Book Review-Review of Suicidology, 2000

State of the art doesn’t move as quickly in some places as we’d like to believe.  Much of the technology in aviation is half a century old.  Much of what we know and believe about suicide has a similarly lengthy history.  It’s in that context that I picked up Review of Suicidology, 2000 – a summary of what was known about suicide in 2000.  Twenty-one years later, we should know more; but some of the things that we knew then are still valid today – and, in fact, much of what was the state of the art then is state of the art today.  The question is what do we know – today?

Suicide on a Schedule

If you’re concerned about whether someone will commit suicide, the calendar has an odd role to play.  The day of the month (first or fifth) and the day of the week (Monday) has a marked difference on the probability of suicide.  These relationships are social constructs, not some biological imperative, and they demonstrate how much of suicide is about our relationships with others.

The world was supposed to end on December 21, 2012 – or rather at 11:59 PM the day before.  However, the world didn’t end.  The interpretation of the Mayan calendar was wrong.  A calendar based on patterns inside of patterns was simply resetting an outer cycle, but it did drive many people to odd behaviors, including borrowing money they knew they couldn’t pay back.  If the world really did end, they wouldn’t have to worry about that.  Oops.

If you want to guess what age most of the runners in a marathon will be, you need only know that the final digit is highly likely to be a nine.  (See When for more.)  The reason seems to be that we use symbolic beginnings as our prompting to take action – including the action to commit suicide.

April Fool’s Day probably draws its roots from the Julian calendar, which aligns the new year to April 1st in the Gregorian calendar we use today.  It’s a day that jokes are played on others, and those jokes are expected.  It’s all a part of the gentle teasing of those who thought April 1st was the start of the year.

However, there may be something to this start of the year, as in the spring – whatever hemisphere you’re in – suicides rise.  This spring peak is presumed to be related to the start of new life.  Since 87% of the world’s population live in the Northern Hemisphere, it’s natural that people would assume that April 1st is the start of spring – and thus the new year of life.  It would be easy to miss that April 1st in the Southern Hemisphere is roughly the start of fall as the seasons are reversed.

Here, we find a natural cycle of birth and rebirth having some impact on the calendar instead of the other way around.

Put Out the Fire

Performance Aids

It’s really about making it easier for people to access the emergency services they need.  We know that even tiny barriers – like not knowing where the student center is or a few minutes of extra walking – can have a disproportionate effect on behaviors.  (See Demand for more.)  As a result, efforts to remove barriers from access can be a huge benefit to preventing suicide.  One tested way was to produce a green card.  The card listed emergency numbers – and it made it easier to reach out in times of need.

In other words, the card became a sort of productivity aid.  (See Job Aids and Performance Support for more.)  Designed to be used at a time of need, they seem to have become invaluable in reducing the loss of life due to suicide.

Refusing Follow Up

There are conflicting answers about whether simple letters or other gentle follow ups are successful at reducing suicide attempts.  In cases where people received relatively automated letters after their discharge, the impact was positive.  On the other hand, if someone initially refused treatment, the letters and follow ups seem to have had no effect.  The difference seems to be in the relationship that was built – or not built – and thus how the follow ups were perceived.

In the context of a relationship, the follow ups were perceived as care and concern, where those who refused care may have believed they were a nuisance.

Compliance and Results

Getting to answers about what really works with suicide prevention isn’t as easy as it might first seem.  You want to demonstrate results of the proposed intervention, but often that relies on compliance with the intervention.  As Change or Die explains, compliance with a treatment program is often challenging.  Immunity to Change explains how there are often hidden reasons why people want to continue to do things as they have been doing, so any behavior change can be hard.

However, if you want to demonstrate results, you’ve got a much greater probability of doing that if you can get compliance with the protocol.  That means doing whatever it takes to get compliance with the protocol – even if that means home visits.  They’ve been shown to improve compliance, even if the program they were used in turned out to not be effective.

Intent

One of the vexing issues is defining what is and what is not suicide.  It hinges on intent.  The question becomes did the person intend to end their life?  If they’re successful in a suicide attempt, there’s no one to ask the question of, and as a result sometimes psychological autopsies are performed.  In truth, these are interviews of those around the person and a review of their activities to try to reveal their mental state when their life ended.  The problem with this is that there is no way to know for sure what was going through their mind – so there’s no way to check the conclusions.

For those who attempt but do not die, we have two problems.  First, did they intend for someone to find them and save them so they could get attention – or not?  Many cases of suicides that ended up being completed seemed as if they might have been intentionally timed so someone would find them before they died.

Second, for those who survive, how many will claim that it was an accident to avoid the negative attention and forced care that they’ll get if it’s determined that it was a suicide attempt?  How many will have initially decided they wanted to end their lives but changed their mind?

The problem gets even deeper when you consider those people who are careless or reckless in the risks they take but who do not overtly or intentionally attempt to end their life.  Is the person who drives recklessly fast a thrill seeker, or are they unconsciously trying to kill themselves?  How about the rock climber who fails to use a rope?

Intent – both conscious and unconscious – is difficult to assess, and it may be the wrong question.

Where Did I Go Wrong?

If it was a suicide, we know that the person made a decision to end their life, and it’s likely a decision that we won’t agree with.  The question is how did their thinking differ from ours?  Is it they couldn’t see other options, they got stuck in the “only” (see The Suicidal Mind)?  Was it they were cognitively constricted such that they didn’t know there were other options?  Or were they unable to recenter their thinking around reality and instead got caught up in their own thoughts and got off the rails?

Implementation Science

Most of the work on suicide has been primary research.  It’s things like the use of fMRI machines and correlations between parasites and suicide.  (See The Neuroscience of Suicidal Behavior for one parasite, Toxoplasma gondii, for example.)  It’s great that we can establish that there is a relationship between something in the environment and suicide rates.  However, it doesn’t solve either of our key problems: assessment and treatment.

To be able to get to a valid assessment, the approach should reasonably identify those at risk – and fail to identify those who aren’t at risk.  The problem is we don’t have this.  We don’t have any tool or technique to accurately identify 90% of the people who are at risk and flag more than 10% of the people who aren’t at risk.  To find these, we need to take the primary research and determine if the correlational relationship is really causal – and that requires testing our interventions.

Interventions are our ability to change outcomes and therefore our ultimate goal.  However, because of the low rate and poor assessment, we find that it’s difficult to get studies together to test suicide prevention.  Even when we know that there’s a correlation, sorting that into an intervention and a control group proves difficult, because it takes large numbers of participants and a large number of years to determine efficacy.

If we’re very lucky, we’ll have the opposite problem.  The initial data shows that our intervention is clearly effective, and ethics requires that we stop the study and implement the intervention for the control group as well.  It’s a nice problem to have, but frustrating from a study design standpoint.

No matter how you cut it, implementation science – figuring out how to use what we know to change outcomes – is difficult, and that’s likely why so little of it is done.

Hopelessness

While depression often gets blamed for a large number of suicides, it may or may not be the root cause – it’s quite possible that depression is only one of two actors in the play of suicide, and depression isn’t the primary one.  It’s certainly true that depressed people are at a greater likelihood to commit suicide.  However, the line isn’t quite straight.  The greatest period of concern should be when the person is coming out of depression, when the psychomotor suppression fades but before they fully recover.  (“Psychomotor suppression” basically means they don’t want to do anything.)  As they emerge from the depths of depression, they often decide that they want to act upon those suicidal thoughts they had.

However, it seems like there’s an even greater correlation between suicide and feelings of hopelessness.  Hopelessness is the human equivalent of what Martin Seligman and his colleagues found and labeled as learned helplessness in dogs.  As Seligman recounts in The Hope Circuit, one of his original colleagues, Steven Maier, discovered through fMRI scanning that it might be more accurately described as a failure to develop learned control or influence.  In the case of people who lose their hope, it may be more accurate to say that they’ve lost their belief in their control or influence of their situation.  That can lead them to want to take back control in the only way left: to die by suicide.

How does one decide that suicide is the only option?  How is it that you decide the world is better off without you?  One pathway is to believe you’re a truly awful person who doesn’t deserve to live.  A second is that your life is filled only with pain and misery, and the only way to end that is to commit suicide.  A third way is to feel as if you’re confronted with a problem for which there is no solution – or no acceptable solution – so suicide is the only option that remains.  The reality of these statements isn’t particularly important; what’s important is your perception of the situation – something that can be accurate or very far from it.

Chronic and Acute

From the above, it’s probably clear that hopelessness may be a chronic condition that persists with someone over the ages, or it may be a fleeting thought that they linger on too long or just can’t shake.  As a result, hopelessness can be viewed from either the lens of a chronic condition for a person where suicide risk is relatively persistent or as an acute situation that requires a bit of reframing to regain a balanced perspective.

We can tend to see our negative circumstances as personal rather than external to us, permanent or temporary, and global or related only to a specific circumstance.  When we see things as the former in each of these categories, we tend to see our circumstances as hopeless – and that’s bad.  The more we can push towards the second categories, the better off we’ll be.

All Or Nothing

Another dangerous trap is to believe that things must be one thing or another.  Thinking that the world is good or bad, helpful or harmful, sets us up for a problem when things don’t go as we’d like.  Instead of recognizing the good in bad people – and the bad in good people – we write people off or distort our perceptions to the point where we can only be disappointed later.  Dichotomous thinking – “either-or” – makes it hard to recognize the nuances in everyday life.

I explained in Fractal Along the Edges that with greater clarity comes the possibility of seeing things not as “either-or” but instead “and.”

Avoidance

It should be simple.  If you want to prevent suicide, then just push back those suicidal thoughts from your mind.  The problem is that the research says this doesn’t work.  What we learned from the research behind White Bears and Other Unwanted Thoughts is that the more that you attempt to directly suppress a thought, the more energy that you give the thought, and it may use that energy to come back with a vengeance.  So, it’s not that simple.  It’s not just a matter of trying to suppress the thoughts.  However, proper distraction and work on changing the way that you view things – like is advocated in Redirect – are ways that you can keep suicidal thoughts out of mind without giving them more power.

Don’t avoid Review of Suicidology, 2000 by suppression or distraction if you want to understand more about how to detect and prevent suicide.