When Young People Need Support: Conversations That Matter with Dr. Melissa Dundas
Episode Description:
In this episode, Dr. Tony Pisani, Kristina Mossgraber, and Dr. Melissa Dundas discuss the critical role primary care providers play in youth suicide prevention. They share personal insights, professional experiences, and practical strategies to support young people beyond just referrals to mental health services.
They cover how to build trust with youth, recognize warning signs, and create a culture of safety within healthcare settings and communities. Whether you're a clinician, educator, parent, or caregiver, this conversation offers valuable takeaways for fostering connection and providing effective support.
Key Topics:
- The Role of Primary Care in Suicide Prevention
- Building Trust with Youth
- The Challenges of Screening and Assessment
- Addressing Means Safety and Foreseeable Changes
- Supporting Families and Caregivers
- Cultural Sensitivity in Mental Health Conversations
- Resources for Continued Learning
Note: This episode was originally released in 2023 through a collaboration with Aetna as “Practical Advice About Youth Suicide Prevention in Primary Care”. We loved this chat with Dr Dundas so much we wanted to share it again with our Never the Same Audience.
Guest:
- Kristina Mossgraber is a suicide prevention advocate with lived experience and part of SafeSide’s faculty, dedicated to improving support systems for those struggling with mental health.
- Dr. Melissa Dundas is a pediatrician and adolescent medicine specialist passionate about integrating mental health support into primary care.
Host:
- Dr. Tony Pisani: Dr. Tony Pisani is a professor, clinician, and founder of SafeSide Prevention, leading its mission to build safer, more connected military, health, education, and workplace communities.
Referenced Resources
Transcript
Tony: Welcome to Never the Same. Today, we're bringing back a conversation that's especially meaningful to me. One we recorded in partnership with Aetna CVS Health before starting the Never the Same podcast. The discussion features Dr. Melissa Dundas, a pediatrician and adolescent medicine specialist whose approach to youth mental health is both practical and deeply compassionate. You'll hear right away why I wish she could be everyone's doctor. She has this wonderful way of making people feel heard and understood that we all can learn from. Whether we interact with young people at work or at home. Joining me for this interview is Kristina Zurich, then Mossgraber, Safe Side Prevention's Lived Experience Lead. Though recorded earlier, the insights and strategies discussed here are as relevant as ever. Here's our conversation.
Melissa: Well, thank you both. Oh, everyone so much for having me here. Um, it's been really interesting journey be able to become involved with suicide prevention. Um, as a pediatrician and adolescent medicine specialist, part of our formal training doesn't encompass suicide prevention and really how to ask those questions, how to format visits, how to support patients and their caregivers. And so while I was a fellow at the University of Rochester, um, Tony had actually found me and we collaborated on a previous project, which actually gave me more education with regards to this area. I would say the number one thing is to actually really establish rapport with you. Um, it might be an area that they're not comfortable speaking about, they've been told not to talk about it. Um, and when we come, when they come into our space, we really want to center them and let them know, like, this is your space. This is your journey, I'm here to listen and then build that form of trust with them. And then it just gives them that opportunity to really be able to, to discuss what's going on.
Tony: Yeah. And I think that that can be really hard. Uh, you know, when, when you're asking these kinds of, of questions, I mean, you know, Melissa, you ask all kinds of questions of youth that are, that are uncomfortable, you know, I'm sure. Um, but they're all uncomfortable in a different way. You know, um, for this one, I mean, I can share some ideas, but I'm just wondering what your thoughts are about, like, what, how do you address this particular topic? Maybe, maybe how you, um, Would typically bring it up and we can then chime in on our thoughts.
Melissa: No, absolutely. So I tend to use what I call a graduation process. So I start off with saying, how are you today? How are you the last couple of days? How have you felt the last couple of weeks? And so it's not this. Right off the bat asking them, Are you having thoughts about wanting to end your life? Are you having suicidal thoughts? Because with teens and youth that might come off as too much to start off. Um, and they may not feel like they can connect with you. So I like to start just very soft with them and then lead into that specific question.
Tony: That's really interesting. I think that's true of adults to actually some. I think it depends upon our own comfort. Like some, some um, you know, some providers need more of a ramp in just to feel comfortable bringing it up. And then some, and some patients need more of a ramp in, um, even when somebody is coming already, maybe expressing other kinds of distress or depression. One, one phrase I sometimes say, well, you know, how bad has it gotten? And then maybe asking, has it ever gotten so bad that you've actually thought about ending your life? Uh, and, and, and moving it into that way that it makes the question kind of a pain thermometer question I'm under, I'm expressing by the way I'm asking it, I'm telling you I understand that suicide is about things feeling really, really bad. This isn't just a question I'm asking for me. This is a question because I want to know your experience.
Kristina: Yeah, I would, I mean, I definitely, it's interesting because, you know, from my perspective of both working with folks and, you know, being a patient or a former patient, you know, myself, I even think about with my primary care physician who got to know me really well, that even when I knew she had to ask about it, I would get anxious. I could feel myself even with relationship we had, you know, you just, it's, it's a, it's an uncomfortable topic. Um, even living in this space, it can be really, really tough, you know, what,
Tony: What, what was, what would make you feel nervous? Like it could get? Yeah.
Kristina: Yeah. You know, it's interesting is just, um, I think, and it's, it's, it's not that way anymore. It's dissipated, you know? Um, but I think especially when I was earlier in my recovery or when I, I think I felt very vulnerable. Um, and I think whenever we feel vulnerable, things can feel a little bit scary. And I, I, I think I just felt that feeling of like almost, oh gosh, what if I say the wrong thing when she asks? And I think a lot of times, especially with our youth too, they're worried about what if I say the wrong thing, what's going to happen?
Tony: Right. Who's going to know? Is this going to get, is this going to get out of my hands? Yep. Exactly. Because we do, we have a, and we have a system where that's a legitimate concern, right? And sometimes with good and important reasons, we need to take steps that are, you know, more. Kind of increasing the intensity. Um, but other times there's also times where maybe we didn't need to, but people do move to coercive kinds of things and getting emergency kinds of services involved when maybe that could have been handled another way, if the person felt more skilled and confident in being able to understand and respond both, both parts of that?
Melissa: That's particularly important with youth as well, because some youth may not understand the true definition of suicide. And so some individuals, if they're having a really tough day, may make comments that allude to that, but that's not actually what they're thinking of doing. And so. That's why, you know, from my perspective, doing that gradual process gives the youth an opportunity to explain truly how they're feeling. So again, you don't get all of these emergency services involved right there and then, that can spook the child, they lose trust in us, never talk to us ever again.
Tony: That's a really interesting part, especially with, much younger, much younger kids. And so what we've been seeing over the past several years is, you know, ages of kids that we previously would have said, well, suicide is, almost never happens. We're starting to see, unfortunately, in the youngest cohort of kids, those rates going up and, uh, actually have a colleague at the University of Rochester, Ariel Sheftal, who is specifically focusing on these younger because we know very little about those youngest, um, those, those youngest, um, um, really children, you know, but younger than 12 years old, even, um, who are really expressing these kinds of things. Yeah, and she's especially focused on, uh, black children and youth, where we, where the research is even less. So she's really focused on a, on a kind of a doubly important area. You know, when it comes to the, you know, kind of asking those questions, uh, we've made a lot of progress in our field, uh, in instituting standardized screening. Um, and I think it's hard to talk about connection without talking about how does screening occur and how does it go wrong? Uh, what are what you all, you know, what your kind of experiences are with that, you know, you know, screening is, I mean, it's helpful if we don't have as part of our routines asking these questions, we're all going to avoid that. Sure. But, uh, what maybe what are some of the things that we can think of to make sure that it doesn't that it goes that's helpful and not harmful,
Kristina: Right. Um, I'll just, I'll jump in Melissa, if that's okay. Absolutely. Yeah. So, um, you know, as you're saying that Tony, all I can think about is, you know, having been in an office where someone is, you know, clearly they're reading the questions off the screen or knows them by heart and it's just sort of typing them in and, and there's no response. And I'm like, well, I don't, I'm not sure why you're even asking other than you have to. Right. And when you feel like someone's just asking, cause they, they have to, you're less likely to be honest and forthcoming because you don't feel a connection and you don't feel that they're actually really listening. I, I, you know, I, it's funny because I'm, you know, I'm, I'm an adult clearly, um, but I also have a, you know, a, a mischievous like teenage side still about me, of course. Yeah. Not me, never. Um, and every once in a while when that used to happen, um, I'd be tempted to give, you know, kind of a, an off the wall answer just to see if they'd even look up. I know, that's my mischievous, you know, like, kiddo-side still, um, but you know, it's, it's funny because for me, I was thinking like, I wonder what would happen if I said something silly? Not something to scare them. Not something, you know, and I was always honest, but um, but it's interesting that sometimes that's what our brain does, is it's just, I think for me, it was also trying to protect myself. Um, yeah.
Tony: It's hard, because there are, especially in primary care, there are a thousand times a thousand requirements. Whenever, whenever we don't know where to put something in public health, the first place we look is in Primary Care because it's a place where we can access people, and so sure, it's understandable that it could say, but I think, I think sometimes we have to, we have to sort of like say, okay, in this very long list of things that that we have to go through in a, in, you know, a flow chart of a medical record. What are the things that can go fast? And what are the things that do need that, that few extra, extra seconds or minutes to talk about? Or what are your, what do you think, Melissa?
Melissa: Yeah, no, definitely. Um, it is more common than I think we talk about where youth in particular are may feel this inclination to not be honest with the first person who asked a set of questions. Um, and typically that ends up being on an individual who may not be the medical person in the clinic, and then they get into our exam room. And then we ask those questions again. And so a lot of us outpatient and primary care are striving to educate everybody along that pathway. So they learn how to ask those questions, even like your tone of voice can make a huge difference to right? And just your body language, Kristina, you had alluded to, like, if we're sitting there, just typing and asking these really sensitive questions. You know, if I was in that position, I probably wouldn't be inclined to answer them, honestly, too. So voice, intonation, intention, body language, all of that really plays into whether or not a child, a teen, a youth is going to be, is going to feel really forthcoming in that measure. But we do see that, though.
Kristina: Yeah.
Tony: I mean, one way while keeping the pace that really needs to happen, one way to convey, you know, let's say a nurse is rooming a patient within, uh, healthcare setting, um, one way to do that is to, is to maybe a short preface to the, to the question saying, saying something like, um, you know, our, our whole team cares about your whole health. And I want to ask you something, cause we really want to understand your experiences. Uh, so I'm going to ask you a couple of questions that may be sensitive, but we really want to know, and then go into it. Now, I don't know. I didn't, you know, kind of check the time on that. It's probably 10 or 15 extra seconds? And that's not nothing when you have a lot of things to cover, but I think, you know, I think as a health care, we have to decide could it, might that be worth those extra seconds to get, you know, even if we only got 10 percent or 15 percent more openness, more people who weren't saying who do, I think the cost benefit of an extra sentence or two might, might pay off.
Melissa: 100%. I would even go as far as saying that it could be lifesaving, right? Which is the goal of all of this.
Kristina: Oh, absolutely. Yeah. It sounds a lot better just, you know, to reflect on that. It sounds a lot better than I have to ask you these questions. Yeah. You know, there was one more sentence you added and it just sounds so much more inviting and caring and, you know, genuine!
Tony: Actually, Pedro. Could you, um, pull up the clip, uh, that we have of a nurse, uh, in a primary care setting, in a telehealth setting, uh, asking this question and kind of bringing it up?
Kristina: Keyla, a nurse in a primary care practice, is talking with Ms. Calderon, who scheduled a telehealth appointment as a follow up from a previous visit. In this practice, all patients are screened for a variety of physical and mental health concerns, including for suicide risk. Keyla has already asked some of those questions and is getting ready to ask Ms. Calderon about suicide. Knowing that these are sensitive questions, Keyla has asked Ms. Calderon if she has privacy to answer those questions and to let her know if that changes. Watch for how Keyla asks with the goal of connecting and better understanding Ms. Calderon's experiences.
Keyla: I'm glad your sinuses are better, but I'm sorry you haven't been able to sleep well. I'll make a note to the doctor. So as you know, we care about every aspect of your health, including your emotional health. Are you okay if I ask you some questions? Okay. So the first question is, in the past few weeks, have you wished you were dead?
Tony: So a couple things there, right? So one thing we didn't talk about before was asking if the person's in a private place. I think, you know, in a telehealth setting, you know, that's really, really key. Um, and, and then. Also asking permission invitation.
Kristina: what I noticed, too.
Tony: Yeah, of course, the first objection like you're going to hear is like, well, what if she says no, you know, um, and you know, I think that's that it's like, but we have to ask. So what if she says no, right? But, um, that objection comes from kind of a funny place and I think it's sometimes we've been so trained to think a certain way about information that we forget that the validity of the information actually matters. Not just the getting it. Because, if she says no, first of all, that's important information and that can be followed up on by itself, right? was not willing to answer these questions about suicide. Okay. Um, that tells us something and we can, we already know more than we would have if we just ask questions and then she didn't feel like, yeah, but, but also, if somebody is telling you no, then if you had asked them, they probably weren't going to tell you the truth. And so what's the point of having, we have to remember that the point of asking is to get data, and it's only good, it's only good to get data if it's good data. Uh, and, and so that's, uh, I think pretty key in keeping that, uh, that, the connection is important for connection itself, but also, kind of like you said before, Melissa, it's also important for getting kind of valid and, and, and, and reliable information.
Melissa: For sure. I just like, I love that, ask for an invitation into that patient space. Right? So it goes along with asking permission. Can I ask these questions? Youth are very susceptible to that too. Like they have their own confines, they have that own space that they protect too. And so extending that invi or asking them for that invitation is just as important in pediatric care as it is in adult care, that as we saw in that video.
Tony: For sure. I think that one more thing that we can say about this kind of connection thing that, uh, that we've been kind of talking about is, um, if we remember that when we're, we use the word assessment, uh, a lot and, and in, um, I think in the context of, of suicide assessment, really, you could almost replace, like, find and replace that word, with the word understanding. So, if I say I want to assess, I want to 'understand' a person's experience, not assess for a set of thoughts. And if we change it like that, and we talk like that, you know, and even so, there's a set of questions I'd like to ask you to help me understand. people want to be understood, not everybody wants to be assessed. That's right.
Kristina: Yeah, that's
Tony: 100%. They probably really don't want to be risk assessed, right? I'd like to assess your risk now. You know, it's kind of like, oh, is this going to hurt? Uh, but, uh, it is, is, you know, but, but, but most people do, if you say you want to understand them, I'm, I'm, I'm up for that.
Kristina: For sure. I mean, it's something it's, I use the phrase, help me understand. I can't tell you how many times a day in so many ways, you know, cause if you just think about it like in professional space and you know, you think about it to your point of people want to be understood and it's amazing how much more genuine, accurate information you can get when instead of perhaps going into a space of judgment or into a space of reactivity, um, maybe you just, you know, lead with, help me understand, you know, tell me more about that, right? And
Tony: yeah,
Kristina: you know,
Tony: no. It's really good. So it is something that's a probably a generally good skill. And then it's like critical when it comes to something that people really don't want to say.
Kristina: For sure.
Tony: Right. And this, and this is, this can be, can be one of those.
Kristina: Yeah.
Tony: Well, I think we want to talk about that. We know in what setting will make a difference. And I think here are our context, you know, talking with you here, Melissa is in primary care or at least health care. In your case, you work mostly in adolescent medicine, but I know you've done a lot of work in primary pediatrics as well. Um, I think the first thing to say about what to do is, um, is to remember that the set of options are more than a mental health referral. A lot of times primary care, uh, professionals have been referred to as gatekeepers, right? Really don't like that. I mean, it's fine. It's not like the word police. It's not so much the word, but I think the idea is like, they're a gatekeeper to a mental health referral. Now, first of all, you don't want to be a gatekeeper. You want to be a gate opener or whatever, but even that it's it makes it seem like your whole role is to identify and refer. Now, a referral is important and but it's not the only thing that, the only helpful and potentially life affirming thing that a primary care professional can do.
Melissa: Oh, absolutely. And we have to remember too, that like not all areas have access to mental health providers, referral resources. And so in primary care, oftentimes, we are the first stop for somebody. And so when we think about what those next stops are, when an individual does endorse suicidal thoughts, wanting to harm themselves. The first question we ask is, well, how do you feel right now? Do you feel safe in this moment? Second thing we try to do in pediatrics is, who do you feel safe talking to? So thank you for like involving me, but whoever you live with, is there somebody at home that you feel comfortable talking to them about? And then the next piece is, well, because you are a minor, you know, I do have to share this information with the person that loves you so much at home. How do you want to do this? How do you want us to share that information? And I use the term "us" so that kids don't feel alone in that process. And then once we invite whoever that loving human being is at their home is talk about, can you keep them safe at home right now? What supports do you feel like you need? And then I will help connect you to those resources. And so it's not just a matter of us as the provider saying. You've told me this, now I'm gonna open the gate and tell you where to go. Let me understand you, not just as the individual human you are, but as the context and the group and the home that you reside within. And what does the whole context of that living situation need and figuring out what to do next.
Tony: And, and, and, you know, for some people where the home is not as safer place, mm-hmm there's other people in the community, you know, schools, teachers, and we can expand what we, you know, kind of what we're doing by supports. Um, yeah. So, and, you know, even, you know, so you mentioned not everywhere has like access and availability to mental health, that's true. But even where there is access and availability, yeah, there's not, people don't, many people don't want to go. And if they do, it's often for a short time. Uh, and so. It is. Um, we can't have our entire strategy for suicide prevention when somebody presents in primary care rely on that. Because no matter how, first of all, there's probably never gonna be enough behavioral health professionals to serve every single community, but even if there was, people are usually in care for a pretty short time. Mm-hmm. Um, and, and, but they remain in primary care, so mm-hmm. Maybe they've gone and, and ho hopefully if the. If if if us as behavioral health providers have done our job right, we've communicated back and we're working in close collaborations in some cases and more and more, there's actual co location and integration, especially in more urban or metropolitan areas, that's great. But usually that will be for a short part. So what so what can do, so I think referring and also knowing where to refer in some where it's available. There are more evidence based suicide specific treatments than we've ever had before. There's more research about that. And maybe in a different conversation, we can go into more depth about those. But second, there are things that that you can say and do that provide that support. And I think some of the things that you just shared were like, you were, you were speaking in a very collaborative way. Um, you know, you're, and I think another one can be to help the young person make sense of suicidal thoughts because not everybody knows that, you know, it's not that uncommon to have those thoughts and it doesn't mean you have to act on them. Right? So it's not uncommon when you're going through those kinds of things. Okay. That might have thoughts like that. And, um, you know, that's I, I, I'm, I can hear that. And, and, um, and it's, it's an important signal for us to listen to because it means things are really, things are really bad. Things are hurt. Things are really hurting. Um, But it doesn't mean that you have to do that or that you will do that. Um, and, you know, we're going to do whatever we can as a team to help you, you know, not just it. Yeah. Not kill yourself. But you know, but we're gonna do everything we can as a team so that you don't feel like you want to do that. Um, and and and another thing. So that's one is to help make sense of that. Understand that it's normal. But I think another is to offer the possibility that, it actually can get better. Uh, we do know we have quite a bit of research to say that if people engage, especially young people, engage with our teams and the kind of supports that we have and give it time, um, which can include a whole, you know, panoply of different kinds of treatments and interventions, engage with it, with, with adults that they know, they can feel better. I mean, I can tell you. You know, many examples of that from from my own life and practice, and I can also show you a lot of research that shows people do get better. So, but we don't always let we don't always let kids know that, um, you gotta be careful because, you know, you don't want to, you know, say something that just feels like totally impossible to somebody sometimes. But I think I don't think that I think sometimes we're so concerned about over promising. That we don't show any hope.
Kristina: Hmm. That's interesting. I think, you know, it's interesting to hear you, um, to say, and every time I hear you say, and every time I hear, you know, people say it, that, um, you know, I know that it's not uncommon for people to have thoughts of suicide, especially when they're struggling, their brain is in so much pain, and, and when I share that with people, the, the. people's like, wait, what? That's, you know, it's, it's, it's often surprising for people. Um, and it, um, you know, it helps kind of normalize the conversation when I'm having it with someone. Because they've been alone, like kind of alone in it. And just thinking it's just me. Exactly. They've been alone in it thinking it's just them. And then thinking if they talked about it immediately, there would be a transport, there'd be intervention, there'd be, you know, EMS involved. And it would, it would escalate to, you know, a pretty traumatic situation. Um, but just to hear like, wow. Again, you know, with everything going on in your life, it's, it's not uncommon to have those thoughts, but you know, it's an indicator to us that it's time to dig a little deeper and understand what might be going on. So you start feeling better.
Tony: Yeah.
Kristina: Yeah.
Tony: Yeah. And then, and then I think, you know, we can, in addition to saying those helpful things, you know, normalizing how people put it into context, offering some hope, those kinds of things, then there's also plans that we can make and that don't take a behavioral health specialist to do. Um, but so making plans for a person's safety now. There are different levels of doing that,
Kristina: right?
Tony: There is an evidence based intervention called the safety planning intervention, um, that has several steps to it, includes kind of following up on those, um, on these plans, helping a person identify their warning signs, things they can do to distract themselves, people they can go to. Um, and sometimes in a primary care setting that. Or certainly an Emergency Department setting, it can be challenging to with time to do all of those steps. Uh, we want to aim toward that, and it might be that you have to sort of say, hey, you know, we can just get started on this today. But I'd like you to come back on Tuesday, um, and keep going with this. Like, I guess there's a couple things, though, that I, I would say, and I'm wondering what you, you know, kind of what your common practice is with this, Melissa? There's a couple of things that I would say would be kind of first on the list to do. Um, even if you can't, you know, kind of go through an entire safety planning process or maybe you don't yet have all of the training and skills or personnel to do that. Um, yeah, I don't know what, what would you, but maybe I could just ask, you know, kind of what, what's your practice in your setting? And then I can share what, what, what suggestions they have for like, okay, if you could just do two things, what would they would be?
Melissa: Absolutely. Um, so I can approach this from two very different points of view, like one, having, you know, at one point in my life worked in a community hospital where, you know, we would schedule more close follow up and do like some of those smaller portions to keep somebody safe versus being at an academic center where I do have access to social work in my clinic, I do have access to a psychologist who can be readily available once that assessment that humanism, that rapport has been built. To help coordinate what those next steps could be. But initially, what I would do with, you know, if I had a youth or a teenager in front of me, um, is that I would again, just understand the degree of safety concerns in that moment. Do they have access to our clinic numbers? So they can call us even after hours if they're going through a period of distress. Do they have access to other national phone lines? And do they have the ability to come back in a couple of days for a quick check in? So I think those two things are like the simplest things that we can do that are actually really life saving in that moment. If we don't have extra things that we can provide them with.
Tony: I love that. Um, I guess what I might add to that, is, um, addressing Means Safety and trying to find out what are one or two things that could happen in the person's life, that could really send them for a loop? So in our framework, we call those Foreseeable Changes and, um, in the, um, in the, in the notes to this episode, we can provide some additional links about this. And in fact, we can include, uh, like a brief kind of four minute, uh, training and how to, how to, how to identify these and use them. Um, we can include a link there, but. The idea behind Foreseeable Changes is that, um, before the person leaves, I really would like to know, you know, maybe from the, from, from, from the young person, from a family member, what would you say? What are like a couple of things that if that happened, you would think? Oh, no, I'm really worried about my daughter or like, oh, no. Um, and, and, and finding out what those couple of, "oh, no" things. And then you can, then that can let you take the conversation to the next level. How likely are those to happen between now and Tuesday? Uh, when you're going to be coming back, you know, and is this something that's likely or not or unlikely? Would we know if it happened or would we not? Those are the kinds of things that can now get us into very concrete. So it's not sort of just okay, you know, what's a sign that you would know you were feeling bad? Well, those are those are good to do, but but they're kind of more general. This is like really nitty gritty. What could happen that could really throw you off? And once you know that about a person, you can then begin to inquire about how predictable, how much visibility, how likely, and how soon is it to happen? And then I think the other, uh, in addition to identifying those Foreseeable Changes, as we call them, is addressing, uh, Means Safety. And what that refers to is, uh, to the extent that we can, uh, trying to put distance between the person and the means that they might use to, uh, to kill themselves. Yeah. And the, the way I think about that is, is I'm, I'm looking in two places, one, any means that this person has specifically mentioned before, and then two, any that are more common for that particular age group or culture. Um, and so, so I might kind of think about those two things in terms of addressing those, um, because I would say of, of, of all the different public health interventions that we've had in, in suicide prevention, reducing access to the means when somebody is in the heat of that, that kind of suicidal crisis, putting some distance between them and those means, um, is, uh, is, is probably the most, the most effective one. And, um, you know, we can't talk about that without talking about um, firearm safety, which, you know, pediatricians have really led the way in, um, uh, which, you know, which really just, which really means that, that, that, uh, really figuring out how can we keep, uh, uh, firearms in a safe location if you have them in your home, uh, and assume that the first two ways you would think of it, the young person has already figured out, uh, and then kind of go, kind of go from there. Um, and it's, you know, this is not to say anything about, you know, firearms in the home or any of that, but it's just that we know statistically, that that can make a suicide more likely. Uh, uh, so, so if, if, if you have a young person at risk, that's a really dangerous combination, so you just want to think it through and then, you know, kind of a couple of levels, a couple of levels down. And I was just mentioning about, about different, um, age groups and cultures, and that, that might be maybe a, a, a final really important topic. I know we only have a bit. More time together today, Melissa and Kristina, I wonder if we if we should talk a little bit about that? Um, it's incredibly important, um, about how do we address these concerns, um, in a variety of different, of course, can't cover every possible cultural group, but maybe just some that we work with, um, you know, what are the things that have to, that sometimes need to be adjusted? Um, and how do we work with family members, uh, from different cultures? And Melissa, I know that you're, um, You're there in New York City and, and, uh, here in Rochester, we've got plenty of, you know, diversity as well, but I mean, you're really in the heart of migration, you know, immigration and all kinds of different melodies of culture. So I wonder what your experiences are in that regard?
Melissa: No, definitely. I do want to like say that it is actually such a privilege to be amongst so many different cultures, um, because that helps really educate clinicians in terms of how to just be even more generalizable and be able to connect with a multitude of different individuals from different backgrounds. Um, but I would say from experience, the most important part is to understand, like understand what is somebody else's understanding of suicide and mental health. Right. I never want to assume that somebody who has recently immigrated here for whatever reason, that we share the same understanding or the same context of what that means. And so again, that's like another invitation to say, hey, can we talk about this? The next part that we really try to do is to destigmatize it and say that, you know, we don't really talk about it. I can say in my Caribbean culture, it's still very taboo to talk about suicide and mental health, but really saying that it's something that everybody from all shapes, sizes, gender, sexualities, races experience. So how can I help you feel comfortable in this space so that we can talk about it together? And there's no judgment here. But you have to approach it with a sense of you can't paint everybody with the same brush. And once you can actually put yourself into that position, then it's actually quite, um, I wouldn't say easy, but it opens up that conversation to speak with individuals cross- culturally and be able to treat everybody with the standard of care.
Tony: You mentioned that they're not to assume that you have the same understanding, um, probably true even within the same culture, but it's especially true, across cultures. I was wondering in your in your experience, what are some of a couple of areas where you've noticed there is that difference or disconnect?
Melissa: Absolutely. So individuals perceptions of struggle. So I've often encountered differences where, let's say I'm working with a family that may have been born and raised in the United States. They're from an affluent community. The child has everything they could possibly want. And the parents are thinking, well, my child can't possibly be having these thoughts or can't possibly be suicidal because they have everything under the sun. And it's so it's navigating that discourse and saying, well, sure, everybody can have all of these superficial things, but there's a disconnect somewhere for your child where they are suffering and it's okay to acknowledge that. And then there's other situations where, you know, with some of our migrant families who have really seen a lot more than any of us may see in our lifetime, may see that as the ultimate struggle and not necessarily the mental health component that either was there before, during that or has resulted because of that, um, what they've gone through. And so it's really showing that, irrespective of what your background is, this perception of, oh, this is a great struggle or there's no struggle, folks can still be struggling with suicidal thoughts, irrespective of those differences. And it's how do we bridge that to say those things actually, at the end of the day, don't matter. It's the individual person and their own internal struggle that we have to center in those conversations.
Tony: Yeah, you know, that, that actually makes me think of, um, another, you know, kind of reaction that people sometimes have, especially in, in very close knit families where, where, where the top or cultures where, where, um, where the ties and like kind of reciprocal ties and bonds are, are very important. Um, I would actually even say that's, in my own, like kind of Italian American family, that's, that's true. Um, and it's probably true in other others as well, but I, I find myself sometimes having that same reaction. Um, like when, when, um, like if somebody in my extended family is struggling, I'm, my first thought is like, well, how could they do that to their. parents or how could they do that to their sisters,
Kristina: Mm.
Tony: you know, like, um, and here I am like, you know, I'm supposed to be the, you know, Psychologist. I'm so open, oh yeah, great, you know, this sister, you know, uh, he's gonna, gonna be there for people. But, but my, but within the context of my own family, I sometimes have that kind of thing like, how could you or how could you say that? I mean, so, so I have a lot of, I have a lot of, um, sympathy when I guess empathy and identity or resonance with when, when, when, when a parent's first reaction is, how could you think that? You know, uh, you know, I, I get that, um, you know, and we have to work with it to not even though I also another part of me cringes, cause it's like, it's going to totally shut the young person down, but I also really understand it. And I think it's, I think that's, it is a key to working with parents and families if, if, cause I think sometimes those of us who work with. with children and youth, we do that because we really like them, you know, and sometimes I have seen in some settings where you can get to this place where like, the kids the hero and the family is the villain. Um, and you know, I think it's a really important to avoid that. And I mean, the way you spoke before really avoids that. And I think that can be that can be really key to just realize like, you know, it's, it's not that easy, it's pretty hard to be a parent. It's pretty hard to support, um, people who are struggling. We have a member of our team who, uh, is, is a family carer. She's, she cared for her brother for a couple of decades with lots of, with suicide, mental health, substance use concerns. It's really hard. Um, and I think, I think we can, I think if we go into those interactions, sort of remembering that, and then even though we probably, in, in, in pediatrics or child psychology, we tend to like, you know, we, we were on the side of the, of the, of the kid. That's why we, why we love this. Um, yeah, just making really sure that, that we, we don't even in our minds kind of pit one against the other and, and, and, and, uh, and, and realize that adults, at least in general, are more likely to be supports, even if they're not perfect. Even if they say things like I do, um, can still be, can still be a valuable resource.
Melissa: No, definitely. And I think to your point there, Tony, um, we're all human at the end of the day, right? And that's why we all are, we're lifelong learners, right? Um, and as long as we recognize that, you know, we, we can have tendencies like that. Um, we can act on them. Right? One thing I have particularly found helpful with parents to kind of in that situation where some parents will be like, why is my child doing this to me? It's it's gently reminding folks that the child isn't choosing this and isn't choosing to feel this way. This isn't a choice, right? And at the end of the day, no toddler, well, toddlers can be savage at times, but no toddler, adolescent, youth, young adult wants to upset their parents. No one like no child wants to deliberately disappoint their parents. And I think when parents hear that, they really understand like, okay, my child is suffering. This has nothing to do with me. Let me recenter this on my kid and get them the help that they need. Um, and I think just like kind of helping reframe that helps the parent understand that like, this isn't a choice. This is no different than diabetes or cancer or any other really terrible medical condition. We have to treat this the same way.
Tony: Well, that seems like a good, I don't know if you had more to say. No, I just,
Kristina: I just wanted to, you know, I'm just going to kind of reflect on what you just said Melissa and what, you know, you've been saying Tony and, um, you know, I've spent a lot of time working with kids in schools and we would go, you know, through the warning signs, what to do. And, and inevitably there'd be a young person who would say, okay, I heard what you said, I tried talking to my parent or my guardian and they said, it's just teenage stuff. You're just making it up. It's, you're manipulative. You're, you know, cry for, people ask me all the time, do people talk about suicide as a cry for attention or a cry for help? And I said, yes, because they need help, right? Because they're hurting. And so I just really appreciate what, you know, what both of you are saying, but, um, just kind of looking at it through the lens of, especially our young people, they don't always have the language and the tools and the understanding to verbalize what it is they need when they're struggling, so sometimes these actions or behaviors that can be sometimes dismissed and misconstrued as behavioral or as, as, you know, being manipulative or this and that are just. Like human, we're humans and you know, trying to need some of this, so.
Tony: Yeah, and I think that brings us full circle to why you know a Primary Care professional is not just a gatekeeper. That's right, because it doesn't it doesn't take a mental health professional to listen understand and be a different, then maybe even sometimes a parent, can be. Um, and you can provide people with a different experience and that's not nothing. Yeah. Uh, might feel like something like what can I offer? I'm not trained in this. What can I offer? You have a lot to offer. You have a lot to offer. A lot to offer. Right. Very true. And, uh, and I think that's, I think that's, That's, that's, uh, uh, you know, maybe an important note to end on that, that people across the healthcare spectrum, uh, have a lot to offer more than just identifying and referring. There are things that we can do and say and, and ways to listen that can really make a difference. So, Melissa, so thank you for, for having this conversation, Kristina, it's so great. It's so fun. I've learned a lot from this. Thank you.