Intellectual Disability and Suicide Risk

The fields of suicide prevention and intellectual disability (ID) share a common myth. Many in both fields believe that this disability acts as a buffer to suicidality. There is no evidence that this is so. As is the case with mental illness and other conditions, those with ID have much the same exposure to suicide risk as the general population. Individuals with ID are at risk along the entire spectrum of suicidal behavior from ideation to threats to attempts. Here we will look at possible sources of suicidality in this population.

Persons with almost any level of ID are vulnerable to psychosocial and environmental factors linked to suicidal behavior. They may have problems with intellectual functioning and everyday social skills. Suicidal intent has been found in individuals with IQs below 50 who made suicide attempts by hanging, stabbing, jumping, or drowning. Research reports serious attempts by individuals with ID who had major depressive episodes and recent significant social losses. In one study, one-third of respondents with ID felt “life is not worth living.”

Adolescents with ID may endure rejection and stigma in school, the community, and at home. Like most young people they want to be accepted by their peers and not be seen as “different.” Those with mild to moderate ID may be at highest risk, they may recognize the detrimental aspects of their disability. At every age they are at increased risk of being victimized. Adults may be exposed to interpersonal stressors, depression and other psychiatric disorders, substance abuse, serious financial and legal issues, loss and bereavement, other traumas, and job and housing problems. They may have fewer protective factors such as resilience and good skills in coping, problem solving, and help-seeking.

A suicide attempt may occur if there is an extremely strong desire to die and the capability for lethal self-harm. A desire for death can come from believing one is a burden to others and/or that one does not belong. Individuals with ID may see themselves as having a negative impact on their families. A belief of being a burden may begin early and be amplified by school or job problems. Difficulty with social norms may lead to feeling disconnected from peers and family. A sense of being trapped by one’s situation adds to risk. A history of self-injury and physical abuse creates a capability for potentially lethal self-harm.

Suicide risk is a reality in intellectually disabled persons. Family members, schools, and providers must be educated regarding suicide risk and protective factors, recognizing possible warning signs, and be trained in basic suicide crisis intervention. Police, other emergency responders, and corrections staffs should be better informed about nature and prevalence of ID and possible suicide risk in this population. Suicide prevention must be put on the intellectual disabilities agenda and the risk inherent to ID must be acknowledged in suicide prevention plans.

Tony Salvatore

How an Elder Suicide Almost Happened

On a Sunday, a few years ago a situation unfolded in a Philadelphia suburb that could have ended in a suicide, but fortunately did not. It entailed a chain of events that illustrate that, in at least this one example, there are many opportunities to “do something” to prevent a suicide.


Mrs. S, an 80-year old widow, recently moved into a Continuing Care Retirement Community offering independent living, assisted living, and skilled nursing care. A few weeks later she was admitted to a local hospital because of an exacerbation of a chronic illness. In the course of her inpatient stay she manifested depressive symptoms and made statements indicating both suicidal ideation and a plan to take all of her medications when she returned to her residence.


The hospital did not have a psychiatric unit but arranged for a psychiatrist to see Mrs. S. The psychiatrist expressed concern about her risk and felt that she should not directly return to her residence. He wrote an order that she be transferred to the skilled nursing facility (SNF) at her retirement community.


Mrs. S was discharged the next day at 2:00 PM. For reasons that are not clear the orders were not followed and an ambulance took Mrs. S to her home. At 2:50 PM, Mrs. S called the assisted living facility (AL) in the complex and told them that she was home and that a psychiatrist had told her that she should be on a “suicide watch.” An LPN said that she would try to find out what was going on.


The LPN called the SNF, which knew nothing about Mrs. S. She next spoke to a nurse on the floor that had cared for Mrs. S and was told of her suicidality. The LPN relayed what she had learned to the SNF Charge Nurse who requested faxed copies of the orders. The RN called Mrs. S’s unit but there was no answer. It was now about 3:30 PM.


Meanwhile Mrs. S went to the AL facility and told an aide what she had been told by the psychiatrist. She said that was going to a concert in the auditorium at 4:00 PM in the hope that it would lift her spirits. The aide alerted the LPN but Mrs. S had left. The LPN contacted the SNF RN who went to the auditorium to try to find Mrs. S. What she found was an overflow crowd of 250 elderly women, many of whom fit Mrs. S’s description.


At 3:55 PM, the SNF RN alerted Security, which was changing shifts at 4:00 PM. Neither the outgoing or incoming security staff knew Mrs. S.  One security officer accompanied the SNF RN back to the auditorium to try to find someone on might know Mrs. S. The other security officer called the dining room and other areas where Mrs. S might be present.


The concert ended at 5:00 PM and Mrs. S had still not been located. At 5:15 PM, as the concertgoers cleared the lobby one of the security officers saw two women conversing on a sofa.  He inquired if either was Mrs. S. One woman said, “I guess you’re looking for me.” The security officer not wanting to run afoul of confidentiality polices returned to the front desk where he could observe Mrs. S. while the other officer called the SNF RN.


The SNF RN arrived five minutes later and told Mrs. S that they were ready to work on her admission. Mrs. S. readily proceeded to the SNF with the RN.


The SNF staff was very concerned about its ability to handle this situation. Mrs. S was admitted to a private room. The call button cord was removed and efforts were made to find a bell that Mrs. S, could used to summon help. Maintenance was contacted about securing the windows. By 6:00 PM Mrs. S was settled in and the SNF staff began checking her every hour.


Epilogue: When last we heard, Mrs. S was still with us and living independently at the CCCR.


Comment: Mrs. S voiced a potentially lethal plan with access to means and a specific timeframe. She should have been strongly encouraged to have a voluntary evaluation at a geripsychiatric facility and, if she declined, a petition for an involuntary psychiatric evaluation (“302”) should have been filed. Hopefully the hospital implemented some precautions during the last day of Mrs. S’s stay (but that is not known). The SNF seems to have taken Mrs. S’s risk seriously but did not seek an assessment. The SNF should have contacted the county crisis center for assistance. The measures taken by the SNF to assure Mrs. S’s safety were minimally adequate. It was suggested that the facility develop a suicide prevention policy for such situations but that has not been done.

Alternative to Hospitalization — Is There Such a Thing?

by Tony Salvatore, M. A.

Over the years (decades actually), I have often heard the phrase “alternative to hospitalization” used in conversations about the suitability and capability of some community-based mental health services to serve as a substitute for inpatient psychiatric care. The implication being that use of these alternatives would be less expensive, less restrictive, less stigmatizing, and less traumatizing than hospitalization while being equally effective. This phrase and the promise that it bespeaks is always taken as a valid assertion and never (in my experience) challenged by users, advocates, or providers of mental health services.

My intuition told me that there was something illogical about this phrase, but I never spoke up because I always assumed that the service in question was being presented as a means of deterring admissions involving individuals who could be safely and effectively treated in community settings. I was wrong. I have discovered that many people strongly believe that the need for inpatient psychiatric care can be met outside of a freestanding psychiatric hospital or a psychiatric unit of a community hospital. Moreover most of those espousing this view also seem to believe that inpatient psychiatric care is over-utilized because adequate substitutes are or could be available.

There are a number of misconceptions about psychiatric hospitalization. One is that it should be up to the patient who, after all, would seem to be in the best position to know if inpatient care is needed. Another is that hospitalization should follow from a determination by an outpatient provider, in the form of a referral, that this level of care is needed. Still another is that admission is solely at the discretion of the psychiatrist covering intake at the hospital. Of these, only the last has any degree of validity. A psychiatrist does indeed order an admission, but it is not based on her or his decision alone.

What is often not understood is that there are explicit criteria for an inpatient psychiatric admission that must be met. These criteria have been established by the various parties regulating, offering, or paying for inpatient psychiatric care. They are based on clinical need and appropriateness for this level of care. Satisfaction of these criteria are the primary purpose of the psychiatric evaluation that must precede any inpatient admission. The criteria of medical necessity for inpatient psychiatric care are basically clear. The individual must:

  1. Have a primary psychiatric diagnosis, excluding intellectual disability, substance abuse, or dementia, unless these conditions co-occur and are secondary to the presence of a diagnosed psychiatric disorder. (NB: Psychiatric diagnosis by itself does not equate to need for hospitalization.)
  2. Require ongoing 24-hour clinical management, monitoring, supervision, and assessment by psychiatry and nursing to develop, implement, and modify the treatment plan, which cannot be done in a less controlled care environment.
  3. Be at significant risk of harm to herself/himself or to others because of an imminent risk of suicide, assaultive behavior, or homicide, represent a risk to self because of psychosis, or demonstrate a serious inability to care for one’s self.

These criteria clearly indicate that, when strictly and correctly applied, there is, in fact, no alternative to, or substitute for, inpatient psychiatric care when that is what an individual needs. There is no single community-based program or any combination of such programs that can deliver the degree of safety, supervision, or service intensity that can be provided in an inpatient psychiatric setting. Put more plainly, someone either needs hospitalization or someone does not, yes or no.

Here is a suggestion: Use an “alternative to inappropriate hospitalization” instead of improperly using hospitalization. Inpatient care should be turned to when it is the only option capable of meeting the individual’s needs. Any other use is unnecessary, wasteful of a limited resource, and potentially harmful. Inpatient psychiatric care is not a “Plan B” for problems that cannot be otherwise resolved. It is not a stand-in for shelters or rehabs that have no beds. It is not a respite for frustrated family members or providers. It is not an alternative to incarceration when the offense is unrelated to any underlying serious mental illness.

There is no alternative to psychiatric hospitalization and psychiatric hospitalization is not an alternative to any other service.

Responsible Reporting of Suicides

NB: While the commentary below originally appeared in The Philadelphia Inquirer in 2004, the issues discussed are, sadly, just as relevant today.  There have been some changes in the manner in which suicide is reported in the media, however there are still glaring misconceptions about the appropriate way to cover a suicide, if it is appropriate in the first place, terms to use and terms to avoid, and a lack of knowledge about facts, risk factors, and warning signs.  The hope is that this article will serve as a reminder about the importance of responsible reporting of suicides and the responsibility of media outlets to provide relevant facts and information.  

Report Suicides Responsibly

by Tony Salvatore, MA

Like many, I was saddened to read of the deaths of David Wallace and his wife, Joan, particularly of the means by which they died (“Eminent architect dies in double suicide,” July 20).

Given David Wallace’s stature, and the comparative rarity of double suicides, I understand why this tragic situation would receive significant media attention. However, from my suicide-prevention perspective, the nature of The Inquirer’s coverage raises a number of concerns.

First, the article appeared on the front page. Second, it included a fairly detailed description of the method by which the couple ended their lives. Third, it made no effort to put the deaths into the context of suicides among elders. Sadly, these are increasing in what is often called a silent epidemic.

A number of organizations have offered guidelines for coverage of suicide. They seek to raise awareness that some vulnerable, high-risk individuals may carry out their own suicides by reading detailed news accounts of how others took their own lives. One such set came in 2001 from the Annenberg Public Policy Center of the University of Pennsylvania, acting in concert with national suicide-prevention organizations.

The report, “Reporting on Suicide: Recommendations for the Media,” explicitly discourages the placement of such stories on the front page or at the top of a broadcast. It is understood that suicides involving prominent persons, public circumstances, multiple deaths, or the very young are generally considered newsworthy. The Wallaces’ deaths fell into two of these categories and merited coverage. However, front-page treatment was not necessary.

Of greater concern was the detailed description of the lethal means that the Wallaces employed – another practice that the Annenberg report discourages.

These details, which I obviously choose not to get into here, were not essential to reporting this loss. Moreover, given that some may see these deaths as rational suicides – Joan Wallace was in hospice care; David Wallace had cancer – some circumspection was in order.

So-called copycat suicides are not limited to youths. It is to be hoped that The Inquirer would not have described the means used in reporting a high-profile teen suicide. The same judgment should have applied here.

Lastly, the Wallaces, David Wallace in particular, were in an age group at high risk of suicide, a fact not well known. According to data from the Centers for Disease Control and Prevention, there is a suicide by someone over 65 every 90 minutes, which amounts to 16 such deaths daily in the United States. Elders account for 20 percent of all suicides but represent only about 12 percent of the population. White men over 85 have a suicide rate six times higher than the national average.

Statewide, says the Pennsylvania Department of Health, there were more than 1,200 suicides among people 65 and over from 1997 through 2001 and fewer than 400 among those 19 or younger.

This same pattern prevails in Southeastern Pennsylvania, where elders accounted for more than 18 percent of all suicides in the same period and youths represented less than 6 percent of the losses.

The point is not that greater numbers make elder suicides more distressing than those at the opposite end of the age spectrum. Rather the point is that The Inquirer, having chosen to highlight the deaths of David and Joan Wallace, could have used this opportunity to inform its readers about the little-known incidence of suicide in the “golden years.”

Depression and hopelessness play a prominent role in elder suicide. Neither condition is normal at any age. Caregivers and health-care providers could have been alerted to these possible precursors to suicide in elders.

The Inquirer could also have noted that frailty makes the elderly less likely to survive suicide attempts. And it could have mentioned that greater social isolation makes it less likely that elders attempting suicide will be discovered in time to save their lives.

With the accelerated aging of our society, we must pay more attention to elder suicide and how the media should treat it. Suicide prevention is obviously not the media’s primary job. Nonetheless, it can play a powerful role in educating the community about this preventable problem.

Tony Salvatore is director of development of Montgomery County Emergency Services Inc., a nonprofit emergency psychiatric agency in Norristown.

Serious Mental Illness and Gun Violence

by Tony Salvatore, MA

mhfirearmsAs an adult mental health crisis center serving southeastern Pennsylvania for almost forty years, Montgomery County Emergency Service is closely following the public discussion regarding violence and serious mental illness.  We deal daily with many of the concerns that have been raised.  Our input was sought by the Commonwealth of Virginia in the wake of the Virginia Tech situation.

As has been noted, such violent events cannot be foreseen and there is often very little opportunity to prevent their occurrence.  Sadly, such events can happen anywhere with no forewarning.  We agree that much more can be done to reduce the risk of such behavior in our communities.  Here we want to share some of the measures in place to do just that in Montgomery County.

First, our work is premised on the evidenced-based reality that the overwhelming majority of people struggling with serious mental illness do not engage in violent acts of any nature.  A very few do and we are prepared to deal with such cases.  However, shootings involving individuals with psychiatric histories in Phoenix, Aurora, and, closer to home, at Western Psychiatric Institute in Pittsburgh, are very rare, but well-publicized.

It is important to understand that as devastating as these events are, they involve only a very small fraction of those with serious mental illness.  Our experience, as supported by NAMI and other mental health advocacy groups, is that individuals with mental illness are far more likely to be victims of violence than perpetrators.  Many of those we serve come to us with severe emotional and physical trauma as a result of exposure to violence and abuse.

Second, because many of those with serious mental illness are very likely to have contact with emergency responders as a consequence of their illness, we have engaged local police and other law enforcement agencies as our partners in creating an early warning system for identifying and getting help as appropriate for those experiencing mental health crises.  We provide ongoing training to all criminal justice personnel in recognizing the signs of mental illness and the basics of crisis intervention.

We provide much more than knowledge and skills.  We back-up what we teach with 24/7 availability to officers in the field to answer questions, and give referrals and advice on resolving a situation in a manner that assures the safety of all parties and leads to the provision of emergency services by our facility or by community resources when the need is less urgent.  Police, in turn, keep us apprised of contacts with individuals at-risk that may warrant follow-up by our Outreach Program.

Third, we facilitate the ability of concerned individuals, including friends and family members, hospital emergency departments, and behavioral health providers, to arrange involuntary emergency psychiatric evaluations for individuals felt to be a danger to themselves or others because of mental illness.  Through the Montgomery County Department of Behavioral Health and Developmental Disabilities, we administer the emergency psychiatric provisions of the state mental health statutes.

We agree that our state and national mental health policies and spending should fit emerging needs and that existing behavioral health resources must be enhanced.  However, we also feel that every effort must be made to make full use of what is on hand to do everything possible to deter possible harm and meet needs as they arise.  To this end, our staff maintain currency on applicable mental health law and community resources so that we can aid those bringing potential emergency situations to our attention in understanding options, making a decision, and mobilizing the optimal intervention.

Fourth, as part of our responsibility to meet the emergency mental health needs of those who are unwilling or unable to do so we also fulfill the requirements of PA Act 77 that restricts purchase or ownership of firearms in Pennsylvania to anyone who is involuntarily admitted to a psychiatric hospital.  Information on all such admissions in Montgomery County is submitted to the PA State Police for entry in a state-wide data base.

Fifth, people with behavioral health problems may get involved with the criminal justice system apart from any crisis situation.  On their behalf, our assistance is sought by District Attorneys, Public Defenders, private defense attorneys, District Justices, Common Pleas Judges, Probation Officers, family members, and the police in clarifying the mental health status and needs of particular individuals.  This happens because our staff is seen as understanding mental illness, being able to assess an individual’s crisis level, and having a strong understanding of mental health laws and regulations. This capability represents a further layer of risk reduction.

Lastly, we fulfill our duties with an acute awareness that our actions have significant consequences for community safety, the welfare of at-risk individuals, and for their personal rights and liberties also.  Accordingly, we feel very strongly that the current prevailing interest in public safety at all costs be tempered by a concern for the rights and privacy of vulnerable individuals who present no threat to the community’s welfare.

Fixing the Mental Health System: Some Starting Points

by Tony Salvatore, M. A.

Every time there is some event anywhere involving mental illness in any way there are cries to “Fix the mental health system!”  There is no denying that the US mental health system needs “fixing” but perhaps we need to look more closely at some of the reasons that this is so and at some of the efforts underway to at least mitigate this state of affairs.

Government under-funding has compelled some providers to “cherry pick” and focus mainly on healthier, wealthier patients.  However, at the same time, the mental health system has become the default provider for the problems that the other community services “silos” do not elect to help.  Some individuals with serious mental illness may go underserved because many mental health providers are dealing, often ineffectively, with clients who have dementia, substance abuse disorders, intellectual disability, and little, if any, mental illness.

Psychiatric beds exist for those who require inpatient psychiatric care because they are a danger to themselves or others due to psychiatric emergencies, such as suicidality or psychosis, or serious illness-related mental health crises.  In most communities there are a dearth of such resources.  Where they are present they may be largely occupied by people who do not need this level of care but for whom other options are unavailable.  Scarce beds may also be filled with treatment-seekers and malingerers.  Such individuals do not benefit from inpatient psychiatric care and deny treatment to those who might.  Psychiatric hospitals have become “Plan B” for the rest of the mental health system as well as for other service sectors.

Efforts are being made on many fronts to divert individuals at risk of incarceration from contact with the criminal justice system.  Police are unavoidably “mental health first responders” because of their public safety role.  In many areas, mental health providers have acted to assure they are trained to recognize signs of potential mental illness and how to safely deal with an individual with severe mental illness.  Montgomery County Emergency Service has been providing such training to local law enforcement agencies and others since 1975.   Elsewhere, police departments have adopted the Crisis Intervention Team (CIT) model.  Programs of this nature divert many whose criminal justice contacts are related to their mental illness from arrest and prison.

Mental health courts are in place and reduce the likelihood of imprisonment of those with mental illness whose offenses are serious enough to bring them into the court system.  Routine court oversight of treatment adherence brings the weight of the judicial system to bear and assures that all parties to care arrangements live up to their responsibilities.  In our service area the “intercept concept” has been used to identify points at which persons with mental illness can be diverted from the criminal justice system.  One “intercept” point with high potential for re-incarceration is after leaving prison.  Forensic outreach services can facilitate community re-entry and providing mental health training to probation and parole personnel to reduce “violations” related to mental illness.

For those with mental illness already in prison or who were not candidates for diversion, the correctional system in some states making changes  In Pennsylvania, for example, the Department of Corrections is creating special housing units for inmates with serious mental illness “who do not fit in well with the rituals of prison life.”  This approach, while far from optimal, establishes settings that may not worsen the existing mental illness, offer some protection to vulnerable inmates, and lessens assignment to solitary confinement.  This addresses the reality that some offenders belong in the correctional system but should be able to access appropriate mental health care when needed.

What our discussion so far shows is that perhaps there is really no such thing as a “mental health system” anymore but rather that mental health-related functions have been dispersed as the entity once charged with managing them has proved increasingly unable to do so.  This may provide an opportunity to resolve the problems presented by the Cartesian mind-body split and adopt a holistic model of health care treating all illnesses and disorders whether based in the brain or in other organs.  This is occurring as behavioral health professionals are being integrated into both primary and specialty health care practices.  Such integration will enhance the effectiveness of psychopharmacological therapies and provide for more effective resolution of side effects and drug-to-drug reactions.

Recently, ethicists at the University of Pennsylvania (JAMA, December 2014) called for a “return to asylums” as a “fix.”  It is unlikely that re-institutionalization will ever take place.  Nonetheless, dismantling the state hospital system did not obviate the need of some individuals with severe and chronic mental illness for long term residential care.  While there will be a need for psychiatric hospitals to stabilize those with acute exacerbations of chronic mental illness, there is really no need for even a state hospital level of care thereafter.  Many patients could be “stepped down” to sub-acute levels of care for stays of three to six months during which treatment plans could be developed with the involvement of the patient, family, and outpatient providers.  Such transitional care could prevent the rapid re-entry stressors of discharges to home from inpatient psychiatric care that drive revolving door re-admissions and drive patients unable to engage with outpatient care to homelessness, substance abuse, and, in too many cases, police contact.

To sum up, perhaps a mental health system that served people whose primary needs primarily related to mental illness would need less fixing than one serving all comers, being all things to all people, and poorly serving all.  Perhaps the best way to fix the mental health system is to assure that other systems do their jobs rather than off-load those they do not wish to serve.  Once this is done attention can be given to deficiencies inherent to the mental health system.

The Music of the Mind: A Diverse & Unique Inpatient Psychiatric Hospital Concert Series

by Gabriel Nathan, M. A. Ed.

There is much that has been written about the intersection of behavioral health treatment and the creative arts.  For decades, certified music, art, dance & movement, and drama therapists have been working with individuals with mental health challenges in ways that enhance and complement the more traditional therapeutic modalities the “medical model” has to offer.

At MCES, patients attend a wide variety of psychoeducational and recreational groups every day of the week, from 9:00am-9:00pm.  These groups can range from Fitness Walking to Suicide Prevention, Coping with Anxiety to Learning Forgiveness, to Trauma and Medication Education to Creative Writing.  While the days on the inpatient unit are filled with opportunities to learn, share, gain insight and feedback, once a month at MCES there is an opportunity to experience something special, outside the realm of what is traditionally thought of as “treatment” or “therapy.”

In 2014, two foundations, The Clayman Family Foundation and the E. Rhodes & Leona B. Carpenter Foundation both awarded MCES grants to fund a year-long concert series on MCES’s inpatient unit.  The notion of having performances for individuals experiencing inpatient treatment is not new, but it has rarely been formalized to this extent, supported by philanthropy, and attracted a such a diversity of talent:

LoewySusanna Loewy is a twice GRAMMY-nominated flutist and educator who lives in Philadelphia.  She has performed with Peter Nero & the Philly Pops, the Philadelphia Orchestra, the Pennsylvania Ballet, and the Louisiana Philharmonic Symphony Orchestra.  Susanna played at Carnegie Hall in 2013, premiering the new works of three contemporary composers.

Susanna’s June 25th concert was her second time back at MCES, and she performed a variety of works from classical to contemporary.  Susanna had performed a Valentine’s Day concert at MCES on February 13th.

MCB2The Merion Concert Band was established in 1977 with the aim to “foster and promote music and the interests of music in the community.”  Since that time, it has grown to become one of the most popular bands of its kind in the area, producing a well-attended annual concert series and attracting professional musicians to play alongside their amateur performers.     

On July 10th, over forty members of the Merion Concert Band played an unforgettable twilight concert in the MCES outdoor courtyard for dozens of enthralled patients and staff.  It was a night to remember.

Nicole Zell 3 (2)Nicole Zell is a singer-songwriter and a mental health advocate, making her a natural choice to perform at MCES.  She has performed in a variety of venues over the last five years, and hosts a radio show called “Soundstage” on WCHE-1520 AM Radio.  Nicole is a member of the Chester County Suicide Prevention Taskforce.

Nicole’s emotional hour of music in September was compelling and revealing about some of her personal struggles, and her music, words, and thoughts resonated with the patients and staff in a powerful way.

Deirdre Flint @ MCESDeirdre Flint was born and bred in Philadelphia, and her music is a blend of hilarity and sincerity.  One minute, she can make you howl with laughter at songs mocking Facebook, bridesmaids’ dresses, or being flat-chested, and the next you could be crying as she sings about the memories of her grandmother’s house.

Also a substitute teacher in the Philadelphia School District, Deirdre Flint’s songs are instructive in nature: about how not to take oneself and one’s world too seriously, about how laughing in the face of adversity can be an essential coping skill.  Deirdre’s unique, funny, and down-to-earth performance at MCES filled the cafeteria with laughter and applause for this one-of-a-kind singer-songwriter.

Staines & Zell (11-21-2014)Bill Staines is perhaps one of the best-known names in folk music today.  He has recorded twenty-two albums over his 40-year career, and travels over 65,000 miles annually, playing at 200 venues nationwide.  Bill has performed on national radio shows “Mountainstage” and “A Prairie Home Companion” and his songs have been featured in several major motion pictures.

On November 21st, Bill Staines traveled from his home in New Hampshire to MCES to perform a set of some of his most memorable and well-known songs for an appreciative audience of staff and patients.

Nicole Zell was warmly welcomed back to MCES to play an opening set for Bill Staines.

The Norristown Chorale has been singing in and around Montgomery County since 1977, performing two main concerts annually for the benefit of the community.  They have performed with the Ambler and Pottstown Symphony Orchestras and have presented Mozart’s Requiem and Handel’s Messiah. 

On December 17th, 50 members of the Norristown Chorale filled the MCES gymnasium with the glorious sounds of Christmas, singing a mix of traditional carols, hymns, and popular songs about the Christmas holiday—a special, heartwarming treat for those who had to be hospitalized so near to Christmas.

Opera North, Inc. is the oldest African-American opera company in Pennsylvania.  They produce and perform new works, full-scale productions, concerts, and educational outreach engagements.  Their director, Leslie Burrs, is deeply invested in connecting with the mental health community.  Opera North, Inc. recently collaborated with the Philadelphia Department of Behavioral Health & Developmental disAbilities on a video project documenting mental health recovery.

Soprano Iris Fairfax, baritone Dan Lickteig and accompanist Pasquale Montenegro of Opera North, Inc. performed a pleasing blend of opera, operetta, and musical theatre pieces for an attentive and engaged audience in January.

Doc Gibbs & Cachet IveyDoc Gibbs performed at MCES on February 16th, along with dancer and instructor Cachet Ivey.  Doc brought along with him percussive instruments from around the globe and had patients performing with him and with each other.

What, to the casual observer, looked like a simple box or a George Foreman grill, Doc Gibbs was able to turn into expressive, tuneful instruments that had people up and moving to Doc’s rhythms and Cachet Ivey’s infectious moves.

Doc Gibbs has performed with Erykah Badu, Wyclef Jean, Grover Washington, Jr. and many others.  He was also the bandleader on the “Emeril, Live!” show from 1997-2007.


Individuals receiving inpatient behavioral health treatment have the same need to experience creativity, artistic expression, and enjoyment of culture as anybody else.  Unfortunately, for many with mental illness diagnoses, access to the arts is severely limited by myriad factors, and inpatient hospitalization is an obvious disruption to an individual’s ability to experience arts and culture.  Through the generosity of the Clayman Family Foundation and the E. Rhodes & Leona B. Carpenter Foundation, we are able to bridge the gap between culture and treatment and offer high-quality performances to our patients and staff, and let the music continue.

Suicide Attempt Survivor Support: A Critical Unmet Need

Montgomery County has a serious problem with suicide, losing over one-hundred residents yearly.  It is probably less well-known that the county has a much bigger problem with non-fatal suicide attempts, all of which raise the individual’s life time suicide risk, and many of which subsequently become fatal attempts.

There is little data on the incidence of suicide attempts, an act in which a person with intent to die acts on a plan using potentially lethal means.  Many attempts occur without coming to anyone’s attention. Those that do usually are as a result of a need for medical treatment, self-reporting by the individual in seeking help, or when there has been an intervention.

Depending on age and gender, the ratio of suicide attempts to fatalities varies widely. Youths make more attempts than adults, men make considerably fewer attempts then women, elders tend to die on their first attempt.  Lethality of means, particularly firearms, accounts for these disparities.

Individuals with serious mental illness, especially schizophrenia, bipolar disorder, and major depression, attempt suicide more frequently than those without these conditions.  Alcohol abuse and dependence figure highly in suicide attempts. Imminent and actual suicide attempts account for a significant number of voluntary and involuntary psychiatric hospitalizations.

We could go on, but suffice it to say that focusing suicide prevention on individuals who have made a suicide attempt would likely save a lot of lives, enhance the recovery prospects and duration of those who may re-traumatize themselves when beset by even passing suicidal thoughts, and free up ERs and psychiatric hospitals to address other needs.

In 2012, the Action Alliance, a national suicide prevention coalition, identified support for attempt survivors as a priority for focus in the revised National Strategy for Suicide Prevention (NSSP).  This led to a national Suicide Attempt Survivors Task Force to help forge a path for stopping suicide attempts and deaths by engaging and supporting people with lived experience of a suicidal crisis.

In 2014, the Pennsylvania Adult Suicide Prevention Plan included an objective (9.1) to “identify all suicide strategies and services that respond to and care for individuals affected in the aftermath of a suicide attempt…and promote awareness of these resources.”  This state plan will presumably motivate the implementation of aftercare resources for suicide attempt survivors at the county level.


There are few suicide attempt support groups anywhere.  A 12-step based “Suicide Anonymous” group met for several years in Norristown, but ceased when its leader moved out-of-state.  At present, the only such support resource that we know of anywhere near Montgomery County is a “Suicide Anonymous” group in Burlington County, NJ:

Rise Above/R.I.T.E. Center

Twin Oaks Community Services

693 Main Street Building C

Lumberton, NJ 08048

1st Floor, Center Door

Group and Skype: 7:00pm 2nd and 4th Thursdays

Skype Only: 1st, 3rd, and 5th Thursdays


So why such a paucity of support groups in a major metropolitan area that probably has support groups for every other malady known to humanity?  Liability for self-injury or fatalities among group participants is often cited.  This probably would not apply to a peer-led group and has not proved insurmountable in the few provider-based groups around the country.  Bigger problems are stigma and finding peer facilitators.  (It is likely that there are a number of Certified Peer Specialists who have “lived experienced” of a suicide attempt as well as group facilitation skills.[i])  Indifference toward the needs of attempt survivors is an issue.  Perhaps those affected by recurrent episodes of acute suicidality will at some point step up.


Repeatedly hospitalizing those who make or almost make suicide attempts may be more part of the problem than part of the solution.  Clearly inpatient care may be indicated for stabilization and safety but there is no evidence of any long-term preventive value.  Moreover, the first 30 days after discharge from a psychiatric facility are a very high risk period for suicide.  Many readmissions within 30 days of discharge involve suicidal behavior.


Here are some on-line information resources on this topic:




[i] See “Peer Specialists can Prevent Suicide” Behavioral Healthcare, September 30, 2010 at

The Nature of Suicide Threats

by Tony Salvatore, M.A.

The term “suicide threat” brings to mind an anguished “cry for help” by someone at imminent risk of suicide.  This may be the case and warrants immediate crisis intervention when it is.  However, there are suicide threats that are less a “cry for help” than an effort to bypass the established channels to get it.  This second form of suicide threat is usually devoid of any imminent risk.  Both variations are frequently encountered by emergency responders and behavioral health staff.


Basically, a suicide threat is a type of “suicide communication” and the common signal of potential suicide risk.  It is “any interpersonal action, verbal or nonverbal, without a direct self-injurious component, that a reasonable person might interpret as…communicating that suicidal behavior might occur in the near future” (Silverman et al., 2007).   Suicide threats may convey definite suicidal intent, involve no suicidal intent, or be unclear as to suicidal intent (Silverman et al., 2007).


A suicide threat may not always be a reflection of suicidal ideation involving any thought of death.  However, any suicide threat connotes the possibility of pending more active and possibly harmful suicidal behavior so it must be taken seriously.  At the very least this should involve screening the individual for signs of suicide risk, a specific suicide plan, and intent.  When these factors are present a voluntary or involuntary psychiatric evaluation may be in order.


A suicide threat grabs most people’s attention, particularly if those it is directed at care about the person voicing the threat or have some responsibility for her or his well-being.  This gives suicide threats the power to provoke a response whether or not suicidal intent is actually present.  Suicide threats get a gatekeeper’s full attention and can immediately open doors.  This feature has not been lost on substance abusers and others who wish to elude contact with the criminal justice system or expedite admission to an inpatient treatment setting.


While we must take a suicide threat at face value as a sign of potential suicide risk, it would be helpful to know when this is actually so.  It has been suggested that the nature of a threat may indicate if it is accompanied by intent.  Consider these two threats:


“I am going to kill myself tonight by [insert lethal means].”

“I will kill myself tonight if I have to go back to jail.”


The first is an unconditional statement of intent with a plan comprising a definite timeframe and means.  The second also gives a timeframe, but it is conditional and “sets the terms” under which “intent” may become effective.  The first is a “non-contingent suicide threat” which is passive and does not include any demands; the second is a “contingent suicide threat” which may be dramatic and predicated on secondary gain to the individual (Lambert, 2002).


Whereas emergency responders, crisis center and ER staff, and facility admissions personnel have probably heard both types of suicide threats, it is likely that they more often hear threats that are conditional in nature.  This is borne out by the research.  Those who make contingent suicide threats are more likely to have diagnoses of substance dependence and also to be at low risk of suicide (Lambert, 2002).  On the other hand, those making non-contingent threats are more likely to be characterized by severe depression rather than substance dependence, and also to be at high risk of suicide.


The nature of the suicide threat may give some indication of the nature of the suicidality and, correspondingly, the level of suicide risk that may be present.  Non-contingent threats tend to be associated with acute suicidality; contingent threats are more often linked to what has been called chronic suicidality.  It is hoped that further research may provide screening and assessment tools that can validly distinguish each type of suicide threat.



The Crisis Continuum

By Tony Salvatore, MA

Mental health consumers and providers, and often family members and others, often use the term “crisis” to encompass a wide range of personal, interpersonal, and environmental situations with current or anticipated negative consequences. This “one size fits all” concept of a crisis is overly simplistic, obscures or minimizes the complexity of the situation, and impedes effective intervention and resolution.

Mental illness-related crises vary in scale and in terms of how they affect the individual. They also seem to follow trajectories and may move to higher levels of risk. All may be triggered by life events (or an individual’s anticipation of an adverse life event) that produces emotional discomfort or even the recurrence of psychiatric symptoms. Continue reading