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.

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.

Book Review-White Bears and Other Unwanted Thoughts

We’ve all had that song we couldn’t get out of our head or that situation we kept playing over and over in our minds.  We’ve had the mental Groundhog Day that some thoughts seem to generate.  White Bears and Other Unwanted Thoughts is a thoughtful walk through the research about what happens when we try to suppress thoughts we don’t want – particularly those that stop, block, or freeze our thinking.

The White Bear

The book, Daniel Wegner explains, isn’t about white bears but is instead about a story of how Tolstoy’s older brother convinced him to stand in a corner until he wasn’t thinking about a white bear.  This, of course, proved difficult.  The more he reminded himself not to think of a white bear, the more he thought of it.  The change is the meta- or abstract idea of not thinking about an object (white bear) requires that you call up the image to understand it, and that, of course, makes you think about it.

It’s a trap.  The more that you actively try to push something out of your mind, the more you must recall what you’re pushing out of your mind, and you find yourself caught in a loop – and one of increasing reinforcement.

Squirrels and other Distractions

For those of us who have seen the Disney/Pixar movie Up, we know Doug the Dog’s obsession with squirrels.  Doug could be distracted by the simple mention of the word – and it would disrupt whatever was happening.  This is disruptive when others use distraction on you, but as an internal tool, it’s a powerful way to shift your thinking from something that you don’t want to think about to something you do.

Where attempts to directly suppress a thought fail, distractions can be a powerful way to shift thinking away from the unwanted thought – if they’re powerful enough.

Marshmallow Stories

Walter Mischel tested children with treats (which was simplified by a reporter to marshmallows).  He lays out the entire process in The Marshmallow Test as he explains the accidental implications.  The test was a delayed gratification test, where if the child could leave the sweet for a few minutes while the researcher was out of the room, they would get two treats.  Some kids did, and some did not.

Some of the children most successful in delaying gratification – and reaping the rewards – were those who used distraction.  The least successful children were those who tried to use their willpower to power through.  (See Willpower for more about how it functions.)  The more they tried to directly ignore the treat that was sitting right there, the more they squirmed – and often succumbed to the temptation.

When Mischel returned later to the results of his momentary torture of children, a powerful story emerged.  The story was those children who had effectively delayed their gratification were more successful in life.  It wasn’t that the limits of the cognitive skills they had learned were confined to their preschool; their ability to delay gratification seemed to serve them throughout their life.

Learning how to delay gratification had lifelong implications, and the best way to do that was to master distractions.

Depressing Distractions

When trying to distract yourself from a disastrous date  or a deliverable debacle, people who aren’t depressed are able to call to mind positive distractors.  They think of a date that did go well (even if the other person isn’t in the picture any longer), or a work deliverable that got rave reviews.  A few moments of basking in the glory of a success made the failure seem more mentally and emotionally distant.

However, the research shows that if you’re depressed, you somehow decide that thinking about a different disaster is the right way to distract yourself from the current thought to be avoided.  Instead of recalling something positive, you’ll recall something neutral or negative.  With prompting, you can get a depressed person to see other positive situations, but it’s not the normal response that the rest of us have.

To be fair, those with depression tend to see the world a bit more accurately than those who are not.  They more accurately predict their chances at asking someone out, getting a promotion and so-on.  (See Superforecasting for more.)  However, they’re not as happy about it.  Our happiness, it seems, is built at least partially on delusion – but that’s not necessarily a bad thing.

Post-Traumatic Stress Disorder

The Body Keeps the Score created the awareness for me that post-traumatic stress disorder (PTSD) was the result of a situation that the person wasn’t able to fully process.  The situation was so horrendous that people would have to block it out of their mind before the processing could be completed.  The act of suppression seems to not just prevent the situation from processing, it may actually be creating the obsession.

Research seems to support the idea that the more you suppress a thought, the easier it is to recall later.  In other words, every time we suppress a thought, we make it easier for the thought to occur.  The solution is to leverage the reality that we habituate to stimuli, and they become less prominent.  Daniel Kahneman discusses bias, including our desensitization and habituation, in Thinking, Fast and Slow.  Albert Bandura successfully demonstrated this in removing snake phobias, which he discusses briefly in Moral Disengagement.  The trick it seems is to progressively walk through only pieces of the situation to the point where you can still feel safe to help the body understand that there’s no need to be fearful.

Exercise of Will

Our thinking is like a focused laser that operates on a relatively narrow band of input and processes only a radically small amount of the data available to us.  We’re bombarded by sensory data and, increasingly, information.  We must select a narrow band of that to focus on.  (See Chris Argyris’ Ladder of Inference, which I discuss in my review of Choice Theory.)  Our ability to control our thoughts is primarily about our ability to control the process of focusing our attention on one thing instead of another.

The more that we’re able to direct our thinking towards those things that are important and useful and avoid thinking about those things which are self-defeating or get us stuck into a loop of thinking, the happier and healthier we are.  Of course, Willpower is more often thought of from the perspective of productivity, but it has a role in our sanity as well.

Mental Repair

The idea that such a fantastically complex machine like our human brain could run without errors is wishful thinking.  What we know is that we’re constantly discovering and recovering from mental defects.  Most people don’t consider laughter much, but it’s one of those mental repair routines.

Inside Jokes explains that, while there are two types of laughter, one of them is associated with an error checking routine in our heads discovering an error and giving us a bit of dopamine because of it.  The typical joke has the format of step, step, change.  It relies on us making assumptions about what the comedian is talking about and the quick change in the meaning of what we were thinking about.  The result is we’re rewarded for realizing that the meanings were changed.

White Bears and Other Unwanted Thoughts proposes that the ability to distract ourselves is also a mental repair routine which is designed to keep us from becoming locked up on a single concept to the exclusion of everything else.  It also believes that we use humor to escape a situation that seems to have become stuck.

Suppressing Emotions

One of my favorite metaphors for the way our brains work is Jonathan Haidt’s Elephant-Rider-Path model that he covers in The Happiness Hypothesis and Dan and Chip Heath picked up in Switch.  It postulates that our reason is the rider on top of a large, emotional elephant.  The rider has the illusion of control, but only until the elephant decides differently.

I’ve been close to people who grew up in environments where emotions were scary and not okay.  The result, in at least one case, was a complete cognitive break when emotions refused to be held back any longer.  That and other situations where suppression of emotions leaked out into other spaces have led me to realize that suppressing emotions is dangerous stuff.

It takes a massive amount of effort on the part of our rational rider to keep such a powerful emotional elephant under control.  When you’re consuming all that mental energy trying to suppress the elephant, there is little left for the rest of life.

Directing the Lightning

Lightning rods are used to direct a lightning strike in a way that prevents damage.  On top of houses, they’re designed to route the lightning down a sizable electrical cable to the ground rather than striking and burning through a house.  One of the effective techniques for distraction is to use lightning rod type thoughts to draw all the attention to something else.

Powerful thoughts – whether due to their importance or the degree to which they’re immersive experiences – can become mental focal point which draw everything in and thus avoid the unwanted thought.

Unhearing and Unseeing

You can’t unhear something, nor can you unsee something.  Whether it’s the critical comment about you made by a friend or colleague or a scene that you shouldn’t see, you can’t get it out of your head.  Once it’s in there, it’s there – no matter what Freud believed.  Though difficult to study directly, there’s every indication that suppressing a thought in any form doesn’t make it disappear.  In fact, there’s evidence to support that even when we believe – rationally – we’re suppressing a thought, we’re not.  We see micro biases start to show up even when the person claims they’re not actually aware of the information consciously any longer.

These subconscious biases drive us more than any of us would care to believe.

Breaking Stereotypes

Al Campanis defended Jackie Robinson when it would have been easy not to.  Jackie Robinson was the first black baseball player to play in the Major Leagues.  Al Campanis was aware of Jackie’s talents and was (reportedly) a friend.  Al was able to see past the stereotypes of the time with Jackie.  Jackie was different; he was someone Al knew personally and knew that the stereotypes didn’t apply to him.  Except that, while Al knew Jackie was a good ball player, he didn’t believe that blacks could manage a baseball team.  His personal relationship with Jackie wasn’t enough to shake this belief.  (See Mistakes Were Made (But Not By Me) for more on this story.)

For the most part, the way that we break stereotypes is to individualize people and situations from the stereotype.  This addresses the immediate situation and allows us to operate – more or less – without the stereotype for that situation.  Over time and enough situations, it’s possible to cause the stereotype to be invalidated.

Buster Benson explains in Why Are We Yelling? that we need stereotypes because they simplify our processing.  The problem comes when these stereotypes are wrong or are too broadly applied.

Malleability of Memory

One important reminder as we leave is that memory is malleable.  It changes every time we think about something.  We forget that the very act of recalling a memory changes it.  Our perceptions are limited, as The Invisible Gorilla points out.  If we spend too much energy suppressing a thought, we may find that the energy becomes attached to the thought.

We need to be careful when we attempt to suppress White Bears and Other Unwanted Thoughts for fear they may come back with a vengeance.

Book Review-A Handbook for the Study of Suicide

One of the most interesting challenges with suicide is figuring out how to study it in a way that leads to better assessments and better interventions.  That’s the heart of A Handbook for the Study of Suicide: learning more about suicide to address assessment, intervention, and useful models.

A Quick History

Views of suicide have changed over time – and they vary by culture.  At various times, suicide to maintain one’s honor was approved by both Greeks and Romans.  But the stories aren’t that simple.  Suicide by slaves was discouraged, because it was essentially stealing property from the master.  In at least one culture with polygamy, wives would compete to be slain and buried with their husband.  The wife who was determined to be the one the husband most loved “won the honor.”

In Italy, suicide was only punishable for three classes of people: criminals, soldiers, and slaves (criminals primarily because it was seen as an attempt to escape punishment).  The criminalization of suicides was one attempt to discourage suicide.  Other attempts were various desecrations of the body, including being dragged naked through town.  They might also be prevented from a burial with standard religious ceremonies.

Other desecrations, such as being pinned down at a crossroads, were an approach to preventing the spirits of those who committed suicide from haunting the living.

Suicide as Sin

If you look at various religions, you can find evidence of some poor choices – for instance the Shakers.  If you’re not interested in procreation, you may find your movement is short-lived.  Similarly, if suicide is too appealing, then you’ll have no one left.  Christianity promises an afterlife that vastly exceeds anything that someone could expect in this life, thereby making death a doorway to something better.  Suicide was simply walking through that doorway.

This became a problem for the early Church, and therefore suicide became progressively associated as a sin until about the last half century.  The arguments that were made associating suicide as a sin varied from the fact that our bodies are temples to associating #6 on God’s Top Ten list, “Thou Shall Not Kill,” to suicide.  Over time, scholars have unwound the foundations for suicide being a sin, and instead suicide was transformed into a weakness or mental illness.

Suicide as Mental Illness

The logic is circular.  Only a person with a mental illness would consider and complete suicide, so everyone who does die by suicide must therefore have a mental illness.  Certainly, the model isn’t literal.  More comprehensive thinking about what’s happening in the mind of the suicidal person can be found in Why People Die by Suicide (Joiner), Man Against Himself (Menninger), and The Suicidal Mind (Schneidman).

Old conceptions that suicide was mental illness give way to the idea that people choose suicide because of the pain they’re experiencing (psychache) or because the forces of desiring life and desiring death tip towards desiring death – without extinguishing the desire for life.

When Suicide is Right

As painful as suicide is to those left behind, what if it’s the right thing?  Consider a person who is terminally ill, fighting pain, and worried about the financial burden that a prolonged illness will create.  In this case, isn’t suicide the right answer?  If this is a reason why suicide is the right answer, at what point does it become the unacceptable answer?  While it’s comforting to think that suicide is never the right answer, there are times when it may be.

In my own life, my grandfather took his own life when he decided that his health was failing and he could no longer have the quality of life that he wanted.  While I miss him, and it was sad that he is gone, I accept that he had reasons for deciding that he was done.

The philosophical problem is what happens when the person is wrong?  What happens when the illness isn’t terminal, it won’t ruin the family, or you can preserve quality of life?

Decision Making

Suicide is a choice – whatever we may think about it, it’s a choice or a decision.  It’s a decision that, of all the options, suicide is the one that seems the most appealing.  However, in all but in a few situations, the right answer isn’t suicide.  So how is it that people believe it’s the right answer?  Part of that comes with the awareness that suicidal people are victims of constrained thinking.  (See The Suicidal Mind.)  Part of the answer may come from a failure to make rational decisions.

Irving Janis and Leon Mann wrote Decision Making back in 1977, and it’s where Janis’ term “groupthink” was popularized.  In this work, we discover the processes that people can use to identify the best alternatives and make rational decisions.  However, Gary Klein’s work, as documented in Sources of Power, helps us to realize that few people use rational decision making.  Instead, he explains, they use recognition-primed decisions that are based on their previous experiences.  Thus they lean on their experiences as much as or more than they try to logically work out what the real options are.

Suicidal persons often become fixated on the one option of suicide to the exclusion of other viable – and even better – options.  Schneidman explains that “only” is the four-letter word of suicide.  (See The Suicidal Mind.)  If we want to reduce suicide, we need to find ways to reduce this fixation, increase skills for finding alternatives, and help people see that there is always hope while you’re alive.

Social Constraints

We don’t steal or loot others’ businesses.  (Or at least most of us don’t.)  The rules of society govern our actions, and even if they’re not fully able to constrain them, they certainly influence them.  How Good People Make Tough Choices is quick to point out that there’s a categorical difference between truly moral temptations and ethical dilemmas.  In the first case, we know what is right – as defined by what society expects – and in the other, we’re balancing multiple foundations of morality that are in conflict.  (See The Righteous Mind for more on the foundations of morality.)

Suicide rates are influenced by the social context and constraints that surround it as is evidenced by the fact that they vary so widely between different countries.  There’s something to the way society is formed that can either encourage suicide or provide insular protection against it.

Internal Perceptions of External Events

Why does a breakup drive one person to suicide but barely phases another?  Why is job loss so traumatic for some and uneventful for others?  If the external event is the same, why aren’t the results the same?  The answer comes in the way that we view the situation.  Our reactions are based primarily on the internal meaning that we assign to the event – not the event itself.  Richard Lazarus in Emotion and Adaptation makes it clear that stressors are not stress.  Our belief about the probability and impact both play a role in our assessment but, critically, so does our belief in our capacity to cope.

Even highly likely and largely impactful events barely register when there are high degrees of self-esteem and internal locus of control.  (See Deci’s work in Why We Do What We Do for more.)  The difference in reactions is therefore about the assessments and capacities – which we can train and instill in people.

The Road of the Gypsy

One of the other interesting findings is that immigrants have a higher rate of suicide than those who are native born to a country.  The cause isn’t known, but it does seem as if those who travel the road of the gypsy are more prone to believe that there’s a magical place where their frustrations with life will be removed.  As Viktor Frankl explains in Man’s Search for Meaning, sometimes these false hopes can be deadly.  It isn’t, however, false hope to believe that you can learn something from A Handbook for the Study of Suicide.

Book Review-Suicide: Inside and Out

Years ago, I was doing a conference in the Union Square area of San Francisco, and I received a warning about the homeless in the area.  During the day, things were fine; but I shouldn’t go walking alone at night, because many of the homeless in the area had untreated mental illness.  As I inquired more about it, I was told that since the state shut down the mental institutions and “dumped” those with mental illnesses on the streets, it was impossible to control the homeless population – and it was riskier to ignore them.

This is what I kept seeing as I was reading Suicide: Inside and Out.  It’s a story of the mental hospitals that are all but gone.  State run facilities are, for the most part, a thing of the past.  They were dismantled both figuratively and literally because of their dysfunction, some of which is explained in the book.

The Ruse

The core of the book is the account of David Kent Renolds who went inside the mental hospital as a patient.  The backstory was devised to make him appear as a suicide risk, and he, at one point, faked a suicide attempt.  Those who criticize the work (and the book) attack it on ethical grounds or on the inconsistencies generated by placing a presumably sane and non-suicidal person in the midst of a system designed for those who needed care.

My own conflict was less about the ruse and more about the factors that moved people further towards – and not away from – suicide.  Thomas Joiner in Why People Die by Suicide focuses on three factors for suicide risk: self-harm tolerance, burdensomeness, and connectedness.  While self-harm tolerance isn’t impacted, burdensomeness and connectedness are both negatively impacted by an inpatient program.  Several aspects of the report indicated the sense that Reynolds was a burden and there was minimal contact with the outside world.  In fact, there was only one pre-arranged contact from the outside world and one meeting with the administrator who knew Reynolds’ true identity.

Suicide Status

Suicide status, or “S-status,” meant certain things, not the least of which was isolation.  Instead of being relatively free to roam in an open ward, suicide watched patients had less mobility and freedom – and certainly less privacy.  While Reynolds explains that aides did their best to provide a modicum of privacy, it was still difficult to balance the need to protect a patient from themselves and simultaneously give them freedom.

The privileges that come with being off suicide status are many, and so it behooves the S-status patient to try to convince the staff that they’re not really considering suicide any longer – whether they are or not.  It’s a careful balance between being seen as sane enough to know you’re sick and seeming that you can’t possibly be as well as you’re letting on.

I’ll Die, If I Want To

One of Reynolds’ observations was that the person dedicated to their self-destruction wouldn’t have much of a problem attempting suicide again, since it’s practically impossible to protect someone from themselves every moment of every day.  It’s too easy to grab a razor or a rope.  It’s even quicker to step in front of a speeding car – all these opportunities and more presented themselves during Reynolds’ experiment.

This leads to the particularly thorny problem with caring for severely and persistently suicidal people.  You can’t take your eyes off of them for a moment for fear that that moment may be their last.

I Am Here

The Fifth Discipline Fieldbook shares that the word “ubuntu” stems from the Zulu phrase “Umuntu ngumuntu ngabantu,” which means “A person is a person because of other people.”  Reynolds made it clear that people failing to acknowledge him – either in general or by speaking about him but not to or with him – was one of the most difficult parts.  He craved acknowledgement as a human being.

This is the most basic form of connectedness – connected to others at a level of at least acknowledgement of existence.  Deeper connections are, of course, necessary.  However, they’re all built on the foundations that people are visible.

Temporal Distortion Field

Today and tomorrow are the same.  There’s little reason to look forward to one day versus the next, because everything is the same.  It’s a monotonous march across the pages of time, which seems to have no beginning, no middle, and no end.  People speak of beach time, where the grid-like confines of a quarter-hour calendar are lost to the waves gently lapping at the shore.  Unlike the pleasant images of the beach, time wasn’t under the patient’s influence or control.

It was 45 minutes of waiting punctuated by 30 minutes of something only to return to 45 minutes of waiting to be interrupted for the next thing that had to happen.

Lack of Control

“Learned helplessness” was Marty Seligman’s phrase for the feeling that you didn’t have any control of your circumstances, so there was no point in trying to make it better.  (See Seligman’s work in The Hope Circuit for more.)  Others have framed the lack of control in terms of a lack of hope.  C.R. Snyder explains in The Psychology of Hope that hope is built on willpower and waypower, where waypower is knowing the path forward.

Inside of the ward, there was no knowing or planning for what was next, because information flowed so poorly that few people really knew what they were supposed to do – and fewer still knew when they were supposed to do it.  In my own work, I’ve discovered that a lack of hope is a very, very dangerous thing and something to be actively avoided.

Suicidal Risk

Then and now, the best indicator of whether someone is a risk for suicide is their own assessment of the risk.  There are no widely accepted screening criteria with high confidence that can be used, and as a result, we still struggle to identify the real suicidal risk of anyone.  We have the statistics to show men vs. women and age-bracket vs. age-bracket, but these are generalities covered by statistical math that doesn’t reveal who needs the most attention – and who will be just fine.

If we’re going to get good at managing suicide, we’ll have to find a way to do better than asking the patient how they feel.  Suicide is too impulsive to believe that people will be able to self-diagnose.

Behavior Isn’t Stable

Kurt Lewin described behavior as a function of both person and environment.  (See A Dynamic Theory of Personality for more.)  He knew that our behavior would change as the conditions changed, and he saw this as an opportunity to create environments for the best results.  However, the psychologists of Reynolds’ day held a different view.  They saw a patient’s behavior as a stable force driven by their makeup that couldn’t be shaped by the situation they were in.

Aides and nurses saw a different and more realistic view as they discovered that the conditions a patient found themselves in could substantially alter the kind of behavior the patient would exhibit.  In the most basic sense, patients would be nicer to those aides and nurses that they felt were kind to them.  This is one of the many factors that impacts patients who exit inpatient treatment.  They go back to the same situation that brought them to seek care in the first place.

Emotional Upheaval

There’s a flurry of activity when a tragedy – of any kind – strikes a person.  There’s initially a wealth of support from every angle.  However, as the days turn to weeks and weeks to months, the degree of support wanes, and the business is replaced with an icy calm.  It’s a time when one can pause, reflect, and wonder what’s next.  It’s a time when suicide may seem like an option.  In the moment of a great tragedy and loss, it can be that the mechanical and tactical aspects of the change are so consuming that they can help you avoid the extended thinking about the meaning of the event and how it will impact the rest of your life.

We see that often it’s when people appear to be getting out of depression or have been released from a hospital that they commit suicide.  Whether it’s that the psychomotor retardation associated with depression is waning or that people finally settle into the long-term implications, it’s not clear.  What is clear is that the danger associated with a loss doesn’t dissipate quickly.

Decoupling from Reality

One of the other concerning aspects of the account is the tendency towards decoupling from reality.  Increasingly, people would become involved in their own thoughts – whether or not they were connected to reality.  One begins a paranoid perception that everyone is out to get them or, at the very least, is always talking about them.  It’s hard to see that the world really doesn’t revolve around you when you’re inside your head, because your own internal world does.

The more that we can help people be grounded in realistic, positive futures, the less likely they are to invent their own distorted view that may tangle living and death in ways that mean they no longer want to live.

In the echo chamber of our minds, minor setbacks become catastrophic events, and minor victories invite celebration.  Unfortunately, we’re more focused on the losses and the negative than the positive, so we’re weighed down by the amplification of the negative more than the amplification of the positive.  (See Thinking, Fast and Slow for more on negative bias.)

Degree Not Kind

The difference between a normal person and an abnormal person is a matter of degree – not of kind.  It’s not that abnormal people are something that normal people are not, it’s just that they’re more or less of it than the normal range of people.  Instead of being in the middle, they’re on the edges.

It’s important to realize that this may be one of the reasons why the staff can’t identify the “normal” person in the abnormal situation.  While other patients can see something different, the staff rarely can.  This is important as we look at suicidal ideation as a continuum on which people fall and not a destination or specific point.

The List of Clues

Near the end of Suicide: Inside and Out is a list of suicidal clues.  They’re supposed to be indicators to look for when you are assessing the potential for suicidal attempts in a person.  I’ve elected not to reproduce them here in part because some are myths and in majority because their predictive value is low.  We get so wrapped up in the idea that we can ask a few questions and sort people into the high risk category (whatever that means) that we fail to realize that suicidal intent comes moment by moment and has very little relationship to the state the person is in when the questions are being asked.

We no longer have the opportunities that existed with David Kent Reynolds did his study – but even if we did, I’m not sure it would reveal any answers to why people commit suicide.  It feels like it doesn’t necessarily help to know Suicide: Inside and Out.

Book Review-After the Ball: How America Will Conquer Its Fear and Hatred of Gays in the 90’s

I was just graduating high school as the book After the Ball: How America Will Conquer Its Fear and Hatred of Gays in the 90’s was published.  There was, obviously, a lot going on in my world, so I can’t say that the perspectives in America about homosexuals was top of mind for me.  I was aware of the fear and hatred but largely as a part of the awareness about AIDS and HIV.  For me, it was never a thing one way or another.  Within a year or two of graduating I met some openly gay and transsexual friends, and we didn’t talk much about how other people treated them.  To me, they were – and are – simply friends.

Reading After the Ball wasn’t about trying to understand homosexuality for me.  I realized that the book stirred a lot of controversy when just putting my hands on a copy was so expensive.  I learned that many of the books had been destroyed by hate groups and that drove the price of the few remaining copies up.  The reason I wanted to read After the Ball was because it was effective.  It changed the perception of gays in the 90s.  A friend of mine with a non-binary child pushed back as I was speaking with him saying that it hadn’t gone far enough.  I suppose that’s true – but it’s equally true that the ball was moved very far down the field towards acceptance of alternative approaches to sexuality.  (See The Anatomy of Love for other approaches to sexuality.)

I was hoping to find a way to bridge the gaps that were created over the past few years as the world faced COVID-19 and the divisiveness that had been created.  I wanted to find a way to help families heal from the divisions that formed Fault Lines.  I can’t say that I found those answers, but I did find some other answers that might be more valuable.

Hate Groups

Calling the religious right a hate group is likely to win me more enemies than friends but that’s what they are – or at least were.  Jesus’ directives are clear: love your neighbor; these things remain faith, hope, and love – and the greatest of these is love.  However, somehow some people get wrapped up in righteousness and pursue fear, hatred, and alienation instead.  Unable to reconcile homosexuality with their view of “right,” they lashed out and attacked – and they encouraged and legitimized psychological and physical harm towards gays.  The enlightened writing of Jonathan Haidt in The Righteous Mind wasn’t available – and probably would have been rejected if it was.  Understanding and acceptance of others wasn’t on the agenda.

I first encountered the title After the Ball in the book The Marketing of Evil.  It called out the book as evil.  I was so shaken by The Marketing of Evil that I broke my process of reviewing books for it.  I didn’t want to draw attention to a book that was so inflammatory.  I still feel that way today as I realize that the worst thing that After the Ball proposes is a propaganda campaign – something that even major corporations do all the time now.

In Defense of Sacred Ideas

It’s not that the perception that the Bible finds homosexuality wrong is completely unfounded.  The hate groups can point to passages that support their assertion.  The story of Sodom and Gomorrah is where we get the word “sodomy” from.  And yet, it seems as if the context is twisted and bent to fit the desires of those who tell the story.

For me, one of the most mis-told stories in the Bible is “turn the other cheek.”  While growing up, I probably heard the sermon a dozen times or more that this meant you should not lash out to protect yourself.  However, when you raise the historical context, you’re confronted with the awareness that what was likely being said is that you should give others a chance to show who they really are.  In historical times, one hand was used for wiping your feces and the other for interacting with others.  If someone was willing to smack your cheek with their left hand it was clear the kind of person they are.

The story of Sodom and Gomorrah is a story that is as much about a failing to respect others’ wishes as it is about sodomy directly.  However, it’s easy to miss this subtlety when the passages condemn the whole of cities instead of focusing on the fundamental lack of respect for one another.

Homophobia and Homo-hatred

The manifest problem isn’t a fear of homosexuality but rather is a hatred of it.  It’s not that people are afraid of homosexuality directly, it’s their lashing out against it and the decision that gay and lesbians must be somehow bad or evil.  It’s the response that causes us to separate the world into us vs. them, and homosexuals are decidedly “them.”  (See Mistakes Were Made (But Not by Me) for more on us vs. them.)

Hatred is the unfortunate and natural outcome of a fear.  Too few people are taught how to address their fears head-on and conquer them in a positive way with tools like desensitization.  (See The Body Keeps Score for more on desensitization.)  Instead of the fears getting smaller, the reactions get larger, and the result is the need to lash out to reduce the fear.  It’s been said, and it’s psychologically accurate, that those who lash out the most about homosexual behavior are the most drawn to it.  Their attacks on homosexuality are primarily to protect themselves from it.

The Big Lie

After the Ball calls it “the big lie.”  The lie is that homosexuality doesn’t exist.  The data puts it at about 10% of the population – and yet too many people don’t believe they know a single homosexual person.  At least, that is what the data said decades ago.  Somehow, one in ten people were homosexual, but people didn’t know anyone who was gay.  Given Robin Dunbar’s work on stable social relationships, this is statistically improbable.  (For more on Dunbar’s work, see High Orbit – Respecting Grieving.)

However, if no one knew anyone who was gay, then maybe, just maybe, it didn’t really exist after all.  We’re willing to accept that there are Yeti with shadowy, impossible to see photos that depict a dark blob, but when it comes to gays, we just can’t believe.

Come Out, Come Out Wherever You Are

“Olly Olly Oxen Free” was the call we’d make when hide and seek was over, that we had given up.  We’re still not quite there with homosexuals.  While much progress has been made with the acceptability of homosexuality, there are still prejudices and biases.  There are still stigmas and shunning, and it makes it hard for those who have homosexual feelings to come out into the open.  It’s hard coming out of the closet.

Courage is not the absence of fear, it’s moving forward despite the fear.  (See Find Your Courage for more.)  If you want to increase courage, you reduce fear.  More people put themselves at professional and personal risk by “coming out of the closet” and openly sharing their homosexual orientation.  This courage is one part of the plan for overcoming fear and hatred.  The more that gays and lesbians are seen as normal and acceptable, the harder it will be for individuals to be attacked, dismissed, and shunned.

Call It What You Will

An exasperated Abraham Lincoln was said to have asked his Cabinet, “How many legs does a lamb have if you call the tail a leg?”  The answer five came up and was quickly rejected by Lincoln. “Wrong!  It’s still four.  Calling it a leg doesn’t make it one.”  The easiest – but not the best — way to deal with a problem is to deny it exists.  The premise here is the problem that straight America just wants gays to cease to exist, and denying that they do in some distorted way makes it true.

Like Lincoln’s quote, it doesn’t make it so – but more importantly, I’m slightly disturbed that it’s framed as a problem.  Instead of looking at homosexuality as a different perspective or set of beliefs, many attempt to elevate it to a difference in values at the level of morality and immorality.  It turns out that what you call it – and how you communicate about it – really matters.

Real Immorality

Part of my frustration with it being converted into a moral issue is that I believe that immorality should be reserved for those things which violate the foundations of morality.  (See The Righteous Mind for the foundations of morality.)  Albert Bandura spoke of the conditions that lead to immoral behavior in Moral Disengagement, and Philip Zimbardo spoke of it in The Lucifer Effect.  Vicktor Frankl spoke about what he saw of the Nazi concentration camps in Man’s Search for Meaning.  The differences are striking.  The first moral foundation is care/harm, and these other examples violate care/harm in ways that all but a few deviants who happen to be homosexual haven’t done.  It should be quickly noted that there are plenty of heterosexual deviants, too.  The point is that homosexuality in and of itself doesn’t mean – or imply – that other people are harmed.

Certainly, we face issues then and today which could be called moral issues – but they’re not the issues about how we interpret the nuances of the Bible – or of other religious texts.  Because people don’t subscribe to your views and are not motivated by the same things that you’re motivated by doesn’t make them evil or bad.  It makes them different.  (See Who Am I? for more on Reiss’ 16 basic motivators and how we’re all motivated by different things.)

The Propaganda Machine

Propaganda gets a bad reputation.  It’s been used in very evil ways.  Perhaps the greatest example is the propaganda war that Adolf Hitler waged against Jews and Russians.  (The Russians get less attention because they had an army and put up a more violent fight.)  The propaganda specifically made both groups seem sub-human.  That process created the conditions which enabled the concentration camps and the attempted genocide.

Propaganda at its most fundamental is a one-sided approach to a topic designed to persuade others that the purveyor of the propaganda’s point of view is right.  The proposed Waging Peace Campaign rests on three pillars.

#1 – Desensitization

If you want to get over fear, the technique developed by Albert Bandura may just be the thing.  Afraid of snakes?  Find safe ways to look at pictures of snakes, then be in the same room, then near them, then touch them, then hold them.  It takes time, but desensitization works.  It’s not the fear of snakes that After the Ball is trying to cure.  It’s fear of homosexuals – and the process works en mass as well as it works one-on-one.  The more that homosexuals are portrayed in mildly uncomfortable but not threatening ways, the more normal it becomes, and the less fear there is.

We know that anything that becomes common elicits less of a reaction.  If encountering openly homosexual people is common, then it shouldn’t be such an issue.

#2 – Jamming

Another, more disruptive, approach to changing perceptions is to introduce two incompatible emotional responses at the same time.  For instance, introducing the idea of a wholesome family and then revealing that the parents are homosexual necessarily creates the need for the two conflicting emotions to be reconciled.  While the process is not easy for the individual, it can be effective at causing the lesser emotion to recede.

Other approaches to jamming place a negative emotion with the positive emotion that drives bigotry.  Bigotry continues because we receive a reward for acting on our bigotry, thus reinforcing it.  (See The Power of Habit for more on reinforcement.)  However, if you spoil the reward by adding in guilt, shame, or regret, you steal the power that the engine needs to reinforce the behavior and thereby lessen it.

#3 – Conversion

While the first two techniques are aimed at reducing fear and bigotry, the third is about increasing likability.  That is, while ambivalence is a good start when you’re coming from bigotry and hatred, it doesn’t go far enough to protect against backsliding.

The real trick is to create friendships with straight people – and to allow those friendships to spread.  This is easier said than done as Mistakes Were Made (But Not By Me) relates how Al Campanis could like Jackie Robinson and know that he was a fine baseball player but simultaneously not believe that he’d make a good manager.

Certainly, making friends and creating affinity with others is the right strategy, the degree to which it may be generalizable is questionable.

Out Come the Freaks

One of the most direct criticisms of the homosexual movement for equality comes in the form of the visibility of the “freaks.”  That is, those people who represent the furthest extreme.  Those who would seek to shock straight America into accepting the movement do more damage than good.  It’s for this reason that Kirk and Madsen recommend that the more socially acceptable come forward (where they’re able) to be spokespersons for the movement rather than allowing parades of debauchery to be the single message that heterosexual America sees.

After the Ball divides homosexuals into two broad categories.  The “Rs” look like and can be seen like straights – and they like it that way.  The “Qs” can’t look like straights – and they don’t want to.  They want to be queer (different).  Despite the natural aversion to standing out and being recognized as gays, if desensitization is to be effective, it needs the “Rs” to take up the banner.  Without the normalcy, gays could be rejected out of hand.

Free Software

Richard Stallman was the programmer-activist who led the charge for free software.  It’s spawned a whole market of open-source and openly licensed software that has made the world better.  Yet many in the world of open-source software cringe when they hear that he’s spoken at another event or to the press.  His beliefs are so extreme that they seriously jeopardized the legitimacy of open source software.

Quietly, other voices started emerging with more moderate views and a less militant approach to finding ways to drive commerce without perceived exploitation.  This is the same approach that After the Ball proposed for improving the relationship between heterosexual and homosexual people.

The Principles

After the Ball proposes a set of principles that gays should use to improve the situation realizing that gays would have to be better than straights to gain acceptance.  They are:

  1. Don’t Just Express Yourself: Communicate –Focus not just on expression but what the message is that you’re sending.
  2. Seek Ye Not the Saved nor the Dammed: Appeal to the Skeptics – The greatest opportunity for any movement is to appeal to those who are interested in learning more and who have not yet developed any prejudices.
  3. Keep Talking – The goal is simply to work on desensitization, and that requires a lot of low-grade discomfort. It’s the kind of discomfort that is acceptably generated through talking.
  4. Keep the Message Focused: You’re a Homosexual, not a Whale – Don’t pickup every other cause like lost puppies and bring them into the fold. Stay focused on what is important.
  5. Portray Gays as Victims of Circumstance and Oppression, not Aggressive Challengers – Look for support and sympathy rather than invite conflict, resistance, and battles.
  6. Give Potential Protectors a Just Cause – Make it easy for others to join the cause by focusing on the fact that gays are being discriminated against rather than trying to convert others’ sexual practices.
  7. Make Gays Look Good – Appearing as model citizens and pillars of society makes it easier for others to support you.
  8. Make Victimizers Look Bad – Where possible and appropriate, allow victimizers’ actions to become well known, so that others are repulsed by their actions.

Civil Disobedience

After the Ball has advice for civil disobedience, from ensuring non-violence (on the part of those practicing it) to communicating the willingness and acceptance of being arrested for the disobedience and the need to connect the act of disobedience with the cause.  Unfair taxation of tea preceded the Boston Tea Party, and so civil disobedience must make the connection between the act and the cause clear.

Stand and Be Counted

Today, we’re three decades after the publication of After the Ball.  Much has changed and gotten better.  Thankfully, gay bashing has receded to rarity.  However, there are still legitimate concerns about the degree to which someone can be open about their sexuality for fear of reprisal.  In some sense, this feels like a continuing journey.  It may be that there is no after in After the Ball; you’ll have to decide for yourself.

Book Review-Man Against Himself

One of the things about researching suicide is you get the very real sense that it’s somehow an internal conflict that boils over into an act of self-aggression.  It’s this very real consideration that leads to Karl Menninger’s 1938 classic book, Man Against Himself.  In it, he seeks to expose his experiences with people who choose to harm themselves – through suicide and other ways.  His belief is that our best defense against self-destructiveness is to bravely expose the inner thoughts of those troubled souls who choose self-harm so we may design interventions against them.

The High Cost of Living

For those who are in constant psychological pain, each day of life is purchased at great cost.  Every day weighs on them more heavily.  It’s these costs that we seek to reduce or eliminate and replace with sources of strength and resources that make them feel as if things are continuing to get better.  However, sometimes our efforts come too late, and people feel the weight of the deficit they’ve been running for so long.

Most of us can’t understand these burdens directly.  Nor can we seem to engage the broader public into the appropriate consideration of the factors that lead to suicide.  We find that suicide then – and now – doesn’t get the kind of attention it deserves.  Instead, we continue to ignore that living can extract a high price for those who are suffering.

External and Internal

If the pain is visible and external, it could be said that suicide remains a heroic death.  It’s the conquering of the forces of life and death that conspired to imprison the suicidal person.  If the torture is internal and invisible, then the suicidal person must have been crazy.  This view is prejudiced and dismissive of the power that our thinking has.  It invalidates psychic pain.  (See The Suicidal Mind for more on psychache – psychological pain.)

The truth is that all suicide is composed of both parts – the visible and the invisible.  We know of invisible things that are no less real because they’re invisible.  We can’t see magnetic fields, but we know they exist.  Most of us have never personally seen a pathogen – whether it be bacteria, virus, or spore.  That doesn’t stop us from becoming infected by them.  Despite our desire to be able to see and understand, we must accept that sometimes we’ll not know what the factors were and whether they were truly internal or if there were unseen external forces at play.

The Long Slide

Menninger proposes that the actual suicide attempt has a long prelude.  The decisions and thoughts that preceded the attempt led to the conclusion.  I struggle here, since the data about whether suicide is preplanned or not is inconsistent at best, with some people seeming to plan out an elaborate event and others seemingly impulsively deciding that the time is now.

That being said, I can acknowledge that many of the seeds of suicidal thought are sown years before.  Just as Dr. Spock learned decades later that his advice to parents may not have been as good as he initially thought, it’s possible that seemingly innocent comments and perspectives led to unhealthy and risky attitudes.  (See Finding Flow for more on Dr. Spock.)

Menninger relates several stories where thoughts that occurred in childhood came to be revisited as a specter in the future.

Self-Punishment

Crime doesn’t pay.  It’s a cliché that was broadcast to all of us in an attempt to reduce the desirability of a life of crime, but the fact that we need the cliché is an indication that this isn’t obviously true.  We’ve internalized somehow that all crimes must be punished – whether or not anyone else sees it.  In some ways, people pursue self-punishment as an atoning sacrifice before others could possibly implement sanctions against them.

Generally, the pull towards self-punishment is in a normal band and it keeps good people on the right track.  (See How Good People Make Tough Choices for more about this mechanism.)  For some, there seems to be no atoning for their perceived sins.  They’re angry at their mother; when she dies in an automobile accident, they blame themselves for her death.  There are no amounts of self-punishment that can compensate for this supposed injustice.  Never mind the fact that no amount of thinking about harm towards another person actually harms them until and unless it is acted upon.

For the suicidal person, it seems as if there’s always another infraction or injustice that must be atoned for, and some of those are so large that there is no way to pay the debt without sacrificing their own lives.  Our conscience “is a strong deterrent and a harsh judge.”

Enmeshment

Enmeshment describes identities of multiple people that are mixed, confused, and fused.  At the extreme, it’s pathological and creates a number of problems.  In its normative state, we all believe that we carry a part of someone else inside us.  We hear the words of our parents, our coaches, our former bosses, etc.  This can be comforting for survivors, because they can believe they continue to carry a part of the suicide victim with them.

However, for those who have pockets of extreme hate, it may create the opening thoughts need to provide a path towards suicide.  If I’m angry at my father, and I kill myself, I somehow kill that part of him that I carry inside of myself.  This isn’t the most direct or bulletproof logic, but it’s often all that a suicidal person needs to push them across the chasm.

Inconsistency with Self-Image

One of the quirky parts of suicide is that it is seen in people who are the recipient of sudden fortune as well as those who are subject to the expected misfortune.  This discontinuity can be explained by a sense of impostor syndrome and the belief that you don’t serve the recognition or positive results that you’re getting.  (See The Years That Matter Most for more on impostor syndrome.)  It denies your reality, and you believe that you can’t find a way to be seen as you see yourself.

The disconnect can lead to a sense of invalidation not just of self-perceptions but of the entire self, and this intensely conflicted state may drive the apathy that’s necessary to create the conditions for suicide.

Get Down or I’ll Shoot

A man is standing at the edge of a bridge considering jumping off as a form of suicide.  The police officer shouts, “Get down or I’ll shoot,” and the potential suicide attempter calmly steps down.  What kind of sense does that make?  Well, the kind of sense to be effective in a world of potential suicide.  Somehow, jumping off the bridge to your death could be okay, but being shot by a police officer is not.  Conversely, there are some people who choose “officer-assisted suicide,” deliberately provoking the police so they will be shot and killed.

There’s weird logic that works inside suicide, including the unescapable fact that many who attempt suicide and are critically injured (but are not dead) plead for assistance and reassure those helping them that they want to live.  Some will eventually die of their injuries, and some will not.  This only confirms the perspective that suicidal people are not singularly focused on death but are instead caught between the desire for life and the desire for death.

Predestined

Sometimes, parents or other authority figures label people.  Little girls are told about their “lot in life,” which must be submissive.  Black Americans are told that they’re inferior – even by their own parents.  The result is that sometimes they sow the seeds of later internal angst either because the person achieves more than what their self-image allows them to accept – or they aren’t successful, and as a result, they believe that they’ll never accomplish anything with their lives.

Tell a girl that she’ll be dominated by men, and she may just seek out precisely the kind of men that will make that label truth.  This is, of course, not what you want.

The Tragedy of Alcohol

At one point, the concern for alcohol was the DTs – delirium tremens.  However, as Menninger explains, he maybe saw one case a year.  The damage that alcohol does is not so much physical as it is psychological.  Sure, there are liver and physical issues – but those are not the most important ones.

The important observation he makes is that he’s been unable to identify the line between casual, social, and acceptable drinking and the point which it becomes an addiction.   That may be because that it is indeed gradual.  Addiction is a coping mechanism that gradually gains control over you instead of you over it.

Alcohol starts as an escape from the problems – but ultimately becomes a much bigger problem.  While it may, for a time, provide a justification for unjustifiable behaviors, ultimately people lose patience and see alcohol as the problem – instead of the solution.

It’s Okay, If They Let You

The big story of my time was the “chase” of O.J. Simpson’s white Ford Bronco on the California freeway and the trial that followed. “If it doesn’t fit, you must acquit.”  For most, the belief is that he got away with murder.  Though he never did admit it, the perception is still the same.

At some level, we continue to be shocked that people who have money, prestige, and power commit crimes – and are never charged.  Ultimately, the same behaviors that would result in prison time for the rest of us is somehow okay, because they’re special and different.  The problem, as Jerry Falwell, Jr. found out, is that you can’t betray the central images that allows you to maintain that power and prestige, or it will come crashing down.

Small Defects of Exaggerated Importance

One of the observations from the safety of outside of the suicidal person is that the problems the suicidal person sees as so large and so horrendous are rarely so bad to the rest of us.  The suicidal person seems to focus on their faults, limitations, and foibles no matter how small and catastrophizes them into unchangeable limitations that can never be overcome.

Instead of a balanced view of both positives and negatives, there’s the irrational magnification of the often-insignificant limitations.  It’s these insignificant things that often pits Man Against Himself.

Book Review-The Savage God

Reading about suicide through the lens of an author about the death of another author isn’t where I’d normally start.  However, The Savage God was referred to by both The Suicidal Mind and Myths about Suicide, so it was clearly a work that held some value for others, so I wanted to read it.  It’s a story – on the surface – about a relationship between Al Alverez and the couple, Ted Hughes and Sylvia Plath.  The key was that Sylvia Plath successfully completed a suicide attempt six months after being estranged from Ted.

No Solutions

Alverez is quick to point out that he has no grand solutions to suicide.  In fact, he doesn’t believe in them because, “Suicide means different things for different people at different times.”  While it may seem that this disclaimer implies that there is no insight into the suicidal mind, nothing is further from the truth.  While he offers no solutions, he does offer a better understanding of how life and death sometimes get tangled on the way to good art.

I must confess that I hadn’t remembered hearing Sylvia Plath’s name before this.  I’m certainly no great fan of poetry so while Virginia Wolff’s name was familiar to me, Slyvia’s was not.  (Virginia Wolff also died by suicide.)

Once a Decade

The attempt that took Sylvia’s life wasn’t her first – far from it.  She seemed to have a “deal’ with death.  She’d tempt fate with some sort of a suicide attempt once a decade, and if she survived, she’d get a new lease on life and a new energy that she could pour into writing.  This magical deal is apparently not unique to her situation, as is explained in Comprehensive Textbook of Suicidology.

Being an artist – a good artist – necessarily requires that someone opens themselves up to their emotions.  That process can sometimes overwhelm a person and make them feel as if they’re pouring out their emotions on the page – and they therefore need some way to replenish them.

Unmentionable Death

The idea that death is unmentionable is a new invention.  Throughout history, we’ve had a more intimate relationship with death.  However, somehow, we decided that if we would speak about death, we’d invite it into our worlds, and so it became the unmentionable.  It was always with us yet simultaneously unspoken.

Death, it seems, is now more taboo and less discussed than sex was for the Victorian era.  Now, we can discuss every form of sex, and the result has been a significant reduction in teen pregnancy.  (See Dialogue – Defensive Routines for more.)  Perhaps if we can regain a healthy respect for and willingness to discuss death and suicide, we can remove the mystery and reduce the magic allure of suicide.

Until the Next Do We Meet

What the Spaniards did to the native Indians was cruel.  The work and the torture were so unbearable for many that they committed suicide to avoid it.  The Spaniards became worried about the loss of their labor force and developed an equally cruel story to prevent the Indians from committing suicide.  They threatened to commit suicide themselves to go to the next world where they would be even harsher to the Indians than in this world.  Apparently, the tactics, no matter how cruel, worked, and the labor force was preserved.

Where most people believe that suicide is an escape, the Spaniards removed this idea.  If you believed that suicide would lead you to an even more torturous existence, then perhaps people wouldn’t try it.  This may be some of the hidden motivation for Christianity’s eventual condemnation of suicidal attempts.

Follow the Money

The Roman perspective on death was slightly pragmatic from a state point of view.  If one committed suicide, it was considered a crime in so much as it was avoiding other charges – and it primarily concerned the inheritance of property.  Property inheritance can be a big deal when it comes to wealthy families.  Capital in the Twenty-First Century explains the importance of inheritance and how our perspectives about it have changed.

For the Romans, there wasn’t a moral aspect to suicide, only a financial one.  Suicide meant that the state could seize a person’s property.  As a result, while suicide was relatively common, no one wanted the label for fear that it would mean their families would be deprived.

Coroner’s Records

Coroners often avoid recording a death as a suicide.  Some refuse to accept that it was a suicide without a note – even if the physical scene is clear.  As The Suicidal Mind shares, the percentage of people who leave suicide notes is low – maybe 20%.  Thus, it’s expected that official statistics that record suicide may still be underreported after many of the legal sanctions have been repealed – and very few are enforced.

This partiality may be seen as compassion on the part of the coroner – and in some cases, it may be comforting to the loved ones left behind.  More broadly, it creates challenges as we try to get an accurate picture of suicide, since we can’t trust the records to tell us the true rate of circumstances.

Ambition Beyond Ambition

Alverez makes a statement that rings true with the statistics: “Here’s the difficulty about suicide: it is an act of ambition that can be committed only when one has passed beyond ambition.”  What rings true about it is that it has been frequently observed that suicide attempts increase at the end of depression treatment.  If depression is a causal factor for suicide, why should people be more susceptible at the end of a successful course of treatment?  There are two plausible answers.

First, depression has a noted psychomotor retardation.  That is, people who have depression don’t want to do anything.  So, if the desire to do nothing recedes before the desire to continue life, you get the willingness to do something – even attempt suicide – which previously seemed like too much work.

The second plausible cause is that people, recognizing the improvement, start to return to the focus of their own lives and other cases.  As a result, the person feels abandoned in some small or large way.  The result is a perception that their life going forward would be one of emptiness and loneliness.  (See Loneliness for more on loneliness.)  One must remember that depression robs a person of the joy that they would normally feel.  Without full restoration of joy, they may see little positive in their lives if people withdraw from them.

The “Logic” of Suicides

Suicide, Alverez notes, is a closed world with its own irresistible logic.  That is, the world of superstitions and omens – what Comprehensive Textbook of Suicidology described as magic.  Our self-talk, our internal voices, are personified, and those that are reassuring and supportive can be pushed away so that they’re no longer heard or hearing them requires great strain.

Of course, for most suicide victims, there is no logic, only twists and turns that appear as logic when the mind is troubled.  (For more on how things can look logical but are not, see Mastering Logical Fallacies.)  As these fallacies become exposed to the person themselves, they may seek suicide as a way to escape the pain of the confusion and conflict in their heads.

The Final Reveal

After sharing insight into Slyvia Plath’s eventual suicide and the events that led there, Alverez finally admits his own attempt at suicide and his reticence to admit that fact.  It seems that even in those who’ve ultimately resisted the allure of suicide, there exists a sense of The Savage God that those who succumb are painfully aware of.  Maybe in reading The Savage God you’ll find a way to live with the image or to understand those who have succumbed to suicide.

Book Review-Bruised and Wounded

While most of the books that I’ve been reading and reviewing over the past several weeks (and months) are focused on the clinical diagnosis of suicide and its prevention, Bruised and Wounded is focused on those who are left in the wake of suicide. The loved ones who must find ways to bravely soldier on when they know that their compass has been lost, and the only map they have no longer applies to the situation.

Maps and Compasses

Our beliefs about the world and the way that it works allows us to predict the future and thereby live in it. Humans are prediction machines (see Mindreading), and to do our marvelous task, we must take many things for granted. Gary Klein, in Sources of Power, is clear that our ability to simulate situations is quite limited, and therefore simplification is necessary. That means we must accept some truths as invariant.

The loss of a loved one, whether a sibling or a child, is a tragic reorganization of the way that things should work. No parent should have to bear the death of their child. It goes against the natural order of things. When something goes against the natural order of things, we know that it’s reorganizing the way that we see the world.

Kinds of Diseases

There are effectively three different kinds of diseases we can encounter:

  • Curable – The kind of disease that we have a treatment for.
  • Treatable – The kind of disease that the person will always have but we can keep at bay through treatment.
  • Terminal – The kind of disease for which we can do little to prevent the person from succumbing to.

While these are the medical versions of these categories, there are similar mental health answers. Some things we’re equipped to address completely, some we can mitigate, and some we have no chance of controlling or conquering.

Those who have encountered a loved one who committed suicide are familiar with the final two types as their loved one fell into one of them. Either their condition seemed unalterable despite the best efforts, or it was under control until something broke, and it couldn’t be (or wasn’t) kept in check any longer.

Desperate Attempt

As was addressed in The Suicidal Mind, suicide is an escape from psychic pain. Bruised and Wounded takes it one step farther to describe it as a desperate attempt. It’s the “only” remaining option. (This is also in The Suicidal Mind.) There are no options left that are good to escape the pain, so this is the only option left.

The fact that it’s a desperate attempt furthers the need to protect and encourage hope in everyone. (See The Psychology of Hope for how to do this and The Hope Circuit for more on why.)

The Rhythm of Recovery

Recovery from loss has its own rhythm, as explained in The Grief Recovery Handbook and On Death and Dying. Recovering from the loss of a loved one is difficult and unpredictable. However, there is a way to recover from being Bruised and Wounded – it might just be found in the book.

Book Review-Comprehensive Textbook of Suicidology

In principle, I must disagree with any book that calls itself comprehensive. It’s impossible to contain everything about a topic in one tome – in part because there’s always new discoveries, and in part because it’s hard to define the edges of a particular area of knowledge. Despite my semantic objections, Comprehensive Textbook of Suicidology does provide a rather impressive array of topics related to suicide.

It’s in the Water

Some cultures seem to repel suicide. Their suicide rates are impressively low, while other countries seem to attract suicide like a magnet. They seem to encourage suicide by their very being. What differentiates one culture from another and causes it to resist suicide isn’t really known. However, there are many factors related to what is – and is not – acceptable as well as degrees of connectedness and other factors. Trust: Human Nature and the Reconstitution of Social Order explains how, while trust is essential in our societies, where we place our trust – in family, company, society, country, etc. – can have a profound impact on the way that society functions and its efficiencies.

So, while little is known about why certain countries are resistant, we do know that some are – and we can look for clues to what might help other societies resist suicide better.

Risk and Protective Factors

Suicide is filled with conflict, the apathy between the desire to live and the desire to die. (See The Suicidal Mind.) Moreover, there are factors that increase someone’s risk of suicide and factors that seem to provide some degree of protection from suicide. This is one of the key challenges with creating an assessment for suicide risk. You can’t just tally up the risk factors and declare a person’s risk for suicide; you must also consider what factors they may have that form a protective bubble around them.

Only

The worst word in suicidology is the word “only.” It’s the worst word, because it’s the expression of the kind of cognitive constriction that leads to deciding suicide is a good option – or, rather, the only option. The tricky part is that if we want to reduce people attempting suicide, we’ve got to make sure that the word “only” isn’t the only word in their vocabulary.

I mentioned in my review of The Neuroscience of Suicidal Behavior that Phillip Tetlock’s work in Superforecasting may hold a key to teaching more people more cognitive diversity and provide some protection against suicide attempts.

Establishing Intention

One of the challenges as it comes to suicide is determining what was a suicide attempt and what was an accident. Consider an automobile accident where a car runs into a tree or a concrete barrier. Was it someone who had a stroke, fell asleep at the wheel, or decided to attempt suicide via an automobile accident? You might be inclined to consider whether there were tire marks indicating hard breaking – but if you did, you’d have to consider that many people change their mind at the last moment, as is evidenced by survivors who jumped off the Golden Gate Bridge (see The Suicidal Mind for more).

The problem for those who are successful at suicide is we’ll never know what really was going through their head. For those that were attempters the shame associated with both suicide and the failed attempt makes self-reports somewhat suspect.

No Switching

There’s a misconception – also covered in Myths about Suicide – that if you stop one suicide attempt, they’ll just find another way. However, the research says differently. If you’re able to remove the preferred method of attempting suicide, they’re unlikely to switch to another form. Certainly, you can’t prevent someone who is intent on committing suicide by removing the most preferable means, but it does have a profound impact.

So, if there’s an opportunity to prevent a suicide attempt or thwart it, we should.

Short Term Protection, Long Term Problem

Sometimes the things we do can provide short term protection but when overused create problems. This is the root of addiction. An addiction is just a coping strategy that begins to take control of you instead of you controlling it. (See The Globalization of Addiction and Dreamland for more.) Despite the risk of alcohol myopia, alcohol can be a short-term strategy for coping with intense stress. Since cognitive constriction is a problem, alcohol unnecessarily narrowing one’s field of view into a myopia is bad. (See The Suicidal Mind for more about alcohol myopia.)

The challenge is that, over time, the risk of a suicide attempt increases if alcohol is continued. Why isn’t precisely clear, but certainly those who could self-identify or be identified as an alcoholic are at substantially greater risk of suicide than those who use alcohol more sparingly.

Loneliness and Isolation

Much has been said about the protective benefits of being connected to other people. Connections with family, friends, clubs, churches, and community have a protective effect against suicidal attempts. The opposite of the spectrum is loneliness. To be clear, one can be alone and not feel loneliness. It’s the perception that there are no other people who care about our wellbeing that represents the risk. (See the book Loneliness for more.)

The greater degree to which someone is isolated, the more at risk they are for feelings of loneliness and therefore suicidal attempts. While we all have varying degrees of need to be socially connected, we all have a minimal need that, when not met, can create dysfunction and pain that drives people towards suicidal ideation. (See Who Am I? for more on motivating factors for people and the different needs for social contact.)

Failure to Fire

One of the challenges for suicide prevention is that, while suicide itself is rare, suicides which are the result of triggering events are even more rare. It’s not that you need to be particularly concerned with someone committing suicide immediately after the death of a loved one or someone with whom they were close. Statistically speaking, people rarely make an immediate or quick decision to “join” the person they lost.

Even other stressful life events rarely push people towards immediate action. It’s not until there’s an opportunity for the feelings of hopelessness to develop and settle in that people decide that they may want to take their own lives. (See The Hope Circuit and The Psychology of Hope for more on hope and hopelessness.)

History of Suicide

From the point of view of contemporary society, suicide has a stigma attached to it. The family of someone who has attempted or committed suicide is seen somehow to blame for the suicide attempt. It’s seen as a shameful act or a failing on the part of the family to provide the kind of stable environment that we all believe leads to well-adjusted people. However, as Judith Harris Rich explains in No Two Alike, there are some things in the environment that just cannot be controlled.

Throughout history, the role of suicide in society has changed rather substantially. In ancient times, controlling the time of one’s own death was a glorified way to die. If you couldn’t die in battle, then suicide was the next best thing. Suicide was also a practical matter. You were expected to commit suicide if you were a burden on society.

Historically, the prohibition against suicide was to prevent you from escaping prosecution for other crimes. It was an economic matter. If you committed suicide, particularly before being charged with another crime, the suicide claim would be made as well causing the seizure of your assets. So, the earliest perspectives on suicide were practical.

When Christianity began to become more popular, a problem arose. Christians promised a great afterlife. You could commit suicide and get there sooner. Therefore, it became necessary to prevent people from suicide to further the faith and to keep the followers from prematurely terminating their own life. The church therefore came up with a set of reasons why suicide was not acceptable – including connections to the sixth commandment, thou shall not kill.

This shift caused suicide to be shunned and ostracized in most places across the planet. While, officially, Christianity has decided that suicide is the result of a mental illness, the stigma against it has not fully receded.

Mental Illness

In many ways, seeing suicide as a mental illness is a good thing. It opens up the door from sinner to victim and removes the sense of volition and therefore culpability from the act. However, this transition has further connected suicide with stigma – as mental health issues still carry a strong stigma of their own.

The other sticky part is the circular logic that sometimes occurs. It is – on the surface – illogical for anyone to want to commit suicide. Therefore, they must have a mental illness – or be insane. In a circular way, to consider suicide you must have a mental illness, even if there may be rational reasons.

Unbounded Optimism

One way to sidestep hopelessness is unbounded optimism – the unbounded optimism of a child. The study saw a very low rate of suicide in younger people. The question became what is it about a child that prevented suicide attempts? (As a sidebar, we’re younger and younger attempts so this may be a historical artifact.)

The answer may be in the fact that for most children all problems are solvable. Their experience is that the problems they see are often solved by their parents and other adults around them. As a result, they are subject to an optimism that no matter what their problems are that they’ll be solved. As people get older, they develop more experience with unsolvable – or seemingly unsolvable problems.

Expected Burdensomeness

Another potential reason is related to what Thomas Joiner points to in his model of suicidal behavior, which is the degree to which someone perceives that they’re a burden. (See Why People Die by Suicide for more on his model.) However, it’s the perception of burdensomeness that matters. Children seem remarkably resilient to understanding the degree to which they’re a burden to their parents.

Parents of teenagers are quite aware of how their children believe they could live on their own and do a better job. They fail to realize the amount of effort that the parents put into their care and support – and therefore don’t feel like they’re such a burden.

Escaping the Pain

There are stories all the time of parents and spouses who murder a person who harmed their loved one. Courtroom shootings are rarer today with the advent of metal detectors outside many court rooms, but it was not uncommon to see defendants getting shot and killed by those who were grieving a loss of a loved one – or a loss of innocence of a child. The temporary insanity defense exists, because people in psychological pain do things that they would not normally do.

People who attempt suicide are doing so because the psychological pain they’re feeling is unbearable. They either believe the current pain is unacceptable or that, over the long term, the pain they face is unbearable, and they don’t expect that it will ever get any better.

Migratory Suicide Risk

One of the key areas of integration that is often overlooked when talking about how connected people are is community integration. Robert Putnam’s work on social capital that he’s written about in both Bowling Alone and Our Kids seems disconnected from the risk of suicidal behavior. However, when you consider that people who have immigrated – who have migrated from their home country – are more susceptible to suicide and suicidal attempts, it causes you to ponder the role not just of intimate connections but the connections that exist between friends and communities.

Robin Dunbar discovered a correlation between the size of the neocortex and the number of stable social relationships in primates – including humans. He suggests that there are different “rings” that relationships operate in and that we need all of them to meet our social needs. (See High Orbit – Respecting Grieving for more.)

Ultimate Alienation

Suicidal people are unable to accurately assess the impact that their decision will have on others. They simultaneously create a burden of the loss itself in the form of grief, anger and rage that the person would desert them, and guilt at having failed them. It’s what Eisenberg called the ultimate alienation. There is, of course, no resolution or reconciliation to this alienation.

With work, families and friends can sidestep the guilt associated with having failed the victim. They can accept that nothing that they could have done would have changed the outcome. While this is a hard place to get to, it’s possible.

The feelings of being deserted may be mediated by the belief that life is good – and that the person who died by suicide was either in different circumstances or didn’t fully appreciate the good things in the world. However, this requires adopting a fundamentally positive view of life that is particularly difficult in the wake of such a loss.

There is no escaping the grief component of the loss. (See The Grief Recovery Handbook for more.) There are ways to move through it more or less effectively – but that’s not the same as avoiding it all together.

Social Integration Failure

Suicide disproportionally impacts family environments that are unstable and chaotic. It is accepted that when social capital is reduced – what the book calls “social integration” – negative social consequences including suicide, divorce, and crime rates increase. It is, therefore, important for society to continue to create and reinforce social capital. Unfortunately, as the work of Robert Putnam in Bowling Alone and Our Kids attests, our social capital has been in decline for decades. The Great Evangelical Recession and Churchless both reinforce the churchgoing aspect of the social capital decline.

Sherry Turkle explains in Alone Together how the ways technology causes us to connect isn’t the same as when we are face-to-face. We’ve realized that the world is flat, and that we can connect with anyone across the world, so we’ve lowered our tolerance for others who have different views than us and we’re seeing that show up everywhere. The polarization of politics is just one of the ways that we can see how people can’t get along anymore.

One of the hidden aspects of 12-step programs is that they provide a new, healthier community for people to connect with. (See Why and How 12-Step Programs Work.) This implies that if we want to reduce suicide, one of the best approaches may be to change the overall social capital environment that we find eroding around us.

Magical Acts

For the suicidal person, the act is a magical experience that somehow transcends death and brings life. It’s more than the belief in reincarnation or an afterlife, it’s a perception that somehow death is itself life. It’s akin to the language that many self-harm inflicting cutters use when they say that the pain reminds them that they’re alive – or that it suppresses the psychological pain they’re feeling (see The Suicidal Mind).

It makes sense that, if the act itself isn’t rational given the traditional bounds of that world, there must be some rationale in the act – and to imbue the act with magical properties allows someone to pursue the irrational, delusional, and illusory.

We can see this in reports of people who’ve attempted suicide only to regret that decision once they see there is no magic in it. Whether it’s going to the emergency room, dialing 911, or applying the brakes immediately before hitting a tree, we see that, when the bubble of magic snaps from around the act, there’s a sense that it’s wrong. There are some so committed to the act that even the fact that the attempt isn’t going as planned won’t free them from the magical pull; but for at least some, when the magic is gone, so is the desire to attempt it. This may further explain why so few suicide attempters make a second attempt. (Any number above zero is too many, but it’s still substantially less than what one might expect.)

Mostly Drunk at Death

On the surface, people believe that here’s a medical point where the amount of alcohol in your system makes you “drunk.” However, complications like tolerance and the reality that “drunk” is a social construct make it impossible to point to a single number that represents drunk. The legislature and courts have defined “drunk” in the context of driving and the point at which they believe the impairment is too much to safely operate a vehicle.

However, we probably all know people for whom one drink is too much and others for whom one drink seems to have no impact whatsoever. As a result, there’s no single number that indicates drunk beyond reason. It’s important to realize this as we learn that most suicides have some degree of alcohol in their system at the time of their death. Was it enough to “take the edge off” or impair judgement? There’s no statistic that can give us this answer.

Daredevils Entertain

At some level, we’ve all got a desire to tempt fate and cheat death. We used to pay to watch daredevils entertain us, because we believed that, in their ability to do the impossible and cheat death, we were somehow cheating death ourselves.

Today, we watch horror movies to feel the adrenaline rush as we live the stories from the safety of our theatre chair or home. We ride roller coasters for the danger that our brains perceive even as we intellectually know that we’re safe. As The Worm at the Core explains, a lot of what we do is to avoid our fear of death. However, what happens when we’re no longer afraid of death? At some level, don’t we invite the possibility of suicide – or homicide?

We hear about murder-suicides in the news because they’re rare and therefore newsworthy. What we don’t hear about is how underlying both murder and suicide is a fundamental loss for the value of life. We miss that the heart of both problems is simply that life no longer has meaning.

Escape from Real Life

There are numerous ways that we escape from real life. With immersive virtual reality environments, we quite literally start to work in a world that exists only in the patterns of the computer and in our own minds. Even without virtual reality, we can become consumed by the two-dimensional experiences of the games that we play.

Comic conventions, costume play, and reenactments are other ways that we escape the real life of today for something different. It may be for pure amusement or as an escape from the challenges and fears that surround today, but they are escapes nonetheless. Suicide can, for some, be seen as an escape from a reality that seems too cruel, too overwhelming, or too gloomy to face.

Self-Punishment and the Need for Compensation

Some people have learned that they’re bad in some way or another. Using the social standard and legal restrictions of the day, they judge themselves to be bad. (See The Righteous Mind for more on the evaluation criteria.) They’ve also internalized that people who are bad must be punished – whether they’re discovered or not. As a result, they resort to self-punishment to compensate for the wrongs that they’ve done.

The challenge with this is that the transgressions are often exaggerated in the minds of the self-persecuting. They fail to offer the same situational allowances that others would make. They judge themselves guilty and allow for no extenuating circumstances.

This leads to normalization of self-harm, which, as Dr. Joiner explains in Why People Die by Suicide, may be a factor in an ultimate attempt. However, more directly, should the transgression be large enough, it’s possible they’ll believe that their death is the only atoning sacrifice that can be made.

Compensating for Safety

How can making things more safe lead to more accidents and fatalities? That’s the heart of the problem of making things safer. Depending upon our assessment of the difference in safety, we may – and often do – overcompensate with riskier behaviors. If you’ve driven in a snowstorm and been passed by someone in a four wheel drive vehicle, you may have wondered why they’re driving so fast. The answer lies in their perceived safety.

They have a surefooted start from a stop, and because of this they develop an overconfidence in their control of their vehicle in treacherous conditions. The results are sometimes catastrophic as they’re unable to stop or stay on the road when it comes time.

With suicidal behavior, it may be that people tempt fate so many times that they begin to believe that the relative safety of their experience makes them immune from death’s grasp, and they “unintentionally” cause their death without necessarily directly attempting to commit suicide.

Good Death

Euthanasia is literally “good death.” Survivors would rarely say that their loved ones died a good death. In some cases, such as medical health decline and perceived burdensomeness, it may be that the death is good and a relief to the family. However, at the broader level, few people wish their loved ones were dead – except perhaps to prevent their further suffering.

Yet some who consider suicide believe that somehow their death will somehow be made good by the act. The believe that their life is a burden or that the inevitable death they may face will be painful or in some way unfitting.

No Blame and No Control

There are many who would blame the survivors for allowing the person to attempt – let alone complete – suicide. This operates from the mistaken belief that one person can control another. (See Compelled to Control and The Nurture Assumption for more.) The truth is that the survivors are no more responsible for their loved one who died by – or attempted – suicide than anyone else. They just happened to be standing closest to the person “when the music stopped.” At some point, the perception needs to shift from blame to compassion and support.

If you decide that you want to understand more of the good and the bad about what we know about suicide and survival, maybe you should consider the Comprehensive Textbook of Suicidology.

Book Review-The Neuroscience of Suicidal Behavior

In my journey in the wake of suicide, the most common thing that I hear is “it doesn’t make sense” or “it is so senseless.” The survivors who must clean up the mess that the person who committed suicide left are wondering why. The Neuroscience of Suicidal Behavior offers no definitive answer but does offer clues towards our own understandings of the tragedy.

The Pseudo Why

There is an answer to “why,” but unfortunately the answer isn’t satisfying. Van Heeringen explains, “Every suicide is the tragic outcome of profound personal suffering and mental pain.” Mental – or psychological – pain drives the desire for suicide, whether planned or impulsive. (See The Suicidal Mind for “psychache,” Shneidman’s term for this condition.) Suicide isn’t a problem for the person attempting it, it’s a solution. It is too often the “only” solution that they see available to them.

The answer is unsatisfying, because too often we ask what kind of psychological pain could be so pervasive and large that someone could find no way out or around the problem. Those on the outside objectively view the problem and recognize that most of the problems in life – the things introducing psychological pain – are solvable. Thus, the idea that the suicidal person saw something difficult is difficult to see.

Degrees of Suicide

It seems as if suicide is binary. Either the person killed themselves, or they did not. However, the edges aren’t so easy. Consider attempted suicides. Should they be considered suicidal? Do you only count them as suicidal if their attempt would have succeeded if not for the intervention of others? What about those who are self-harming (e.g. cutting)? Are they considered suicidal before their first attempt? What about those who claim to have attempted suicide, but it’s later discovered that they made no attempt? How do we classify those who run their cars off the road into trees? Were they being intentional – or not?

Given that ~70% of suicidal attempts are successful on their first attempt, it’s worth being concerned about where we draw the lines. Thus, instead of one word for suicide, van Heeringen shares a few terms: parasuicide, pseudo-suicide, deliberate self-harm, self-harm, and non-suicidal self-injury (NSSI).

To categorize suicidal attempts, three dimensions are introduced:

  • Lethality – To what degree is the action (or inaction) going to lead to death? Will it be immediate or take a long time to complete?
  • Planning – How much work did the person put into planning their attempt? Was it meticulously planned or seemingly impulsive?
  • Intent – Did the person intend death, or did they create situations that would likely lead to their avoidance of death?

Non-Suicidal Self Injury (NSSI)

Thomas Joiner in Why People Die by Suicide was clear that he views the willingness to inflict self-harm as a key factor in suicide. Van Heeringen seems to agree, indicating that NSSI may be a “gateway” to unlock more lethal forms of self-harm that lead to suicide.

Economic Uncertainty

An odd statistic arises. In the quest for correlation, unemployment was considered as a contributing factor to suicide. However, the odd conclusion was that suicide rates rose before unemployment rates. There are several potential explanations for this. (Emile Durkheim said, “These being the facts, what is the explanation?”)

One explanation is that it is economic uncertainty that causes suicide rates to rise. This is consistent with Durkheim’s suggestion that it’s the transition in the economic situation that causes the rise in suicide rates. Both at the top and bottom of the business cycle, suicide rates are reduced.

This is supported by the idea that victims of suicide typically have an inconsistent work history. The prospect that competitors or a new technology will invalidate the need for someone – or discussions of performance on the job – can easily drive people to the belief that their only answer is suicide.

Stress

The neurochemicals inside the brains of those who have committed suicide are different than those of a representative sample of the general population. They have a blunted reaction to cortisol, suggesting that they may have habituated to abnormally high levels because of persistent stress. (See Why Zebras Don’t Get Ulcers for comprehensive coverage of neurological and physical aspects of the stress response.)

Other impacts of stress may create challenges as well. For instance, tryptophan is a precursor to serotonin, a key neurochemical associated with feelings of happiness. Stress causes pathways for tryptophan that may cause a reduction in the amount available for the creation of serotonin. Thus, stress management is a key tool for preventing suicide. (See Emotion and Adaptation for more on stress management.)

Parasites

One of the other insights from Why Zebras Don’t Get Ulcers is Helicobacter pylori. It’s the pathogen (bacteria) that causes ulcers. Many people are infected with it, but it lives in homeostasis in the stomach. It survives the acidic environment but rarely gets the upper hand. Introduce stress, and the body reduces immune response and repeatedly decreases digestion. The result is that H. pylori gets the upper hand and eats through the lining of the stomach.

A parasite called Toxoplasma gondii may have a similar relationship with our immune system – reaching a balance that doesn’t seem to impact us but may have important implications for suicide. It’s estimated that 30-40% of humans are infected with T. Gondii, but for most of us, it doesn’t seem to be a problem. However, immunocompromised patients may succumb to toxoplasmosis.

This is moderately troubling, but the story gets more troubling when you realize that, in rats, T. Gondii inhibits fear of cat urine. (See Dreamland for more.) T. Gondii replicates in cats. Obviously, rats’ natural predators are cats. They should fear cat urine, because it means that a cat is around. T. Gondii seems to shut down this fear. The result is an infected rat is eaten by another cat who becomes a host for T. Gondii and the cycle of replication increases.

If we consider that suicide isn’t a desire to die but rather the conflict of the desire to live and the desire to die, tipping the scales towards less fear of death can have tragic consequences. Multiple research studies have shown an increased prevalence of T. Gondii in suicide attempters and those who have completed a suicide attempt successfully. If Worm at the Core is correct in that the fear of death drives us all in persistent but unseen ways, removing the fear of death could have tragic consequences. This means that T. Gondii may play a sinister role in suicidal deaths.

Impulsivity

One of the key unanswered questions with suicide is the degree to which suicides are planned. Some factors point to the idea that all suicides are planned – but much research implies that it’s not. For instance, it’s estimated that 1 in 6 people have considered suicide at some point – and Thomas Joiner argues in Myths about Suicide, this should be considered preplanning.

Conversely, we know that more restrictive gun control laws, which limit access to lethal weapons, tends to reduce the incidence of suicide. In short, removing the weapon from a time of impulsivity has the effect of preventing the suicide. However, impulsivity of self-harming behaviors doesn’t appear to correlate well with the personality trait of impulsivity.

Not All Indicators Are Created Equal

Perhaps the largest problem in preventing suicide is that there are no clear indicators that indicate a high likelihood that someone will – or won’t – attempt suicide. Even the opening quote regarding mental (psychological) pain isn’t sufficient on its surface. There are many people who experience both physical and psychological pain who don’t commit suicide. Consider Vicktor Frankl who wrote Man’s Search for Meaning. He experienced unimaginable pain as a prisoner of a concentration camp and yet took that experience and developed logotherapy to help others – rather than end his own life.

Even though 1 in 6 people may at some point in their lives consider suicide, only about 12 in 100,000 are successful in a suicide attempt. Clearly, there’s a large discrepancy between those that give suicide some thought and those who act on their thoughts.

However, one of the recurring concepts is the sense of hopelessness that those who are attempting suicide feel. They feel as if suicide is their only escape from their pain. In fact, at least one person who attempted suicide has felt suicide was their only option until they leaped from the Golden Gate Bridge, at which point they realized every problem in their life was solvable – except for having just leapt from the bridge. (See The Hope Circuit for more on hope, and The Suicidal Mind for more on the story.)

Normal and Abnormal

As survivors struggle to understand, they often recognize that the situation the suicidal person found themselves in wasn’t unique or abnormal. Suicide is not, therefore, a normal reaction to an abnormal situation. It is instead an abnormal reaction to a normal situation. We all lose love, get divorced, and suffer all kinds of loss. (See The Grief Recovery Handbook for grief as a response to loss, and Divorce for more on the specific loss of divorce.) Since the precipitating factors are normal, we can only conclude that suicide is an abnormal response to the normal situations that many of us find ourselves in from time to time.

If we’re going to find a way to reduce suicide, we need to be able to develop skills in everyone to avoid these abnormal reactions, and we must be able to detect when these abnormal responses might occur. One clue may be the ability to assign value to long-term risks and outcomes – or not.

Constricted Thinking

In Why People Die by Suicide, Thomas Joiner explains the constricted and constrained thinking that often happens with suicide attempters. However, there may be an even earlier indicator available – that is their ability to properly assign risk to long-term consequences. If you’re going to predict well, you might look at Nate Silver and his book The Signal and the Noise or Philip Tetlock and his work in Superforecasting. Both look at the process of predicting future events and how to make those predictions more accurate. Tetlock in particular made a striking observation. Those forecasters with the greatest precision had greater cognitive diversity.

The best forecasters are those who consider the situation from multiple perspectives. Instead of viewing things with one point of view, they intentionally cultivate alternative views – and try to evaluate the relative merits. It’s the same sort of thing that Scott Page encourages in The Difference. However, instead of the diversity being experienced inside the mind of one person, it’s shared across a team of people – which may be a way to accomplish both diversity of thought and social connection.

Entrapment and Hopelessness

The problem with constricted thinking is that it leads to the perception that there is no way out – or only one way out. This can lead to a feeling of entrapment in a situation – whether you actually are or not. Often, it’s constricted thinking preventing visibility of other options, like blinders on a horse. You can only see the most obvious and easy solutions before you, no matter how bad or even ridiculous they are when evaluated rationally.

The problem with entrapment – as it pertains to suicide – is that it’s difficult to identify when someone might feel trapped, because it happens due to internal mental processes being decoupled from reality. (Sometimes with the assistance of alcohol.) It’s equally true to say that the suicidal person is entrapped by their own thinking as much as – or more than –the circumstances they find themselves in. They’re in a prison of their own making. Other options and those who care are all locked out.

Because of mental entrapment, people feel hopeless – and that’s one of the most dangerous situations that someone can find themselves in. Like a trapped animal, there’s no telling what a hopeless person will do – and as evidence, I offer that they sometimes attempt suicide.

I explained in my review of Why People Die by Suicide how too few people really understand how hope works – and what can be done to cultivate it as a cognitive process.

Epigenome

“They come from good stock.” It’s a statement that exposes the layperson view of genetics. Born (literally) from agricultural beginnings, the statement hints to the kind of genetic predisposition that our research into the details of the human genome has led to. However, genetics have their limits, as we’ve discovered. Instead of the genes laying out a predetermined path for a person (or animal), they seem to interact with the environment to form the lives of people. The question isn’t nature (genetics) or nurture (environment) – it’s both. (See No Two Alike and The Blank Slate for more.)

Some of the strangest observations in all of science are things like the Adverse Childhood Experiences (ACE) study, and how the health of adults is substantially influenced by the number of stressful events that a child faced decades earlier. (See How Children Succeed for more.) It appears that the causal arrow can come from a quiver even earlier in the life of children. FOAD – Fetal Onset of Adult Disease – proposes that the life of a child is influenced by the stress that the mother faces during pregnancy. (This is the research of David Barker, and it’s recounted in Why Zebras Don’t Get Ulcers.)

Specific Memories

One of the keys to knowing if someone is being completely truthful is the degree to which they’re able to recall specific memories. In hiring, it’s suggested that we look for specific examples. (See Who: The “A” Method for Hiring for more on hiring, ) If we’re trying to determine whether someone is lying or not, we’re encouraged to use specific language and questions to trigger a monitorable response. (See Telling Lies for more.) When speaking with children, we know that we’re not getting real answers if they don’t involve specifics. (See How to Talk So Kids Will Listen & Listen So Kids Will Talk.)

In the context of suicide, research shows that those with a higher probability of suicidal behavior are less likely to access specific autobiographical memories. They respond with generalities about how their childhood was okay or that they were happy. Those who are less likely to have a suicidal behavior are able to access specific memories – both positive and negative.

Physical vs. Psychological Trauma

One of the common factors in those with suicidal behaviors is some sort of abuse as a child. Both physical and sexual abuse are associated with future suicidal behaviors, but there is an interesting intermediating factor. It’s not the age at which the abuse started or even its duration. The factor is the relational proximity between the abuser and the child. Parents seem to have the greatest impact, followed by siblings, relatives, and close friends.

This seems to suggest that it’s not the physical trauma that is the primary factor. It suggests that it’s the betrayal and resulting lack of safety that create the greatest difficulty. (See Trust and Betrayal in the Workplace for more on betrayal and Find Your Courage for more on safety.)

No matter what brings you to interest in suicide, The Neuroscience of Suicidal Behavior will increase your awareness and understanding of the tragedies that occur before the tragedy of suicide.