Caring Contacts as Suicide Prevention Health ConditionsFeaturedBreast CancerIBD MigraineMultiple Sclerosis (MS)Rheumatoid ArthritisType 2 DiabetesSponsored TopicsArticlesAcid RefluxADHDAllergiesAlzheimer's & DementiaBipolar DisorderCancerCrohn's DiseaseChronic PainCold & FluCOPDDepressionFibromyalgiaHeart DiseaseHigh CholesterolHIVHypertensionIPFOsteoarthritisPsoriasisSkin Disorders and CareSTDsDiscoverWellness TopicsNutritionFitnessSkin CareSexual HealthWomen's HealthMental HealthSleepOriginal SeriesFresh Food FastDiagnosis DiariesYou’re Not AlonePresent TenseVideo SeriesYouth in FocusHealthy HarvestNo More SilenceFuture of HealthPlanHealth ChallengesMindful EatingSugar SavvyMove Your BodyGut HealthMood FoodsAlign Your SpineFind CarePrimary CareMental HealthOB-GYNDermatologistsNeurologistsCardiologistsOrthopedistsLifestyle QuizzesWeight ManagementAm I Depressed? A Quiz for TeensAre You a Workaholic?How Well Do You Sleep?Tools & ResourcesHealth NewsFind a DietFind Healthy SnacksDrugs A-ZHealth A-ZConnectFind Your Bezzy CommunityBreast CancerInflammatory Bowel DiseasePsoriatic ArthritisMigraineMultiple SclerosisPsoriasisFollow us on social mediaShopProducts by ConditionInsomniaStress ReliefBack PainNeck PainSleep ApneaHot SleepersAllergiesPain ReliefProduct ReviewsVitamins & SupplementsSleepMental HealthNutritionAt-Home TestingCBDMen’s HealthWomen’s HealthHealth ConditionsDiscoverPlanConnectShopSubscribe

Send A Letter Save A Life Suicide Prevention Through Caring Contacts

Medically reviewed by Bethany Juby, PsyD — By Lucy Tu on October 3, 2022Share on PinterestHero Images/Offset ImagesOne week after his 13th emergency room visit, Tom Poretti, a 43-year-old veteran, received the nurse’s letter: “Dear Tom, this is Becca from the clinic,” the letter began. “I hope you are well and taking good care of yourself. We’re here if you need us.” The card ended with the ER’s phone number and the national suicide hotline. Poretti vaguely remembered signing a consent form to receive letters during his last hospital visit, but the postcard that arrived a week later still caught him by surprise. “The letter was the first message of real support that resonated since the pandemic started,” Poretti recalls. “It made me feel like someone was finally listening to me, looking out for me.”

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.

Suffering is a heavy burden to carry at times but you are never a burden for feeling it br

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.

Hi Tom it s Becca again I hope today is a wonderful day for you Your birthday is coming up and we re wishing you a great year If you ever need us we re here for you

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.

If you or someone you know needs help

Call 988 for the National Suicide Prevention Lifeline. You can also text HOME to 741-741 for free, 24-hour support from the Crisis Text Line. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources. Last medically reviewed on October 3, 2022

How we vetted this article

SourcesHistoryHealthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.Calati R, et al. (2018). Suicidal thoughts and behaviors and social isolation: A narrative review of the literature.
pubmed.ncbi.nlm.nih.gov/30445391/Carter GL. (2018). Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning.
cambridge.org/core/journals/the-british-journal-of-psychiatry/article/postcards-from-the-edge-24month-outcomes-of-a-randomised-controlled-trial-for-hospitaltreated-selfpoisoning/E1D8870B47A4562B7F352B26238BD659Centers for Disease Control and Prevention. (2022). Fact sheet: Facts about suicide. l
cdc.gov/suicide/facts/index.htmComtois KA. (2019). Effect of augmenting standard care for military personnel with brief caring text messages for suicide prevention.
jamanetwork.com/journals/jamapsychiatry/fullarticle/2723658Hassanian-Moghaddam H, et al. (2016). Postcards in Persia: A twelve to twenty-four month follow-up of a randomized controlled trial for hospital-treated deliberate self-poisoning.
tandfonline.com/doi/full/10.1080/13811118.2015.1004473Kerbrat AH. (2022). Personal interview.
Leichter J. (2022). Personal interview.
Marsh L. (2022). Personal interview.
Motto JA. (1976). Suicide prevention for high-risk persons who refuse treatment.
pubmed.ncbi.nlm.nih.gov/1023455/Motto JA, et al. (2001). A randomized controlled trial of postcrisis suicide prevention.
pubmed.ncbi.nlm.nih.gov/11376235/Porett T. (2022). Personal interview.
Reger MA, et al. (2022). Development of the veterans crisis line caring letters suicide prevention intervention.
onlinelibrary.wiley.com/doi/10.1111/1475-6773.13985Wilken A. (2022). Personal interview.
Wood T. (2022). Personal interview.
Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. Current Version Oct 3, 2022 By Lucy Tu Edited By Taneasha White Medically Reviewed By Bethany Juby, PsyD Copy Edited By Copy Editors Share this articleMedically reviewed by Bethany Juby, PsyD — By Lucy Tu on October 3, 2022

Read this next

Supporting a Child Whose Lost a Parent to Suicide The ways that surviving parents in the Black community can support themselves and their children after losing a loved one to suicide.READ MORELoneliness and Depression: What’s the Connection?Medically reviewed by Alex Klein, PsyD There’s no doubt that loneliness and depression share some kind of connection, but does one really lead to the other?READ MOREUnderstanding Suicidal Depression People may feel suicidal depression, though the clinical diagnosis is depression with suicidal thoughts. We explore what suicidal depression is and…READ MOREThe 988 Suicide Prevention Hotline Is Live, but Are Call Centers Prepared? The National Suicide Prevention Lifeline number became 988 on July 16 to make calling for help in a moment of crisis more accessible. The anticipated…READ MOREOnly 2% of Children Who Begin Gender-Affirming Hormone Treatment StopREAD MOREUnplugged: A Tech-Free Gift Guide for Anyone Who Needs to Tune Out (Um, All of Us) No matter who you're buying for, gifting a non-tech gift can help bring them joy that doesn't involve screen time.READ MORE12 Days of Tech 2022: The Coolest Wellness Gadgets and Gizmos for Everyone on Your List Looking for just the right wellness gadget to gift someone for the holidays? Here are 12 thoughtful and practical ideas for those who love tech.READ MOREHow to Prep Yourself for the Post-Holiday BluesMedically reviewed by Joslyn Jelinek, LCSW Not everyone feels joyous during the holidays and beyond. Here's how to cope.READ MOREYour Guide to Psychodrama Therapy For those living with past or current trama, psychodrama therapy can be a key part of their recovery. Let's look at how it works.READ MORE