by Catherine Ryan and stars Kevin Spacey, Haley Joel Osment and Helen Hunt.  The story is about a seventh-grade teacher challenging his students to do something to change the world.  One student imagines a different world where we care about others and do something for them, however small, to help. The only request is for the person who receives the gift to pay it forward to others.  If each person does something for three others, and each one of them does the same for three more, before long there is a chain reaction with thousands, perhaps millions of caring people: a culture of caring. The challenge of Natalie’s Light is to begin the chain reaction: For each of us to connect with others: with people who will then continue this journey of human caring. It will be transforming.