Book Review-Assessment and Prediction of Suicide

I didn’t get past the foreword before the book proclaimed, “For no one has the gift of prophecy.”  So starts the attempt at Assessment and Prediction of Suicide.  It was the best thinking about how to predict and assess suicidal potential in 1992, and admittedly there’s work to be done.  Even today, we’ve not managed to crack the prediction puzzle as it pertains to preventing suicide.  All is not, however, lost.  There are insights from the work that we can bring forward into our present and into the future.

Ego Vulnerabilities

What if we were going about the problem of predicting suicide all wrong?  What if instead of looking for individual responses, factors, or scores, we looked for vulnerabilities?  Our ability to predict suicide based on questionnaires or clinical skill has been seriously limited in a challenging environment.

If we change the assumption and work with Lewin’s behavior as a function of both person and environment (or situation), we’d realize that anyone can become suicidal given the right circumstances.  The question becomes how the person and their psyche interact with the environment in ways that promote or prevent suicide.  (See A Dynamic Theory of Personality for more on Lewin’s equation.)

Instead of looking for a single marker, we could look towards aspects in a person’s psyche that make them more apt to suicide in a wider range of circumstances.  We could then seek to narrow those circumstances for everyone.  At least one study seems to identify a set of ego vulnerabilities that leads to greater suicide.  The vulnerabilities are:

  • High self-expectations
  • Ambivalence towards death
  • Supportive stance towards pain
  • Inability to mourn the loss of romantic or unrealistic gratifications
  • Rigidity of perception

We know from other research that non-depressed people have a slightly more positive view than they should.  Depressed people are more realistic.  (See How We Know What Isn’t So for more.)  The factors above, however, are more troubling.  They echo some of the thinking of other, more contemporary, suicidologists.  For instance, the ambivalence towards death that Thomas Joiner believes is a factor.  (See Why People Die by Suicide.)

Put Out the Fire

Predictive Expertise

Edward Shneidman had probably more expertise in suicide than anyone else before his death.  In an experiment, he ranked 30 cases from definite suicide (1) to definitely non-suicide (30).  His first four were suicides, but his fifth one was not.  His sixth ranked case was a suicide, however.  This is an impressive statement with a very, very low accidental probability.  However, the problem is that there’s no way to operationalize his knowledge and help others understand who may – and who many not – die by suicide.

His expertise is like the fire captains that Gary Klein studied and their innate ability to predict.  Klein, in Sources of Power, explains that it’s their experience that causes them to simulate the situations and more accurately predict outcomes.  The problem with this is there’s no known shortcut.  For others to develop this capacity, they’ve got to be given a large amount of experience with appropriate feedback.  That’s impractical – if not impossible – to do.

Certainly, Shneidman’s predictive capacity could have been better having misclassified the fifth person in his ranking – but his performance was far and away better than most.  (See Peak for more about being the best possible in any given field.)

Suicide Strikes When Depression Lifts

It seems paradoxical.  At the bottom of depression, the suicide risk goes down.  In fact, the riskiest time in depression for suicide is when the symptoms are abating.  It’s when the depression seems to be lifting that the psychomotor suppression lifts before the mood, creating a sense of need for action coupled with the perspective that everything is bad.

Alcohol and Social Supports

Alcohol has been linked to suicide by numerous studies.  However, paradoxically, alcohol seems to serve as a short-term protective yet long-term positive correlative of suicide.  What’s difficult to detangle is whether it’s alcohol itself that is the cause of increased suicides or whether it’s the social and economic effects that often come with long-term alcoholism.

Alcoholics who are active in their addictions tend to have a less stable work history, failed romantic and familial relationships, and the erosion of social supports.  Alcoholism seems to serve as a slow progression towards suicide.

Hostile Relationships

So, too, has much research identified the need for social connections and how this forms a protective factor against suicide.  However, too little has been made of the quality of the connections rather than the quantity.  Robin Dunbar’s work led to a model of the number of stable social relationships of primates based on the size of the neocortex.  (See High Orbit – Respecting Grieving for more.)  It turns out the number for humans is somewhere between 100 and 250, with the most widely quoted number being 150.  Dunbar had other “rings” or “circles” of closeness as well, but it’s the stable social relationship level that most focus on.  One could easily argue that you have more than 250 Facebook friends – but those aren’t stable social relationships and that’s why we call them Facebook friends rather than real friends.

However, in the case of suicide detection, there’s something more telling than an accounting of the people you know and the positive relationships you have.  It’s more telling to know those who have close negative relationships.  Strained close relations or relational impacts are far more indicative of suicidal potential than the number of friends that you have.

If you don’t believe that the negative expression of something can be so powerful, consider that when John Gottman was predicting – with 91% accuracy – the divorce rate of couples, he needed only 3 minutes to make his determination.  The key was that it was three minutes of arguing that he needed to see.  If behaviors were present, he expected they’d divorce; if they weren’t, and restorative factors were instead present, he predicted that they would not divorce.  It’s simple, but it’s based on the idea that knowing what’s wrong in relationships is often far more telling than what’s right.

Triggering Events and Chronic Stressors

One of the problems with suicide is that it seems as if the person just reaches a breaking point where they can take no more.  They simply can’t cope effectively with the circumstances that life has brought them to.  This can come through a single event, but it’s suggested that it’s often a long history of small challenges that wear a person down until they break.

It’s like a pressure vessel – think hairspray can, propane tank, or similar container of compressed gas.  Pressure vessels explode when the internal pressure exceeds their capacity to contain them.  The problem with pressure vessels is that they tend to explode violently and unpredictably.  No one knows whether it’s 1,000 psi or 1,001 psi but when it fails it will be catastrophic.  Considering the initial suicide attempt success rate of 70-75% the results are often catastrophic for human lives as well.

Those around the potentially suicidal individual begin to expect drama in their relationships and struggles and don’t realize that this may be the straw that breaks the camel’s back.  They may believe that the person is getting stronger with each challenge – as in Nassim Taleb’s Antifragile.  Instead, the person may be losing hope.  (See The Psychology of Hope for more.)

In one of the rare places where I must disagree, the volume says that clinicians must predict when things will become too much for their patients.  Like predicting the failure of a pressure vessel, it’s simply not possible to know when this would occur.

The Assumption of Efficacy

One of the challenges in any attempt to prove an intervention works is to create separate groups that receive different treatments – including the control, which is presumed ineffective.  However, in truth, psychologists rarely even attempt to practice this.  They simply see their patients and expect that the good outcomes are a result of their work and the bad outcomes are the result of a patient who wasn’t committed to therapy.  This thinking leads only to the conclusion that the therapy works – if you’re willing to work it.

Therefore, psychologists believe that their therapies are effective – because they don’t have suicides – but when there would have been no suicides without their intervention.  This is the kind of thinking that is explained in Science and Pseudoscience in Psychology.  Creating control groups and testing is indeed hard, but it’s critical if we are ever to demonstrate that therapy works.

Magical Possessions

One of the confusing twists that we sometimes find in the suicidal mind is that by committing suicide, they can harm someone else.  Whether this is because they identify a part of someone else in themselves or because they believe that they’re depriving someone else of their property, the thinking may have a logical flaw or two.  (See Mastering Logical Fallacies for more.)

We’ve done away with slavery, so suicide, to literally deprive someone of their property, isn’t truth any longer, but that doesn’t change the fact that people feel as if they’re somehow beholden to another and can cause them pain in their death.

Intentions

Perhaps one of the most problematic areas of assessing suicide is assessing intent – either before or after an incident.  Intent is such a fuzzy concept even with the opportunity to interview someone.  We believe that intentions are conscious and present in our minds when we realize that sometimes our own behaviors are driven by hidden forces that are difficult to see until we’re upon – or often past – them.  When the people involved are no longer available for interview, it becomes even harder.

Intent itself is at the core of suicidal definition.  That is, suicide is intended self-termination.  Without clarity in someone being able to assess their own intent, how could a third possibly look into the inner workings of someone and see their intent?

Coroners must make some attempt as they check the box on death certificates: natural, accidental, suicide, or homicide.  What if it’s more than one?  What if it was an accident, but at some level, the risks involved naturally lead to the conclusion?  What separates the extreme sports athlete and the hobbyist who is trying riskier stunts?  These are the questions that we’ll grapple with as the bright line between suicide and other forms of death becomes fuzzy.  (See Fractal Along the Edges for more.)

Suicide is Undesirable

One of the undercurrents that exists in general society is that suicide is always undesirable.  This comes at odds with the freedoms afforded people to manage their own lives.  It also conflicts with people in old age who believe that they’re no longer positively contributing to society, have had a good life, and are ready to die.

This, of course, raises the key concern about how people define “positively contributing.”  Often discounted is the wisdom that can be brought to younger generations.  There are, perhaps, no answers to some of these quandaries that people find themselves in, finding where they have value and when they’re truly a drain on others.  Burdensomeness is one of Joiner’s factors toward suicide as he explains in Why People Die by Suicide.

While I recognize the moral and ethical implications of deciding who has the right to die by suicide and those who do not, I believe that we must first open the door to the idea that not every suicide is undesirable from a societal point of view.

Postvention

The care for those who are close to those who die by suicide has a long history.  Shneidman coined the term in the 1960s to refer to those near a suicide and approaches to alleviate the suffering felt by the survivors.  There is no magic formula, program, or three step method to it.  Postvention is simply care and concern, or compassion, for those left behind.

Inkblots and Pictures

I believe that people sometimes reveal things about themselves when asked to express a response to an image.  I believe that images are powerful tools in unlocking what’s inside our heads.  However, I also strongly believe that the usefulness of tools like the Rorschach test and the Thematic Apperception Test (TAT) have been incredibly overblown.  They’re used for everything – and seemingly valid for few, if any.  The Cult of Personality Testing explains how their validity is questionable.  My subsequent research has discovered that they’re completely inadmissible in federal court cases – as is any expert testimony based on them.

In short, they’re not reliable – and their use for identification of patients who will attempt suicide bears out the same conclusion.

All or Nothing

Dichotomous (all or nothing) thinking is associated with those who attempt suicide.  Shneidman in The Suicidal Mind explains that “only” is the four letter word of suicide.  People believe that the only solution is suicide – or not.  The fixation and cognitive constriction such that there are no shades of gray is a key area of interest for me.  If we could teach people to see alternatives, to see that things are not all good or all bad, we might be able to disrupt the thinking that leads to suicide.

Nothing in the world is all or nothing.  There are always shades of gray.  The trick is to figure out how to help people see these and consider multiple options other than suicide.

The Werther Effect

It’s the name given to copycat suicides as the result of publicity (or more generally awareness) of another suicide.  It’s the reason that the American Association of Suicidologists (AAS) developed guidelines for the media for reporting on suicides.  The problem is that no one wants to trigger an epidemic of suicides because of the reporting of one.

Generally, the research supports that there are ways of reporting suicide that are more likely to create a copycat effect and ways that are less likely.  For most of us, it’s important to recognize that how we portray suicide may have an impact on others.  Certainly, glamorizing the suicide is a bad idea, but other more subtle ways may be positive or negative.

Prohibition and Suicide

The reduction of suicide during times of war is well documented.  It’s presumed that this is due to the alignment to a mission and that suicide would disappoint others or dishonor those who are dying to protect the cause.  However, there’s a lesser researched phenomenon that can’t be easily explained.  During Prohibition in the United States, when alcohol was arguably harder to get, suicide rates went down.

This is confusing, because short-term alcohol use seems to provide a protection against suicide, while long-term use and the generally resulting life conditions seems to be positively correlated with suicide.  I’m not sure what to make of the idea that suicide was lower.  Maybe Prohibition broke addictions.  Maybe the alcohol myopia didn’t happen for many (see The Suicidal Mind).  Whatever the cause, the finding is another intriguing discussion about the Assessment and Prediction of Suicide.