Surviving the Stigma

The Collins family liked to spend the last few hours of summer light at Narragansett Town Beach. By 6 p.m., there’d be more seagulls on the sand than people, and the beach itself seemed to relax, unburdened by the crowds. On a June evening in 2016, Mark and Beth Collins gathered their daughter Taylor, son Chris, and puppies, Copper and Oli, for a sunset walk. 

It had been a hard year. After a sunny childhood, their youngest — a star athlete, gifted musician and mathematician — found himself in the iron grip of crippling anxiety. It struck in the fall of his first semester at Amherst College, and refused to let go, despite Chris dedicating every bit of energy he had to recovery. He got all the formal modes of treatment: hospitalization, medication, outpatient therapy, and he worked his own program of exercise and healthy eating. He pushed himself forward, continuing his studies in fits and starts, and he was resolved to return to Amherst.

On that warm June evening, Chris sat cross-legged on a beach towel, cradling Oli in his lap, eyes behind sunglasses, and a backwards Ocean State Waves baseball cap pushing ruffles of tawny hair to his shoulders. This was the Chris most people saw — a young man at ease with himself and the world.

“He was smiling at me and I liked the light, so I took the picture,” recalls Beth. “It was a good day, and I wanted to remember it.”  

In January 2018, after a second medical leave, Chris Collins made it back to campus, but not through the semester. He died on March 29, Holy Thursday; he was 20. 

Mark and Beth Collins knew that their son was empathetic — at four years old he recognized a friend’s sadness with a wordless arm around the shoulders; in third grade, he composed and performed a song of hope for a sick kid he barely knew. But they were unprepared for the scores of people who had their own Chris Collins story, told in enough letters to fill two three-inch binders.  

The Collinses are a family of talkers, huggers and doers. They knew they had to capture the compassion that had flowed so easily from their son and give it a purpose. Two months later, they launched the Chris Collins Foundation to raise awareness of mental illness and reduce its stigma, by getting kids to talk to each other about it. Now operating in ten schools, the foundation trains student-led groups to sponsor all kinds of activities — presentations, posters and entire weeks devoted to mental health. 

“When we are honest about our feelings, we open a door,” Beth says.

In 2020, 45,979 Americans died by suicide; another 1.2 million were estimated to have attempted suicide, according to the Centers for Disease Control and Prevention. Suicide is the leading cause of death among the incarcerated; it disproportionately impacts veterans, middle-age adults, and rural, LGBTQ+ and tribal communities. Owning a handgun dramatically elevates the risk of suicide. Self-reported suicide attempts for Black adolescents rose by 73 percent between 1991 to 2017. Recent CDC data showed that nearly 60 percent of teen girls felt persistently sad or hopeless in 2021; 30 percent seriously considered attempting suicide. 

“This is a public health problem — more than half of us have lost someone to suicide,” says Dr. Jill Harkavy-Friedman of the American Foundation for Suicide Prevention, the largest private funder of such research, including in Rhode Island. “And we know that suicide is very complex. The research has shown that there are biological, psychological, social and environmental factors that contribute to suicide. There’s never just one that leads people to take their lives.”

In 2020, Rhode Island ranked forty-eighth out of fifty-one states, including Washington, D.C., in the number of suicides per capita. For the ten-year period before the COVID pandemic, annual suicide deaths here averaged 116.

“Rhode Island does have a low rate of suicide,” says Tara Cooper, who tracks this data for the Rhode Island Department of Health. “But, each year, anywhere from ninety to 120 [people] take their lives, and that is way too many.” 

FOR MUCH OF RECORDED HISTORY, suicide was condemned as an act of cowardice, a sin and a crime. The survivor of an attempt could be imprisoned and fined; the families barred from the rituals of mourning. The earliest philosophical and theological debates classifying suicide as a type of betrayal gave way to those around its origins. By the early nineteenth century, sociologists and psychiatrists joined the discussion. Over centuries of examination, our understanding of suicide has evolved, but it is far from complete. Even the last fifteen years have seen fundamental shifts, says Ivan Miller, a clinical psychologist, Brown University Medical School professor and Butler Hospital researcher.    

“It used to be thought that suicide was a symptom of depression or other kinds of psychiatric disorders and if you treated the disorder, the suicide risk would go away. That’s true in some cases,” he says. “But we’ve come to believe that suicide is a phenomenon on its own and needs to be studied and treated as a separate entity.”  

In 2020, Brown University established the Consortium for Research Innovation in Suicide Prevention, an interdisciplinary group of researchers working with their academic peers and providers, such as the Providence VA Medical Center and Butler Hospital, to determine the psychological, emotional and neurological factors that lead to self-harm, and to translate those findings into interventions. 

“Rhode Island does have a low rate of suicide, but, each year, anywhere from ninety to 120 [people] take their lives, and that is way too many.” —Tara Cooper, Rhode Island Department of Health

Jennifer Barredo and Michael Armey use technology in different ways to pinpoint suicide predictors. 

Neuroscientist Barredo studies neuroimaging to understand how parts of our brains involved in executive function — the higher-level cognitive process responsible for planning and decision-making — transition individuals from thinking about suicide to acting on those thoughts. Her current study at the Providence VA Medical Center involves measuring subjects’ ability to suddenly inhibit their response to a simple task repeated hundreds of times in a short span. After several decades of brain imaging studies trying to link neural activity to a specific disorder, such as depression, scientists have refocused on the performance of the brain’s functional networks.  

“Is there something different about the brains of people who respond to medication or psychotherapy versus those who do not? Over time and across multiple studies, we will have a better picture of who doesn’t respond to something in particular and maybe that information can streamline the treatment decision process.” For example, stimulating parts of the brain could expedite and help retain the knowledge and coping skills patients learn in therapy.  

“It’s a long game,” she says. 

Armey, CRISP’s associate director, is using a phone app to better understand the connections between emotions and suicide risk. His studies track negative emotions and how changes in one’s emotional state predict increases in suicidal ideation over time. Subjects in his
current study respond to brief surveys that pop up randomly on their phones throughout the day about their emotions and how well they are managing them in the moment. Abrupt surges in feelings of anger and hopelessness turn out to be strong predictors of suicide risk.

“We know in general the groups of people who are at risk for suicide but identifying which of those individuals in those groups is going to make a suicide attempt is extremely hard. The best predictor we have is the presence of a mental illness,” he says. “Tens of millions of people in the U.S. alone have a diagnoseable mental illness at some point in their lives. That doesn’t tell us much about who is going to make a suicide attempt in the future. We find the things that happen in their day-to-day lives are more important than those groups.”

Miller, along with colleague Lauren Weinstock, is studying how robust outreach can guide people away from suicide. Miller, who had studied chronic and treatment-resistant depression for years, began to examine its potential after a follow-up interview with a chronically
depressed subject who was doing well after multiple rounds of medication and therapy. “What was the thing that helped you the most?” Miller asked. “The time I missed an appointment and your assistant called to find out how I was,” Miller recalled. “Typically, we wait for patients to come to us. What that meant to me was that for a lot of impaired people, we needed to reach out to them.”

The Coping Long Term with Active Suicide Program, developed by Miller, Weinstock and colleague Brandon Gaudiano, addresses multiple risk factors using therapies delivered in-person and by phone. These interactions build problem-solving skills, define personal values, and align actions and choices with those values. Weinstock, whose research has examined interventions for vulnerable groups, such as ex-offenders, says that research is changing clinical practice.  

“The uptake is slower than we’d like, but that is a function of funding and the capacity of the system to make these changes,” she says. “I am sensing a bit of sea change in recognition of the incredible need to integrate suicide prevention into their systems and rely on evidence-based research to make that happen.”

OVER FOUR YEARS, TARA BOULAIS’ DAUGHTER cycled through hospitals, programs and therapists to cope with childhood trauma of neglect and sexual abuse. Boulais had been optimistic. Fully integrated into the mental health community, she is a member of the Governor’s Council on Behavioral Health, sits on the board of Oasis Wellness and Recovery Center (a peer counseling nonprofit) and produces programs for the local chapter of the National Alliance on Mental Illness, among her many roles. She knew how to get the gears going. 

Boulais, who assumed legal guardianship of her daughter when she was fourteen, had persuaded the Department of Children, Youth and Families to provide for her care — even though she wasn’t technically in the state system. School was the bright spot; the teenager was a good student. But she struggled with relationships and regulating her emotions. As a guardian, Boulais lost whole afternoons on the phone with providers, DCYF and school officials trying to find the right therapeutic fit. The programs were sometimes effective, but they were too short, and the cast of counselors kept changing. She told Boulais, “I’ve got twelve different journals because I’ve had twelve different therapists.” 

“She has to constantly reacquaint herself with the story of the family and we never get to the root of anything. It’s all surface work,” Boulais says. “I feel like I failed her because I promised her care that didn’t follow through.” 

Rhode Island’s mental health care system is not so much a smoothly joined landscape as a loose archipelago of psychological services. There is no single inventory of all the programs and treatment options across the state, which run the gamut from hospitalization to private-pay and publicly funded clinical therapy to peer counseling.  

There are 370 behavioral health care beds in the state — 102 for children and adolescents, 197 for adults and seventy-one for seniors. Roger Williams, Rhode Island, Newport and Butler hospitals serve the adult population, and Hasbro and Bradley hospitals treat children ages eighteen and younger. Among them, there is a full suite of inpatient, outpatient and partial-stay programs offering research-based medications and treatments which, when properly matched to the patient, improve outcomes. 

“We have a lot of great resources,” says Bradley Hospital President Dr. Henry Sachs III. “But it is fractured. You have so many small entities doing their own thing, you don’t get any economies of scale and it’s hard work.”  

Treatment options include talk therapies such as dialectical behavior therapy or cognitive behavioral therapy, which help individuals understand the effect of thoughts on emotions, and how to change thinking patterns. Other patients benefit from brain stimulation therapies such as electroconvulsive therapy and magnetic transcranial stimulation. Suicide risk screening has become more prevalent during emergency room and primary care visits. Safety plans — a patient- and therapist-developed list of the stressors, stress relievers, trusted contacts and clinical resources for that moment of crisis — are a routine tool. 

“I think our options are getting better,” says Dr. Ghulam M. Surti, Butler Hospital’s chief medical officer. “But the main goal is to identify people who need help. How do we convince people to seek help? I know we have a [mental health provider] shortage, but there are people who are acutely suicidal who do not tell anybody.”   

The Providence Center and Gateway Healthcare are the state’s largest community behavioral health providers for the under-served. Each year, some 22,500 Rhode Islanders use their mental health, substance abuse and wraparound services, including food, housing and job training. The Providence Vet Center is another community-based provider specifically for veterans, current service members and their families struggling with the transition to civilian life or traumatic experiences from active duty. Peer support is a strong treatment adjunct. The state has 193 peer specialists — people with lived experience who undergo training and certification to help others, and six peer recovery centers. Oasis Wellness and Recovery Center is one, serving 7,400 Rhode Islanders in 2022, via fourteen support groups dedicated to different aspects of mental illness and trauma, with an emphasis on recovery.  

“No single thing works for everyone,” says Oasis Director Jim McNulty, who knows the power of community from his own experience in a support group. “When I walked into that room, it was the first time I had ever been around other people who knew what I was experiencing. I really didn’t have to explain it to them.”

Despite all there is, it is not enough. There is a dearth of mental health providers in Rhode Island, and public and private insurance reimbursement rates are extremely low. Very few psychiatrists accept insurance; some new clinicians give up the profession for less stressful jobs with better pay. On any given day, fifty to 100 people needing psychiatric care are stuck in the emergency rooms from days to weeks because there are insufficient beds, says Rhode Island Mental Health Advocate Megan Clingham.

“If you are not insured or underinsured and can’t pay out of pocket, there’s nowhere to go,” says Beth Lamarre, executive director of NAMI Rhode Island, the state’s chapter of the National Alliance on Mental Illness. “The handful of community mental health centers do offer mental health services on a sliding scale, but they are up to their eyeballs with waiting lists.”

The frustration reaches down to the primary care level, where newly minted nurse practitioner Katrina Geaber worries about pediatric patients in acute distress waiting in an ER, because she couldn’t find a bed. 

“Safety is always your first priority,” she says. “It’s very discouraging.”

“We’ve made some strides,” says Clingham. “We need a direct investment in our system of care for human beings who are suffering and dying. It’s a humanitarian crisis right now and the only thing that’s going to help is an infusion of money.” 

The federal and state governments are building system capacity. In July 2022, the federal government launched a revamped 988 national crisis hotline to replace the old ten-digit number. In January, under the Veteran Suicide Prevention Act, any veteran in a suicidal crisis can go to any VA or non-VA health care facility for emergency services, inpatient or residential care for free.

“Over 60 percent of veterans who took their own lives are not enrolled in the VA or haven’t been to the VA in the previous year,” says Lawrence Connell, director of the VA Providence Healthcare System. “We are trying to get our arms around those veterans. We lose sixteen a day, and the VA’s really doing a full-court press to reduce that number.” 

At the state level, officials are establishing a new twelve-bed unit for adolescent girls and a behavioral health nursing home unit for adults with mental health challenges who require a level of care beyond the capabilities of a traditional nursing home. The state is also putting $30 million into the creation of certified community behavioral health clinics — partnerships among existing providers to integrate patients’ mental and physical health and provide a single entity to coordinate all services.  

“We’re cognizant of the fact that there are gaps in services, in access to services and providers, and we are trying to make the investment to connect those things going forward,” says Tom Martin, of the state’s Department of Behavioral Healthcare, Developmental Disabilities and Hospitals. “We do a lot of outreach, but if you aren’t connecting to treatment, you are bridging to nowhere.”

“But the main goal is to identify people who need help. How do we convince people to seek help?” —Dr. Ghulam M. Surti, Butler Hospital’s Chief Medical Officer

STEVE MONDACA HOLDS HIS 40-CALIBER PISTOL, open-palmed, in the den of his Coventry home. There, melded on the grip, is a photo of his seven-year-old son. The first thing people do when they pick up a firearm is give it a visual check, and Mondaca put it there to remind himself of who he holds most dear.

In April 2006, he deployed to Afghanistan, a fun-loving nineteen-year-old who liked playing video games and hanging out. A National Guard infantryman, he had hoped for combat duty, but instead was stationed in Laghman Province, guarding the civilian teams capturing Afghani hearts and minds through nation-building. He returned home thirteen months later, broken in ways he did not understand or even recognize.  

In the following decade, Mondaca progressed professionally, married and started a family. But he was frequently drinking himself into oblivion. In Afghanistan, Mondaca knew where the enemy was likely to strike, and he was ready, amped up on hard rock, with a well-oiled weapon. At home, the threats came out of nowhere — the pop of a firecracker, or a roadside garbage bag resembling an IED sent adrenaline coursing through his body. In Mehtar Lam, he grieved the three unit members lost in action, and spent one of his last active-duty days documenting the body parts of schoolchildren killed by a suicide bomber. Here, he was losing his buddies at an alarming rate to self-inflicted gunshot wounds. At one point, he mentally ranked all the veterans he knew for suicide risk, and at the bottom of the list was Matt, a young guardsman he had befriended. 

“We called him ‘Chuckles,’ because he always had a smile on his face,” says Mondaca.

But a few months after a funeral for another veteran who died by suicide, Matt took his own life.  

“The big takeaway for me was to stop assuming I knew where people are at mentally, because anyone can put up a facade,” he says. “That was the tipping point for me to consider suicide as an active option because if the happiest human being on earth, who had clearly struggled with personal issues, could achieve the peacefulness of getting himself out of the situation, why shouldn’t I?”

A handful of times, stewing in anger and sadness, he considered following suit, but the thought of hurting his family always stayed his hand. Mondaca tried therapy and medication, but eventually found his equilibrium in fatherhood and in volunteering with the Combat Veterans Motorcycle Association. In 2019, he founded SafeGuard, a free service to affix the image of a loved one to firearms. 

“We want to use images that are meaningful to the veteran so if they pick up that firearm intending to pull the trigger, they will see that image. We want to get them to realize that there is more here for you than there isn’t.”

Suicide prevention and intervention is a multiverse of immediate and long-term efforts designed to interrupt a crisis, provide the basics that reduce stress — housing, jobs, food — or simply start a community conversation about mental health. 

Some groups attack by limiting lethal means. The Overwatch Project trains and encourages veterans to reach out to struggling comrades to take temporary custody of their guns. The idea is to put time and distance between the impulse and the act, says board president Mike Ritz of Providence. The project just won a $500,000 VA grant for its unique approach. 

“We have not seen a nationwide campaign that targets gun owners directly and teaches them how to help, peer-to-peer, without getting authorities involved,” Ritz says.  

Meanwhile, the Bristol Police Department is working to install license-reading cameras at the foot of the Mount Hope Bridge, to alert officers that a person intent on suicide is headed for the bridge.

“This adds a layer of notification,” says Lieutenant Steven St. Pierre. “We’ve found that people will traverse the bridge two or three times before they act on their suicidal intent. The bridge camera will notify everyone on patrol the vehicle we are looking for.”

The bulk of prevention and intervention work operates upstream. The state’s departments of Health, BHDDH and the Executive Office of Health and Human Services are the primary funders of a large network of agencies and programs, including seven regional prevention task forces, which tackle suicide, among other behavioral health issues. The East Bay Community Action Program, which operates the Bristol Health Equity Zone and its suicide prevention workgroup, collaborates with other partners to address community needs at every level. EBCAP’s mental health services include walk-in clinics and a twenty-four-hour hotline where “we’ll do a suicide evaluation right over the phone, stabilize people, get them to see us in the morning and into a program,” says Amy Lagasse, EBCAP’s vice president of behavioral health.

The Rhode Island Youth Suicide Prevention Program operates in eighty middle and high schools, offering teacher training, suicide risk screening, brief interventions and follow-up services. Coordinated by Rhode Island Student Assistance Services, the partnership includes the Health Department, Brown University and Bradley Hospital, which operates KidsLink. Since 2015, KidsLink has diverted children from emergency rooms by offering school staff immediate consultation and discussion of the appropriate next steps. In its first two years, KidsLink helped bring down the state’s youth suicide rate by 40 percent at a time when the national rate rose 24 percent.

SUICIDE BEGINS IN TRAGEDY, but often ends as a cause. The ranks of preventers and intervenors are filled with survivors like Erin Goodman, who became a peer recovery specialist after coming back from her own brush with suicide. “You can get stuck — it gets
secretive and shameful — and the fear. Once my thinking was rational, I leaned into therapy and my faith,” says Goodman, who works for Wood River Health’s Washington County Zero Suicide Program. “I felt I was still here for a reason and I could use the second chance I was given.”

Another large contingent salvages hope from the wreckage. Missy Ames, board chair of the state’s chapter of the American Foundation for Suicide Prevention, got involved with the organization’s public education and advocacy efforts, starting with an Out of the Darkness Walk, after the death of her friend Johnnie. He was “the light in the room,” she says. How could he suddenly go dark without her knowing?   

“I wanted to be educated — to recognize the warning signs in the future for my friends and family,” she says. “There isn’t anything more I can do for Johnnie, but there’s so much I can do for my community.” 

The suicide of a family member and “numerous military friends” led North Kingstown Town Councilman Matt McCoy to become an advocate of gun legislation and a teacher of mental health first aid. “It’s a lifelong trauma,” he says. “I want people to better appreciate that mental illnesses are common like physical ailments, and if you have early intervention, you can prevent that decision to take their lives.”

A third group, having felt the free-floating angst, has volunteered to become a part of the safety net. Lauren Manton, a Narragansett High School senior and member of the Chris Collins Foundation’s P2P program, has seen their campaigns make a difference.   “Maybe we can’t erase that stigma,” she says, “but we can have real conversations, and hopefully, we can help each other.”

In the last five years, Bradley Hospital has trained more than 7,000 Rhode Islanders in the basics of suicide prevention. “Everyone has to deal with it — every family, every school is in the first line of defense,” says Bradley Hospital’s Sachs. “The workforce is everybody.”

THAT JUNE 2016 PHOTO of Chris Collins hangs above the mantlepiece of the Collinses’ South Kingstown home and fronts the foundation’s website, where his smile remains an invitation to unburden yourself, and stay awhile. 

“So many people talked about his smile. The way he remembered their names and what was going on in their lives. When he would say, ‘How are you?’ it wasn’t a token hello, it was ‘I want to know how you are.’ This is what keeps me going, because it’s often difficult,” Mark Collins says. 

“I try to hold on to the thought of how many other people is he helping.” 

 

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RESOURCES

Get Help Now

If you or someone you know is experiencing a mental health crisis or thoughts of suicide, call the 24/7 statewide BH Link hotline at 988. Or you can use the Crisis Text Line to connect with a crisis coordinator within twenty-five seconds on average. Text HELLO to 988 and communicate until you feel safe. BH Link’s behavioral health facility at 975 Waterman Ave. in East Providence is also open 24/7. bhlink.org

 

Hotline Help

Someone who cares is just a call away.

National Suicide & Crisis Hotline: Call 988

ANAD Eating Disorder Helpline: 1-888-375-7767

Crisis Text Line: Text HOME to 741741

Latino Mental Health Network:
mhnri.wixsite.com/latinomhnetworkri

National Alliance on Mental Illness Helpline: 1-800-950-6264

National Eating Disorder Association Hotline: Text or call 1-800-931-2237.
Online chatting available.

Substance Abuse and Mental Health Services Administration National Helpline:
1-800-662-HELP (4357)

Teen Hotline: Call 1-800-852-8336 or text TEEN to 839863

Trans Hotline: 1-877-565-8860

Trevor Project: Call 1-866-488-7386 or text START to 678-678

Veterans Crisis Line: Dial 988 and press 1 or text 838255 —K.T

 

Get Involved

Contact the American Foundation for Suicide Prevention through area director Kerrie Constant at 917-920-0639 or kconstant@afsp.org.

The Chris Collins Foundation is a peer-to-peer mental health awareness program that partners with the University of Michigan Depression Center to bring student-led help to local schools. chriscollinsfoundation.org