0:00:00.3: Welcome to Resource On The Go, a podcast from the National Sexual Violence Resource Center on understanding, responding to, and preventing sexual assault and abuse. I'm Mo Lewis, Prevention Coordinator at NSVRC. On today's episode, I'm talking with Anole Halper, Clinical Social Worker and Public Health Professional, about the toolkit they created for the North Carolina Coalition Against Sexual Assault called Meeting This Moment: Facilitating Suicide Prevention Workshops for Youth in School and Community Settings.

0:00:48.8: Thanks, Anole, for being here. I'm really glad that you are able to be part of the podcast. I love this toolkit. And I'm wondering if you can tell me just more about the creation of it, where you got the idea, how it came to be.

0:01:03.6: Absolutely. Well, yeah, thank you so much for having me. I'm really honored and excited to be here as well. So yeah, I've had an interest in suicide prevention for many years and have practiced clinical or clinical adjacent kind of social work with youth in mental health crisis for a few years. I've talked through suicidality with many young people, minors and adults. So a colleague of mine who I knew, known for many years at the North Carolina Coalition Against Sexual Assault, reached out to me because her rape prevention education grant recipients, so these are folks who do presentations with youth in school and community settings, and even though they were there to talk about sexual violence prevention and consent and sexual health and stuff like that, the youth they were working with were bringing up the serious emotional distress and hopelessness and suicide that they were experiencing and that their friends and friend groups were experiencing. 

0:02:04.3: And they were kind of at a loss for how to navigate this, like they didn't have any training on this and they felt like they needed some support. So they reached out to my colleague at NCCASA who oversaw that prevention program. And so NCCASA contracted with me to come up with a model that could be used by these grant recipients. So I definitely want to give credit to NCCASA. This is their project. I was the consultant who worked on it. So we kind of fleshed it out over a few years, culminating in a toolkit about how to deliver these mental health workshops to youth.

0:02:39.3: Yeah, I love this toolkit. Being able to read through it, I was thinking this is exactly what I could have used many years ago. And I feel like it's something that many people can use now. So what all is included in the toolkit?

0:02:53.0: Yeah, so it basically breaks down in 13 pages why and how to hold these workshops. So the way the workshops work, I think we'll get a lot into the why in this conversation, kind of explaining the necessity of this intervention. But the way the workshops work, they empower young people to design a crisis plan for themselves, maybe using an app or another tool in a group setting where everyone around them is also sharing and normalizing their experiences of distress and coping skills. So that's a lot of words. Let me kind of explain what that might look like. So for example, the facilitator says, how do you know when you're having a hard time? And the participants are jotting this down in an app or on a piece of paper that's called a crisis plan or a safety plan. And then someone might also say at the same time, I shut down and I stop talking. And the facilitator could be like, oh, you shut down and stop talking. They could flip chart it. They could be like, that's normal. Does anyone else have that kind of thing happen? Does anyone else shut down when they're having a hard time?

0:03:59.8: Yeah, that can happen. And go through and really collectively kind of build an understanding of this is what it looks like when we're struggling and this is how we cope. So the coping skills are also kind of the second piece of that. So how do you cope when you're having a hard time? You send memes? Who else sends memes? Right. We love memes. So the outline theoretical model workshop also includes discussion of how to navigate boundaries with friends and how to loop in adults because we know that young people talk to each other about suicide and really depend on their friend groups. And research shows that these peer groups are really helpful, but also that they feel ill-equipped to navigate crisis. And so we want to support them in feeling resourced and prepared to set healthy boundaries.

0:04:46.2: I like all the elements that are included. It seems so robust and it's a lot of things that I think any sort of prevention educator would want to know about or have included in this toolkit. And when I read it, I also was kind of blown away at some of the things that were really different about this toolkit than some things that we think about normally in doing sexual violence prevention work. So a lot of times we talk about prevention needing to be really specific to a community or group. And this is like the opposite of being targeted. Instead of pulling people out or talking with only specific groups or really making it specific to a community, the recommendation here is to have it really be broad and reach a wide audience. And so I'm wondering if you can say more about why that is and why that works.

0:05:42.0: Absolutely. So yeah, I feel that I have a long answer to this. So first I kind of want to lay out the existing kind of landscape of conventional mental health interventions for suicide, especially with youth. So if you look at a model like Mental Health First Aid that's been widely adopted, the conventional model for suicidality is you assess that there's risk, maybe do a little bit of empathizing and active listening, and then get them professional help. So it's like the referrer, referrer. So let's say that you're a 14 year old who's struggling, you finally work up the nerve to share that with your teacher, they took a training, they're like, thank you for telling me, I'm sorry, you're hurting, let's go to the counselor. So you're like, okay, appreciate the empathy, but you're shuffled to the office, it's a little bit disorienting.

0:06:28.1: The counselor says, wow, thanks for telling me, they ask you a bunch of questions, they do some assessment, maybe they do a little bit of safety planning, but they have 1000 clients at the school, you're really at risk and they're worried and you can tell that they're worried. And so they're like, I'm here for you, but you also have to see a therapist in the community. And I also have to tell your parents and, here's a list of referrals, maybe they call your parents give them the list of referrals. And I totally, Anole, I'm stepping out of this scenario, I get where this is coming from. Folks want to get people the appropriate level of care. And I think there's also a lot of concern in the world about liability. But I think sometimes in that concern about liability, we lose sight of the basics of what people with SI are actually experiencing and what they need, and what actually works. And so yeah, can I use my really crude metaphor that I used in...

0:07:24.0: Yes. I love any sort of metaphor. I feel like...

0:07:29.2: Yeah, I said certain interventions for suicidality are like covering your ass with something transparent. What's the point? If this intervention doesn't actually work, we're not actually doing the right thing for liability, like the school is saying, oh, we referred the person out to the therapist, but the kid never sees the therapist because they can't access the therapist because of when their parents work and insurance, and they don't have a ride and whatever else, how effective is that at checking the box? That box is unchecked.

0:08:02.9: It's a lot of roadblocks.

0:08:04.9: Right, the school pretends they're checking boxes, but the experience for the actual individual who's experiencing pain is, yeah, one of the folks I quoted in the toolkit is like, it's like navigating this maze of these riddles, it just feels really impossible. So it's not just that you maybe get referred to a therapist who doesn't take your insurance, and the ones who do have a waitlist, and your parents are working and can't take you to the appointment. It's the message that you got from this process. And so suicidality is inherently alienating and isolating people experiencing as I feel alien from those around them. And when we focus on plucking people out of their world, and their social environment, we are reinforcing that message on this really deep level. So if the primary causes of SI, or kind of the emotional experience of it is disconnection and disenfranchisement, and that model really reinforces both. And so the other thing that you learn because of that as a 14 year old is not to disclose again, because nothing supportive actually happened. And the primary reason that young people don't disclose is fear of breaching confidentiality, which happened in this case, right?

0:09:13.7: And fear of hospitalization. And there's a version of the story, especially for youth of color and disabled youth or both, where the young person is restrained by police and taken to the hospital and experiences trauma because a great number of people that are hospitalized for SI do experience trauma, and only are released after a 48 hour hold, a 72 hour hold, with no healing having taken place with someone having strip searched them and watch them shower and then thrown back into this milieu where they still don't know how to get through the day, right? And how to function and how to feel kind of safe in their own mind. And so people who complete suicide tend to not disclose because of these fears. And in one study, which are justified, right, they are rational.

0:10:01.5: And in one study, youth who died by suicide had engaged with mental health treatment at the same rates as those in the comparison group who died by car accidents. So that was kind of the random sample. So expecting disclosure of suicidality and then alienating people for disclosing isn't working. Which is not to say that we never have folks engage with mental health treat. I think, yeah, this is kind of an aside, but that is kind of built into the toolkit is like when is BS being really transparent in the workshop about when a disclosure would need to take place and allowing folks to share what they feel comfortable sharing at their own pace and to practice informed consent and rather than the goal being like to kind of get people to disclose so you can pull them out and refer them to be like giving them the option to disclose and letting them know what that is really going to look like.

0:10:58.2: That might look like we call your parents or whatever, which is fair and rational and makes sense. But we're expecting disclosure and then alienating people for it isn't working. And so, yeah, I think the antidote to that comes from radical mental health organizations and interventions like the Icarus Project, the Fireweed Collective and mutual aid groups and the answer is community. Right? And it's empowerment, and it's like allowing people to kind of be in control of their own process and to connect with others while they do that, right? So that's kind of the basis for this intervention, how to incorporate and center both those things. And so yeah, some crisis plans specifically designed for group workshop settings were designed by people with lived experience. And these democratically developed tools are politicized.

0:11:47.1: And that framing is particularly relevant for marginalized youth who are most at risk of suicide and also least likely to trust and engage with professionals, right? So youth of color, LGBTQ youth just have higher rates. And yeah, very valid reasons to distrust these systems. So to kind of wrap up the argument, according to the 2021 Youth Risk Behavior Survey, or YRBS, which is fully back on the internet, about one in five high school has seriously considered suicide in the past year. And that's noteworthy because it's the same as the proportion who are sexually active. So our field recognizes that it's best practice to provide young people with inclusive safer sex resources without requiring them to disclose information about their sex lives or go to a doctor's office. There's some information we recognize it's important to have widely available, right?

0:12:43.6: And so similarly, we have to give youth the best tools available to cope with suicidality without needing them to tell anyone in particular that they're thinking of suicide. And that might require us to skill up. So just like issues like sexual violence and STIs have required prevention professionals to learn how to talk about sex, the youth mental health crisis means that we might need to grow more comfortable talking about deep emotional pain, similarly frank and nonjudgmental ways, which can be a little bit awkward. And I want to acknowledge that. 

0:13:19.3: It also sounds so, I don't know, normalizing. I'm thinking about something related to social norms with this and just the impact that being in a group of all different people, just your classmates, your regular everyday people that you have class with and having people be like, oh yeah, I feel this way too, or I feel similarly seems like it could have a really positive effect for people to not feel so alone.

0:13:46.9: Yeah, absolutely. I think that's the idea. And to have a grownup just being really chill about it with them, I think also can be, it can be really healing in and of itself, right? Just that process. And so, yeah, I definitely think that's part of the logic of it.

0:14:08.5: So one thing I find so interesting about this resource is that it's a single workshop. It's just like a one-time 90 minute workshop that any instructor could do in any classroom. And the reason why it's so interesting to me is because in prevention specifically, we don't usually recommend that people do one-time presentations. It's because of this potential boomerang effect where harmful beliefs could be inadvertently strengthened. But this type of one-time intervention has been shown to be effective in reducing distress and risk. And I just, I think it's so cool. And I'm wondering if you can share more about why this structure is effective.

0:14:52.7: Yeah, so I first just want to acknowledge that it's kind of the caveat that we need to give of it's evidence informed, but not evidence based. Right? So I suspect this will work. I have reason to believe it will work, but I don't yet have the evidence I'd like yet. And y'all can be a part of the process of collecting it and creating that evidence. I did kind of dig into the research on what they call single session interventions for youth mental health, SSIs. And I think they're like adjacent, but they're typically, I think they're typically individual, they're not kind of delivered in a group setting. But I dug into kind of the principles of what make them work or not regardless. And this one kind of lit review came up with this little acronym about it, of course. And basically there are like these four pieces. 

0:15:45.4: They work if they normalize concepts, if they empower youths to have a helper or expert role, if they have "saying is believing exercises" to solidify learning, to actually be practicing it. And if they include testimonials and evidence from valued others. So I think the only thing it's missing, they wanted brain science to normalize concepts. So I don't have the brain science, but it is normalizing the concepts anyway. So I think this has three and a half out of the four principles of what supposed to make a single session intervention work. But I think kind of we can kind of conclude on a broader level why the boomerang effect might not be there, right?

0:16:30.1: And that's because it's not about challenging people's existing beliefs. It's not like you think this about masculinity, but it's wrong. It's about building on and documenting what they already know about themselves and have maybe just never put into words or put into words in a group setting. And so even though the group setting is novel, I think we've talked a little bit about why it's also really critical, and I think really central. And I think it's really drawing from these radical movements whose wisdom and knowledge I trust because they're coming from folks with lived experience who we need to listen to, right?

0:17:10.4: And so according to the folks who created this similar intervention called TMAPs, it's like a little bit more in depth. Person who wrote this website was probably Sascha Altman DuBrul. He's the founder of the Icarus Project. So he said, when we make and share our crisis plans with others, they become potent tools for healing and liberation. Because the workshop is a collective experience, the process itself can reduce isolation and risk. Yeah, I don't know if that kind of answers your question.

0:17:39.2: It totally answers the question. I think it's so powerful to have people build on their strengths and resources. And it's something that I think is part of prevention. But I can just see this being such a great add on or interwoven piece to prevention work that people are already doing and it would really meet the need that so many young people are having right now. Doing. And something like you were talking about before, people going into do prevention, but finding that that's actually not something you could do quite yet, because there are all these other things that young people are focused on and thinking about. So yeah, I'm really a fan. I'm wondering if you could envision people who are already doing prevention work, like weaving this in or adding it to what they're doing.

0:18:33.9: Yeah, I mean, I think there's lots of different ways. I think it could just... It's kind of written out in the toolkit as like a, I think 60 or 90 minute workshop, I think folks could absolutely deliver it that way. It includes all the components and kind of how to deliver them. So hopefully, it feels accessible for folks. And I also think they could be broken up maybe every week while you're... Or often you're going into schools or into a community setting. You could do a piece of it and do like this component or that component, so that there's some space to air these things that are really on folks mind. Because I think, it was like 20% of young people had thought about suicide, but 40% had experienced severe distress in the 2021 YRBS. And I think when folks are experiencing that distress and hopelessness, yeah, it can, like you said, it can just be really hard to focus on other things, right?

0:19:40.5: And so creating space to air, yeah, this might be something that's coming up right now. And you might be suffering with this, we're going to create some room to talk about it can just allow folks the spaciousness to like, be present to what you want to say about sexual violence prevention and condoms, but also their math class, and maybe dinner that night. Because I think so often when people are suffering, there's this cognitive, this very painful cognitive dissonance between the daily tasks that they're being asked to perform, and this intense existential pain that they're in. And there's that mismatch can be maybe even more painful than the emotional experience itself, right? And so by creating space, you're closing that gap, and allowing folks to bring their feelings into their lives in a way that I think is really powerful.

0:20:44.8: Yeah, I think so too. I'm envisioning that people will listen to this and want to find it and want to use it. And I know we were talking about how this is evidence informed and not necessarily evidence based. And one of the things that I love, I mean, I'm a big fan of things that are evidence informed, because a lot of this officially research stuff is so just not a possibility for people. So one of the things that I love is that you included sample evaluation questions. And I'm wondering, this is just me being curious. Are you interested in people reaching out with their evaluation experiences and how this works for them?

0:21:34.3: Absolutely, I would really, really love to see folks evaluation results, I would be so excited to create a spreadsheet and start aggregating and analyzing that data and seeing what happens. So yeah, folks can email that to me, anole.halper@gmail.com, first name dot last name. Yeah, it would be really wonderful. And also just, it doesn't need to be the official eval results. I'd just love to hear what folks experiences. I'm open to feedback on this intervention. I'm always down to iterate.

0:22:08.3: Yeah.

0:22:09.2: Yeah.

0:22:10.2: This is great. Thank you so much. I am wondering, where can people find this resource? I mean, we're gonna include it in the show notes, of course. But where else could people find it?

0:22:22.3: I feel like the show notes is probably the best place because it's a really long web address and it was kind of... So yeah, so the North Carolina Coalition Against Sexual Assault is hosting it on their website. But yeah, the link will be provided directly in the show notes.

0:22:39.9: I love this. It feels so important and timely, and unique, and also very deeply resourced. And made up of so much good, like deep knowledge. So I'm really glad that you made this. And I'm really glad that NCCASA asked you to make this. And I'm really glad that you are also making it available to everybody else.

0:23:06.0: Me too, I'm also really excited and I'm really appreciative that you kind of see what I put into it because it's just a white paper, it's just on the internet and sometimes you're just kind of researching into the void and you don't really know how it's going to go. So yeah, I really hope that everyone, that folks who are listening who are interested, try it out, see how it goes and give feedback, incorporate some of these ideas into their work and take what works and ditch what doesn't and stay in touch in community.

0:23:41.0: Thanks for listening to this episode of Resource On The Go. For more resources and information about preventing sexual assault, visit our website at nsvrc.org. You can also get in touch with us by emailing resources nsvrc-respecttogether.org.