Send A Letter, Save A Life: Suicide Prevention Through Caring Contacts

Connection between loneliness and depression

“PTSD, anxiety, major depressive disorder,” Poretti counts off on his fingers.

“Since 2015, my list of medications has been five times longer than the weekly grocery receipt,” he continues.

Suicide remains the second-leading cause of death for U.S. residents between the ages of 10-14 and 25-34. In 2020 alone, an estimated 12.2 million adults seriously considered suicide, and it was responsible for 46,000 deaths.

If you take a step back, those numbers don’t begin to capture the epidemic’s full contours.

“Friends, family, co-workers, acquaintances, so many people are deeply and often traumatically affected by just one suicide,” says Tony Wood, chair of the American Association of Suicidology.

“Multiply that by several orders of magnitude and you have a sliver of the scope of this problem.”

For Poretti, his list of illnesses only grew throughout the COVID-19 pandemic.

Before pandemic-imposed isolation ensued in March 2021, Poretti attended art classes at a local community college in Seattle. The painting was therapeutic, and he considered the other students his closest friends.

But when in-person sessions halted, Poretti lost contact with his sole support system. He ended up in the emergency room five weeks later, then six more times in the next year.

Problems with current interventions

The field of suicidology — the scientific study of suicidal behavior and suicide prevention — has only taken off in the last few decades.

Wood says that historically, the field has relied on “heavy interventions.” This includes constant scrutiny, physical restraints on patients, and an unending list of prescription pills, often leaving patients feeling isolated or emotionally disjointed.

Because of this, relying solely on these types of clinical practices can feel antithetical to preventing suicidality, a condition tied heavily to feelings of loneliness.

How Caring Contacts Changes These Processes

Like many patients and healthcare providers, Poretti refers to suicide as a “death of despair.”

He describes his worst moments as a flash flood of emotions barreling into a complete disconnect from the world.

“Suicidal people experience a profound sense of disconnection even when they do, in fact, have people in their lives,” says Amanda H. Kerbrat, LICSW and research scientist at the Center for Suicide Prevention and Recovery (CSPAR) in the University of Washington’s Department of Psychiatry and Behavioral Sciences.

Feelings of social isolation have long been recognized as a primary risk factor associated with suicidal outcomes. This is what Caring Contacts — the suicide prevention model that inspired the letter sent to Poretti — is attempting to address.

Pioneered by psychiatrist Jerome Motto in the 1970s, Caring Contacts involves a healthcare provider periodically reaching out to suicidal individuals with nondemanding expressions of concern, support, and interest.

There are three core principles:

• Contact is first initiated by the provider, not the patient.
• Messages should be sent multiple times over the course of a year or longer.
• Most importantly, continued contact is not contingent on the recipient’s response — regardless of whether a patient replies to the first message, they receive a second.

By communicating care and concern without demanding anything in return, the messages can help people survive the two-year period following a psychiatric crisis when they are most likely to take their lives.

The intervention is the only approach shown to prevent deaths by suicide in randomized clinical trials. Other studies have found that Caring Contacts also reduces hospitalizations, suicidal ideation, and suicide attempts.

Results of Caring Contacts ignored

The simplicity of the Caring Contacts model has been seen as a negative attribute, with many questioning how sending out a few letters could make a difference.

“Because suicide and loneliness are these complex, distressing phenomena, most people think suicide prevention has to involve overly complex, heavy interventions too,” says Wood.

Despite its proven efficacy, the model has been met with apathy. Motto’s follow-up study, which showed that participants had lower suicide rates for years even after the letters ceased, was also largely ignored.

Kerbrat, who later published a study with 658 active-duty military personnel ultimately proving the skepticism wrong, recalls similar indifference from agencies who wouldn’t fund CSPAR’s research in the early 2000s

“A very typical response at the time was disbelief that simply sending someone letters that were brief and didn’t have significant content could have a suicide prevention effect,” Kerbrat says.

Questions Around Process

In Fargo, North Dakota, a suicide prevention task force at Sanford Health instituted a two-year pilot initiative to answer outstanding logistical questions around the program, such as methods for patient selection and content of the messages.

Within the pilot program, any patient discharged from the clinic’s primary care department or emergency room with a diagnosis of suicidality received a follow-up message within 72 hours, allowing them to opt into Caring Contacts.

The 19 patients who completed the year-long program reported significant improvements on the Social Connectedness Scale, which measures perceived feelings of social belonging, support, and inclusion.

Larissa Marsh, LMSW and integrated health therapist and licensed master social worker at Sanford Health, hand-wrote the cards. She and Arlene Wilken, a member of the suicide prevention task force whose husband took his life in 2014, carefully developed each message.

As Marsh explains, the messages “de-sterilize” the patient-clinician encounter, letting patients know they’re cared for even after their appointment ends. Patients are treated as more than a composite of X-Rays or lab results — they’re treated as people.

Caring Contacts acts as a supplement to long-term treatments rather than a substitute, leading patients to be more likely to return to a clinic for follow-up care or proactively seek treatment if suicidal ideation recurs.

Jeffrey Leichter, PhD, LP, a licensed psychologist and lead administrator for behavioral health integration at Sanford Health, adds that the program has immense benefits for the clinic’s geographically scattered patients.

“As a group, people in rural communities wait much longer to seek mental health care than people in urban communities because there’s a fear of thinking others will believe there’s something unchangeably wrong with them.”

Leichter emphasized the importance of mental health being seen as health.“I know it sounds like unicorns and rainbows, but the letters help eliminate those very arbitrary silos that you either have a physical health problem or a mental health problem.”

Outside of Fargo, large-scale implementation of these programs have proven feasible too.

The U.S. Department of Veterans Affairs and a research team at the Boston University School of Public Health recently published findings on the Caring Letters project, in which veterans who contacted the VA’s Crisis Line received follow-up letters from peer veterans and volunteer health providers.

In the first 12 months, 543,353 letters were mailed to more than 100,000 veterans.

Although the precise components of Caring Contacts are tweaked across settings, patient testimonies echo similar sentiments in each iteration:

“I didn’t realize people cared about me in this way.”

“These letters help pull me out of the darkness.”

“I remember at the beginning of my crisis, within 10 days I received a notice (Caring Letter)… And I wasn’t able to slip through the cracks. I was immediately able to seek out resources.”

“I felt refreshed that my life does have meaning.”

Some patients described mending relationships with their previously estranged family and friends, motivated by a newfound sense of social connection.

In other words: it’s less of a silver bullet and more of a silver lining in suicide prevention.

Takeaway

Over the past several decades, projects and initiatives to address the connection between loneliness and suicidality have been addressed through variations of the Caring Contacts program.

Over 9 months, Poretti has received six letters as part of his clinic’s Caring Contacts program, and he saved all of them.

When he reads the letters, he’s not just someone who starts each day with three different antipsychotic drugs. He’s someone who recites whole episodes of Spongebob Squarepants with his nephew, who loves making pottery, and enjoys painting with watercolors.

On his bad days, Poretti unearths the postcards from his nightstand, and they help him feel like more than a patient. “Like a whole person,” Poretti says.