Book Review-The End of Hope

What differentiates the good programs from the bad?  How can you find the programs that will make a difference for addiction or suicide?  What if the answer comes down to hope?  The End of Hope is a retrospective of an affluent, private hospital that operated for years with no concerns for the suicide of its patients, but it faced a change when one patient made an attempt and it triggered four more – including a few successes – in the period of six months.

What could cause a facility with a great record and a belief they could cure anything to become the home of an epidemic?

The Power of Placebo

Was the success of the hospital due to the people that came together to start it or the brilliant work of the director of nursing?  Maybe.  It’s possible that they facility operated flawlessly but then lost their groove to the point of patients attempting suicide.  Or it could be that the active ingredient in what they were selling was always hope.

Hope was that people came to the facility, and then they got better.  Everyone got to see the marvelous results that the hospital had.  Even those who had been through other treatments unsuccessfully could go and be saved.

Hope is single-handedly the most powerful force in medicine.  It out-competes most drugs and confounds many studies.  If you tell folks you’re testing a new medicine and give them a sugar pill, they’ll suddenly get better – for no apparent reason.  The placebo effect is well known – and the most difficult thing to guard against when designing a study.

Staff Emotions

One of the key components is how the staff felt and how their feelings were subtly transmitted to the patients as a loss of hope.  Did the changes in staff at the hospital and the related lack of confidence erode the sense of hope, thereby making it feel as if patients were less likely to recover?  There are no obvious and definitive answers.  There are only questions about how a lack of clarity and confidence might have changed the general feel.

There was a change in the managing physician who had a different philosophy than had previously been used.  Pharmacology and electroshock therapy were options more than they had ever been, and the organization wasn’t exactly on board.

Feelings of Control

Prior to the epidemic, the staff felt like they could control suicide.  They believed that their skills and the institution itself could thwart any effort towards suicide, and it was within their power to help a suicidal person recover.  The confidence ran so high that it protected against the potential failures they might have.

A strange thing happens when people appear confident.  We generally trust them more, like them more, and follow their lead.  That isn’t to say that they’re right but that we’re more willing to follow where confident people go.  When that confidence wanes, we often experience the pop of the bubble of magic that follows them, and we snap out of our willingness to follow.

The Temptation to Regress

Much was made of a patient’s temptation to regress.  In Suicide: Inside and Out, there is a glimpse of how little time was spent on resolving issues while someone was in an inpatient setting.  There’s painfully little work being done on getting better and a lot of time just being housed.

The tendency to regress is a natural result of not having to worry about anything or work on anything.  In Being Mortal, Atul Gawande explains how something as simple as needing to care for a plant reduced mortality in nursing homes and senior living situations.  With nothing to care for, why would a patient even need to remain an adult?  They have no control and no responsibilities.

Labels and Expectations

Perhaps one of the most striking things that surfaces is the fact that people were told directly and indirectly that they were a risk to themselves.  This couldn’t have helped but instead created a labeling effect where people began to accept and believe the labels that were being applied to them.

Over time, this labeling became a part of their core identity, and therefore no amount of work could separate them from suicidal thoughts, because it had become a core part of who they were.

The notes as communicated in The End of Hope didn’t seem to recognize this process in play or the mechanics.

Doctor’s Orders

Another subtle change may have made a big difference.  Rather than communicating to patients about the positive changes that the staff was seeing, they stopped commenting all together.  Ostensibly, this was so that they didn’t counteract the physician.  After all, the nurses and aids wouldn’t want to tell a patient they’re getting better if the physician didn’t agree.  The problem is that this had the impact of causing patients concern – and a loss of hope – that they weren’t getting better.

It’s possible to communicate to people that there are signs of progress to give them hope without making a global statement about the progress of their case.  It’s possible to encourage people without making a definitive statement about their chances for success.

You’re Only as Sick as Your Secrets

In addiction recovery circles, there’s the statement, “You’re only as sick as your secrets.”  The intent is for addicts to start appropriately sharing with trusted people so they’re not shouldering their secret on their own.

There’s evidence in The End of Hope that people were holding on to secrets and those secrets were keeping them from being able to fully connect with the loved ones in their life.  Some of those secrets were how they felt but others were about things they had done.  In either case, the secrets seemed to nag at them in ways that were unhealthy.

Sick Cycles

Sometimes, a set of people get into reinforcing loops of triggering behavior.  A does something that triggers B, and B in response does something that triggers A.  This cycle reinforces itself until something interrupts it.  Wives criticize their husbands’ drinking.  Husbands drink more to compensate for the poor feelings – since that’s why they were drinking in the first place.  This further triggers the wives and more complaining.

There are cycles that are much more complex and asymmetric, but the basic pattern holds.  Recognizing the roles these cycles can play in reducing the psychic resources and perspectives of people is an important aspect of suicide prevention.

Magical Responsibility

As a result of a loss, there can be great trauma.  Sometimes, in searching for answers and ways that things could have been prevented, the only answer is the magical one.  When a baby is lost through spontaneous abortion, the mother believes that she must have been responsible.  There must have been a way that she could have prevented it.

Sometimes there are things that can be found that might have possibly helped.  Maybe the mother forgot her prenatal vitamins one day.  However, no rational filter is applied to realize that there are many who don’t remember them every day, and even more who get little or no prenatal care.

The reality of the situation doesn’t seem to interfere with the thinking pattern.  It’s like if there’s a magical solution, then they can take some responsibility and therefore control.  If there’s no magic to it, then they’re helpless.

The biggest point to consider in the prevention of suicide – and in life – is not to ever allow The End of Hope.

Book Review-Social Forces in Urban Suicide

What are the forces that drive suicide?  How is it that we’re reducing the material suffering of the globe (albeit too slowly), yet suicide rates are going up?  Ronald Maris shared his work Social Forces in Urban Suicide back in 1969.  Admittedly, it’s been a while since, but there are several insights about suicide that survive the test of time.

The Test of Time

Maris says, “Some years ago George Lundberg wrote that sociology is perhaps the only science in which a leader of a century ago would not be greatly handicapped if he should suddenly come to life again.  Although Lundberg’s dictum is less true of contemporary sociology, it is still uncomfortably close to the truth” (p. 3).  It’s one of the aspects of suicidology that has allowed me to quickly traverse back decades in time – or, in this case, half a century.  It seems like what we believe and what we know hasn’t really changed substantially in a long time.  That’s sad and scary, and it should be a call to action.

It’s not to say that we’ve learned nothing – we have learned some.  However, it is to say that the rate of learning is painfully slow, and in the meantime, thousands of people die each year.  We’ve got to find a way to change that.

Individuals and Society

One of the key challenges in the study of suicidology is the tension between Durkheim’s work in statistical analysis of societal rates and the individual, psychological approach of Karl Menninger (see Man Against Himself).  A society and the problems that are associated with it aren’t the sum of individuals.  They’re not, because the organization of individuals matters.

Individuals interact in systemic ways that creates and is created by the society.  It means thinking about problems from the perspectives of systems thinking and wicked problems.  (See Thinking in Systems for more on systems thinking and Dialogue Mapping for more on wicked problems.)  We can’t take apart a society and, by seeing the individuals, understand how it works together.  Francis Fukuyama explains in Trust that even the balance of trust moving between society or cultural anchors and familial anchors has a profound impact on society.  Robert Putnam observed small changes that, over time, has changed the basic fabric of the American life.  (He cataloged these in Bowling Alone and Our Kids.)  Chuck Underwood in America’s Generations exposes how subtle events in the lives of various generations have resulted in large changes in the attitudes of the generation.

Societal Control

Sociology is concerned with the way that individuals interact in societies and institutions.  It’s no surprise that the question arises about the degree to which society impacts the suicide rate – and how those influences are seen in the society.

Maris reversed the beliefs of Durkheim that suicide would be more prevalent in upper social classes.  That is to say that suicide seems more prevalent in lower social economic status (SES), a fact that Maris attributes to fatalistic suicides being more prevalent in lower SES.  Durkheim predicted that the greater anomic (deregulated) suicides would have a greater impact.

This, however, exposes control structures built into the fabric of society.  We see instances of this in the laws and social customs of a society.  The Righteous Mind separates these social conventions from moral imperatives.  Anatomy of Love exposes how laws may or may not expose the true social customs.  We find that while adultery is codified in many laws, it’s only if you get caught that it is a problem.

We may be facing a time when social constraints are losing their control.  In Alone Together, Sherry Turkle explores the changes we’re facing because of the rapid rise of technology.  She shares a concern that we’re simultaneously more connected and less intimate.  We’re less deeply enmeshed in a community, because we can reach out beyond our geographic bounds, and that’s making us less dependent upon our neighbors and our community and therefore less bound by the conventions.

Bandura’s work in Moral Disengagement leads to clues.  As we find that we’re accepted in other places and there are simultaneously fewer repercussions of failing to follow social conventions, they become more normal and acceptable.  The diffuse nature of our new world is cutting the underpinnings of the social conventions of moral behavior from underneath us.

Despite the weakening, there remain many ways that social conventions drive our behavior.  For instance, even during the LA Riots in 1992, people parked inside of the parking spot lines.  Sometimes, our behaviors are wired so deeply down that we don’t violate them even when we’re being lawless.

Craving the Control

We actually crave the rules of social convention.  It eases the pressure for being ourselves.  We don’t have to figure out who we are if we can just conform to social conventions.  Just as it’s easier to have constraints to create (see Creative Confidence), it’s easier to live when you know what the rules are.  Compelled to Control makes the point that everyone wants to be controlled but no one wants to be controlled, but this comment applies primarily to person-to-person relationships.  It doesn’t apply to society-to-person relationships.  Certainly, anything can be taken to an extreme where it can be rejected, but in the normal case, knowing the conventions and rules allows you to predict the future behaviors of others, and that is sacrosanct for humans.

We want freedom – but inside the bounds that we set.  Too much, and we feel micromanaged; not enough, and we feel lost.  It’s what happens to “empty nesters” when their children leave the house.  They’re suddenly given a great deal of time, and they don’t know what to with it.  The expectations when you’re a parent of a child in the house leads to a desirable predictability.

Not Excessive Individualization

Some have speculated that one of the factors in suicide is excessive individualization.  This wasn’t Maris’ conclusion.  This is consistent with the preceding references.  It’s not that someone is an individual that matters – in fact, accepting oneself might protect against suicide.  (See How to Be an Adult in Relationships and I Thought It Was Just Me (But it Isn’t).)  Instead, it’s the unwinding of social connections – or negative social interactions – that appears to lead to suicide.

Settled but Not Settled

Maris’ research showed something odd.  There was some belief that suicide was done by transients and people whose lives were characterized by relational, home, and work chaos.  However, the research showed that almost 30 percent of those dying by suicide were in their place of residence for 41 years or more.  While this shows the same elderly suicide skewing that exists elsewhere, it simultaneously challenges the notion that all suicides are the result of instability and uncertainty.

It can be that these people felt there was nothing left to live for, that they couldn’t maintain their life, or a variety of other possibilities, but the result was the same.  Sometimes, seeing how people are unsettled internally can’t be measured by external factors.

Alcoholism

Alcoholism raises its head here as a form of slow suicide.  While, at one level, this makes sense.  There’s increased probability of suicide and certainly comorbidities.  However, the nuanced view wonders where the line between alcohol as a coping skill and alcoholism exists.  The answer is generically compulsion and negative consequences – but that’s not a clear bright line.

As much as I’m not a fan of alcoholism because I’ve seen the havoc it can cause, I’m also not willing to condemn everyone that drinks alcohol as being on the path to suicide.  I think that, for me, there are bigger Social Forces in Urban Suicide.

Book Review-After Suicide

It’s unthinkable.  The loss of a spouse, child, or loved one.  It’s even more unthinkable to know that the death was the result of a suicide.  After Suicide follows 12 widows who lost their husbands.  It walks the twisting road of their relationships, how their husbands ended up dying by suicide, and what they did after that.

The Weight of Marriage

The design of the study was explicitly one of a marital relationship, and it revealed the weight that was placed on the relationship by both parties.  As I mentioned in Anatomy of Love, our relationship with marriage has changed.  There was the belief that women needed to get married.  There was the sense that, without a marriage, a woman wasn’t safe.  This came out in more than a few of the stories.

It was also clear that the marriages these couples experienced weren’t always the best.  In some cases, the marriage was the façade.  They were “playing house” instead of being connected and working together.

Insecurities

For men, there seemed to be a higher focus on their money-making career; for women, the quality of their marriage seemed to be more important.  Some of this may be a reflection of historic roles, but it may also reflect a fundamental difference in approach.  That being said, the loss of perceived value seemed to lead more or less directly down the suicide’s path.  Joiner’s awareness of burdensomeness as a factor in suicide is clear.  (See Why People Die by Suicide.)

For some, the sense of worth was driven by the need to be needed.  In a sense the opposite of burdensomeness, they needed to know that they added value by the way that they supported others.  This seemed to provide some protection against the question of inherent worth.  If they were valuable to another, then they had to have value, and there was no need to explore the inherent value question.

Strength

It was the need to become strong that broke the cycle for at least one of the women.  Her husband was away at war, and she learned that she could take care of a baby, herself, and a house.  In short, she lived experiences that proved to her that she didn’t need to have a man.  She didn’t need anyone to survive.  And that broke the cycle.

Not every woman was so lucky.  Some remained stuck in a codependent relationship where they were taking care of the husband’s addictions and compensating for his weaknesses.  In some cases, this created a sick cycle where her actions would trigger him and vice versa.

A Series of Deaths

One of the ways that life is perceived is as a death of who we are now so that we can become someone else tomorrow.  This is a great perspective if you’re looking at growth but is a bit dangerous in that it connects growth with concepts of death and may be part of how people decide that they will somehow gain life through their own death.

It’s true in some sense that the caterpillar dies to become a butterfly; however, it’s also true that they are the same no matter how different they appear on the outside.

Growing in the Same Direction

One of the challenges after a divorce is that your perspective on marriage changes.  (See Divorce for more on divorce.)  In some cases, the women in the study recognized that it’s important that both parties in a marriage grow but that they grow in the same direction.  It’s not good to have one person growing to the east and the other growing to the west.  It only serves to separate people.

There’s a certain pragmatism post-divorce that you can live without another person, and as a result you stay in the marriage, because it’s good for both of you.  It’s a good perspective, but also one that’s difficult to reconcile in every situation.  It’s hard to hear that “I don’t have to have you” and know they mean “I want to be with you, but I don’t have to be.”  It requires a degree of self-awareness to hear the meaning behind the words.

Stories

In the stories, there are both similarities and differences.  We can’t summarize how suicide survivors (those left behind) will feel or behave after the act.  We can make some generalizations about loss and grief but ultimately the context and framework of the relationship is unique and therefore there is no way of stating what people must be feeling.  Instead, all we can do is find ways to accept, identify, and understand with survivors After Suicide.

Book Review-Transformed by Trauma: Stories of Posttraumatic Growth

Most people know about post-traumatic stress disorder (PTSD).  They’ve read an article or blog post or heard a podcast about how people are struggling to cope after a traumatic event.  However, there’s another story to be told.  Transformed by Trauma: Stories of Posttraumatic Growth tells those stories.  It explains how trauma can harm us and how we can also grow from it – sometimes both at the same time.

Primer on Post Traumatic Stress Disorder (PTSD)

While everyone may know about PTSD, that doesn’t mean that everyone understands how it works and what to do about it.  James Pennebaker in Opening Up explains that PTSD may be the inability to process a traumatic event.  In other words, it’s not what happened, it’s how we’re able to process – or not process – what happened.  Normally, as we sleep, we reprocess the day’s events, filing them away for future use.

Robert Sapolsky in Why Zebras Don’t Get Ulcers explains how sleep, and particularly the ability to get into the rapid eye movement (REM) stage of sleep, is critical to integrating our experiences into a coherent story for storage into long-term memory.  Any disruption of this process prevents the memories from being properly stored and can either make them relatively permanently inaccessible or require processing again.  Those items that are the most emotionally charged are likely to need to be processed again until the processing can complete successfully.

In traumatic events, it’s possible that the integration work of the event itself can trigger the failure to complete REM sleep.  The event may be sufficiently emotionally activating that an individual is awoken by the physiological response to the integration process.  This disrupts the process and requires that it happen again – and again.  Many PTSD suffers find that flashbacks of situations occur both while awake and while dreaming.  These flashbacks may indicate that the traumatic experience was never fully processed.  To alleviate the challenges associated with PTSD, it may be that the key is to find ways to make it possible to process the traumatic event.  (See The Body Keeps the Score for more about techniques for processing.)

Richard Lazarus in Emotion and Adaptation explains that what happens in our world is less about what it is objectively and more about how we appraise what happened.  This perspective makes it possible for PTSD suffers to change the perspective on a trauma to the point where it doesn’t emotionally activate so strongly that the event can’t be processed effectively.  The short version is that by changing the meaning – the appraisal – it’s possible to substantially reduce the emotional and therefore physiological activation associated with an event.

Consider a veteran who inadvertently kills a child during a combat situation.  The fact is not itself emotionally charged.  What’s emotionally charged is the feelings that it was wrong and that it should (and could) have been prevented – or the identification of the child as someone related to the veteran for whom the veteran would grieve.

In the first condition, because it is assessed to be preventable, the conclusion is that the person is to blame and therefore not a good person.  This sets up an inner conflict with the ego, and this conflict creates activation.  (See Change or Die and How We Know What Isn’t So for more on our ego.)

In the second condition, the identification of the child as someone for whom the veteran would feel loss, activates the grief associated with that loss.  The key is, of course, to decouple the identification, but this is substantially easier said than done.

In either condition, finding ways to stabilize the individual’s sense of self and general sense of calm can make it possible to process the events over time.  In fact, the process of developing the skills necessary to cope with PTSD may be the kernel for the development of posttraumatic growth.

Finding Posttraumatic Growth (PTG)

Posttraumatic growth (PTG) isn’t the opposite of PTSD; in fact, you can have trouble integrating an event into your world and at the same time experience the characteristic reorganization of values that accompanies PTG.  PTG is, at its heart, a renewed or changed sense of meaning and purpose.  People find that the traumas they’ve survived have caused them to experience the world differently and value things differently.

There are five areas for growth because of this new view of the world:

  • Personal Strength
  • Relationships with Others
  • New Possibilities
  • Appreciation for Life
  • Spiritual and Existential Change

Sometimes, the trauma that you experience virtually forces you to see things differently.  Sometimes the one change brings a ripple effect of others that must be seen differently to come into alignment with reality.

For instance, the death of a son or daughter forces parents to recognize that they cannot always protect their children.  There’s a choice to be made in these cases: one choice is to find ways to accept the new reality and move towards creating situations of greater support and safety for them.  Conversely, it’s possible to become consumed by the specific situation that caused the death.  It can be that you see the world differently and at the same time can’t fully process the event.

In many more cases, the perspective change from the trauma is more subtle and less “required.”  It’s in these cases when the capacity to grow is most important.  Antifragile explains that growth comes from repeated strains that are of the right kind, at the right time, and to the right degree.  The greater degree to which you’re conditioned to reevaluate your perspective of the world and your values, the more readily you’ll adopt the sub-required perspective shifts that can be learned from trauma.

Victimhood

It’s one thing to have been a victim and another to feel like a victim.  It’s the difference between what has happened and how we view ourselves and the world.  One is a history lesson, and the other is a future prediction.  One of the keys to gaining PTG is to release the feelings of being a victim and find a way to accept the previous reality while also accepting that it’s not necessarily a reality for the future.  It’s not easy to decide to move out of “victimhood.”  It’s an easy place to get into but difficult to gain the courage to leave – but leaving it is important.

Leaving victimhood behind is a lot about changing your perception of yourself and your capabilities.  You can’t change the past, but you don’t have to stay there either.  Though it’s not simple or easy, it’s possible to redefine situations as growth experiences, and that opens the possibility to develop a new strength.

Distress

Experiencing PTG or coming to the other side of a traumatic event is no guarantee that there won’t be further traumatic events.  However, the goal isn’t to eliminate the traumatic events in the world that you cannot control.  The goal is to develop a set of coping strategies that prevent you from remaining in acute distress.  Whether these strategies involve asking others for help or tapping newly developed skills, the objective is to confront distress and find a way to become Transformed by Trauma – in a positive way.

Book Review-Suicide: Guidelines for Assessment, Management, and Treatment

There’s a yearning on the part of those who have encountered suicide.  It’s a yearning for answers.  Answers to questions like how can I know that someone is at risk?  What do I do to minimize someone’s risk?  And how would I treat someone who is at risk for suicide?  These are the questions that Suicide: Guidelines for Assessment, Management, and Treatment seeks to address.  Like the other literature on suicide, there are no clean, simple answers.  There are only rough markers that delineate the edge of our knowledge about suicide.  This is the exploration of what we know and the awareness that it’s not enough.

Proxy Relationships and Marriage

In all research, there’s the challenge of teasing out the relevant factors.  Is it age that’s the real variable or the deteriorating health status that normally comes with age?  Is it alcoholism, or is it the lack of steady work, home, and relationships that are normally associated with alcoholism?  One of the other factors that is often associated with suicide is marriage.  Marriage seems to form a protective factor for both men and women.  However, the question becomes whether marriage becomes a proxy for some other variable that investigators didn’t think to ask about.

What if the true inhibitor of suicide wasn’t marriage or even a close partnering relationship?  What if the protective factor was something like having children under the age of 18?  That’s an insightful question to be asked.  While the solution may not be to encourage people to have more children any more than we encourage them to get married, it is helpful to know so that we can explore ways to amplify the protective effect.

In Being Mortal, Atul Gawande explained the research that said that showed that people who had something to take care of – as simple as a plant – were less likely to die.  It’s simple and maybe that same thing has a negative influence on suicide as well, we can only speculate.

Mental Healthcare

Mental healthcare is losing its stigma slowly.  As much as two-thirds of people who have mental illness that could be formally diagnosed never make contact with the mental healthcare system.  Though 50% of those who die by suicide saw a healthcare provider within the preceding 30 days, they’re unlikely to have seen a mental health professional.  The implication of this is that we cannot hope to prevent suicide by interacting solely with mental health professionals.  They simply don’t see enough people to make the difference we need as a society.

If we want to make a huge difference in mental healthcare, we have to help healthcare providers know what to do, how to refer, and how to follow up.

Ten Step Assessment

The recommended approach is a 10-step sequence that gets progressively closer to a concerning situation and provides an approach for identifying high and moderate risk patients.  The steps are as follows:

  1. Listen
  2. Pinpoint dysphoric affects.
  3. Evaluate hopelessness.
  4. Probe for morbid thoughts [If there are none, skip to Step 10. If there are some, then…]
  5. Passive thoughts of death only? [If yes, skip to Step 10. If no, then…]
  6. Specific methods of suicide contemplated? [If no, continue. If yes, skip to Step 8…]
  7. Likelihood of suicide? [Then skip to Step 10.]
  8. Assess all suicidal plans.
  9. Probe for homicidal thoughts.
  10. Interview family members and intimates for evidence of morbid or suicidal thinking.

These may not address everyone’s potential for suicide, but they’re substantially more detailed than most healthcare providers have ever asked their patients.

Natural Negative Reactions

In a bit of twisted logic, most people who died by suicide were known to be depressed before their act – and in most cases, the depression was considered normal for their circumstances.  The tricky bit about this is the language of depression, which, in terms of DSM-5, has a specific set of diagnostic criteria – including a minimum time component.  The layman use of depression is as a synonym for sadness.  More challenging is that DSM-5 tries to draw the line between normal responses to tragedy and loss and the excessive reactions associated with major depressive episodes.

It’s one thing to say that you should treat every depression seriously and quite another to determine on a situation-by-situation basis whether the response is normal or represents a problem.  In the short term, there isn’t an answer; but in the moderate term (two weeks), it may be possible.

My concern is that this approach is a trap that forces professionals into feeling guilty that they didn’t detect the problem, when the truth is that there was often no way for the processional to distinguish between “normal” and “abnormal.”

Incorrect Assessment

Children (and adults) often misinterpret situations and assume they’ve got a causal role or a partial causal role in situations that have nothing to do with them.  Children believe that they’re somehow responsible for their parents’ divorce.  They may also believe their thoughts about wishing that someone would die actually made them die by accident or other means.

The result of these mistaken assessments is that the child (or adult) carries around hidden guilt and shame.  They can’t imagine how they could be so evil as to wish someone’s death or so able to cause a parent’s divorce but be so powerless to stop it.  Sometimes, it’s these incorrect assessments that lead people to the guilt and shame that ultimately drags them under where suicide can take them.

Peer Protection

Judith Harris Rich in The Nurture Assumption and No Two Alike explains peer pressure and how a parent’s influence on a child is powerful but not all powerful.  Their relationships with their peers has a strong pull on their personalities and their behaviors.  What Rich doesn’t cover is the degree to which these relationships form a powerful protection against suicide.

The more cohesive and adaptable the family is has a powerful protective effect, but so, too, does the degree to which someone feels connected to their peers.

More Reliable and Valid

Most mental health professionals routinely screen for suicidal concerns, but few do so using existing tools and scales.  When asked why not, the answer was that they would use them if they were more reliable and valid.  It’s a simple response with profound implications.  The implications are that if we wish to get to standards of care, we need to plan to get to those standards by creating an offering that delivers on the promise of high sensitivity and specificity.  That is, the tool must identify those who may commit suicide soon and only those individuals.  It’s a tall order, but it’s what we need if we expect clinicians to cluster around a standard for assessment.

Getting the Last Word

A common refrain from those who attempt suicide but fail is often that they feel as if they’re unheard or powerless.  That is, they see suicide as a way to get in the last word in an argument or discussion.  They believe that their act cannot be misinterpreted and that the other party (or parties) won’t be able to negate, refute, or minimize their communication.

One of the cornerstones to Motivational Interviewing is the awareness that the patient is the expert on their lives.  It creates an atmosphere of validation that they feel as if they’re heard, because the interviewer approaches them from that perspective rather than from the perspective of expertise that the patient can’t hope to meet.

Safety Through Dying

Sometimes, suicidal folks believe that they’ll achieve safety through dying.  It’s an odd thought process that involves some logical fallacies.  (See Mastering Logical Fallacies for more.)  The short form is that there is no more risk of dying if you’re already dead, so, in some sense, you do achieve safety through suicide.  What is often overlooked is the basic drive away from death.  (See The Worm at the Core for more.)  If that drive gets temporarily turned off, it’s possible to find logically-sounding illogical paths that lead to suicide as the answer.

Obviously, this isn’t the best answer, and it would be great to encourage rational thought rather than just rational-sounding thought, but that isn’t possible in every case.

Never Enough Beds

Some level of false positives for suicide screening should be acceptable.  After all, isn’t it better to treat a few people that wouldn’t eventually suicide than miss those who would?  The logic is sound, but the scale and the resource limits aren’t.  First, with suicide being a very rare case (12-15 per 100,000), one can be very accurate by saying no one will attempt or die by suicide.  Obviously, this needlessly allows individuals to die, but it’s statistically sound.

The converse problem, then, is to identify the small percentage of the population that has the potential to become one of those with experience with suicide.  Even a small positive error results in many, many more individuals.  Even if the screen identified 1 in 100 with potential, it overestimates the risk by about 8 times and the downstream treatment systems aren’t capable of handling it.  There’s a truism that there are never enough mental health beds available.

In my experience having had friends needing a place to be from time to time, there’s rarely a bed available, and this isn’t changing.  There’s always a shortage.  So, if the assessment leads to the conclusion that there is risk, what’s the treatment possibility?

Documentation of Rationale

One of the unfortunate issues that we must face when considering suicide is the reflexive legal attack that sometimes follows a suicide.  Those with licenses must concern themselves with their legal obligation and how the courts might interpret their behavior.  The answer to this is to simply document the rationale behind the treatment and interventions.  Even if others don’t agree with the conclusions, they can follow the process that was used, and this is generally enough.

However, documentation has a better, more positive purpose.  Proper documentation creates the opportunity to learn.  Phil Tetlock in Superforecasting explains that the ability to measure, test, assess, and learn from predictions is essential to improving predictive capacities.  We need to better determine what we’re doing that’s working and what isn’t.  We can only do this if we’re willing to invest in writing down what we were thinking – and why.

Limits

Professionals – and laypeople – are advised to stay within their areas of expertise and to consult others when they’re beyond or at the edge of their expertise.  The only problem with this idea is that for all of us on the journey, there are very few effective guides in the world of suicide.  In a sense, we’re all beyond our area of expertise.  That should tell us that we need to be more active in how we seek out resources, so that together we might find better Guidelines for Assessment, Management, and Treatment.

Book Review-Assessment and Prediction of Suicide

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

Ego Vulnerabilities

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

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

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

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

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

Predictive Expertise

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

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

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

Suicide Strikes When Depression Lifts

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

Alcohol and Social Supports

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

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

Hostile Relationships

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

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

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

Triggering Events and Chronic Stressors

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

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

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

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

The Assumption of Efficacy

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

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

Magical Possessions

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

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

Intentions

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

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

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

Suicide is Undesirable

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

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

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

Postvention

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

Inkblots and Pictures

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

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

All or Nothing

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

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

The Werther Effect

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

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

Prohibition and Suicide

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

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

Book Review-Love’s Story Told: A Life of Henry A. Murray

It was a secret love affair for over 40 years.  It was two preeminent psychologists.  And it’s difficult to get to Love’s Story Told: A Life of Henry A. Murray without stumbling between the public appearance and the private relationships.  I came to Murray through his work with Christiana Morgan and the Thematic Apperception Test (TAT).  It’s a popular projective test like the Rorschach inkblot test, and it has some of the same challenges.  But I’m way ahead of myself – I need to take a step back and explain Murray and the loves of his life.

Wealthy, Even by Wealthy Standards

Murray was born to a well-to-do family and spent his time at boarding schools before heading to Harvard for his education.  He didn’t seem to be constrained to any one place or even continent as his life seemed to have him constantly traveling from America to Europe and beyond.

As might be expected from someone who grew up with wealth, he enjoyed rum, rowing, and romance.  Much is made of his battles with a professional coach for the Harvard rowing team and the rivalry with Yale.  It seems as if these challenging moments pushed Murray as much as his schoolwork.

Josephine Rantoul

Jo was born to wealth herself, and after a short courtship, she and Henry were married.  Their marriage was described as more helpmate and “pal” than romantically driven.  Their marriage was outwardly positive but internally driven by challenges of infidelity.  In addition to the “40-year secret love affair,” there are at least two other chronicled dalliances.  While Jo was certainly aware of the “secret love affair,” it’s unclear about the others.

Ultimately, Jo felt as if it wouldn’t be acceptable to divorce Henry, and he felt the same, so they remained married even after the big secret was revealed.

Christiana Morgan

She had a husband as well.  Will had Christiana’s hand in marriage.  In fact, the two couples traveled together – and separately – before Murray’s romance with Christiana.  It was certainly disappointing to Will and Jo that Christiana and Murray had an affair, but it was something that both seemed resigned to.  Will because he devoutly loved Christiana and seemed willing to put up with almost anything to have her, and Jo for the social implications.

Christiana would come to work with Henry at Harvard and would co-author the Thematic Apperception Test (TAT) but not before both Henry and she had visited with Carl Jung.

Carl Jung

Jung is probably only second to Freud in terms of recognition in the world of psychology.  His work is the genesis for a large number of works including the Myers-Briggs Type Indicator (MBTI).  (See The Cult of Personality Testing for more on MBTI.)  However, most interestingly, Jung had a former patient, Toni Wolff, as a lover with the consent and perhaps even approval of Jung’s wife, Emma.  This was the legitimization that Murray and Morgan needed.  Sitting for tea with Emma, Toni Wolff, and Carl had to have been an odd experience.

Morgan and Murray’s relationships with Jung continued for years and only really stopped when it became apparent that Jung was using Morgan’s visions as the source for his Visions seminars.  The realization that this secret was on the verge of getting out caused Murray to interject and ask Morgan to stop sharing her visions with Jung.

Jo, for her part in the story with Jung, considered him to be a “dirty old man.”  However, she did seem somewhat more settled after the talk where he explained that Murray was not that different than other men.  This hearkens to the duality of sex as explained in Anatomy of Love, where we profess monogamy with discrete affairs on the side.

The Underworld

Jung explained that Wolff exposed him to the sense of the underworld.  Morgan did the same.  She was able to flow with her feelings and consciousness that seemed unreachable to both Jung and Murray.  Neither man could on their own be so free flowing, and thus used the women as ways to investigate the emotions that they couldn’t themselves let out for fear of losing themselves to it.

Christiana continued to explore the underworld of her psyche with visions and artistry long after she stopped sharing with Jung.  It was this exploration that led her and Murray to the thought of the dyad.

The Dyad

Morgan and Murray believed that, in working together, they could perfect love and share it with the rest of the world – when the time was right.  She would bring visions, emotions, and artistry.  He’d bring cold, calculating reason.  Together, they believed that they could unlock the very secrets of love.  They never completed their mission.  Both, in their own language, eventually would declare their work a failure.  Through 40 years of effort, they’d struggle to understand, define, and document their experiences, and they’d ultimately fail.

The scribe for their endeavor was Christiana, who seemed much more taken with the idea. Henry’s writings are a small portion of the content available from their experiences.  It seemed that the differences in their worlds would pull them apart, bring them back together, and ultimately torture them both.

The Separations

After their initial love making session, Christiana and Henry were apart for about a year.  In fact, there were many times in their relationship of 40 years when they were apart.  The sketches have Henry traveling with and without Jo across Europe, and Will and Christiana taking separate roads of their own.

Despite the long-term view of a 40-year secret love affair, there were many periods when the pair weren’t together.  However, more importantly, their goals rarely were.  Christiana routinely wanted more than Henry was willing to give, and Henry wanted more out of life than Christiana.  This set the stage for the fundamental disconnect in their relationship.

For Christiana, the dyad was the thing.  For Henry, it was a thing.  Though he acquiesced about his fascination with Herman Melville and his desire to write a book about him in favor of the dyad, there seem to be many cases where the dyad wasn’t as important as his work in the clinic and, particularly, his book, Explorations in Personality.

Sex

No love story is complete without sex, but here the sex wasn’t a part of the love making process as it was a way for both of them to recover from pain.  In the later years, there was Christiana’s desire for pain and domination and Henry’s struggle with the process.  It’s fair to say that for Christiana the sex and the pleasure associated with it was a primary aim, where for Henry it seemed to be secondary.

More broadly, Henry is said to have lived with a great deal of guilt for the pain and turmoil that he inflicted on both Jo and Christiana.  His guilt, though well hidden, never left him.

The TAT

My first experience with Henry Murray and Christiana Morgan was through the TAT.  During a custody evaluation an evaluator used this test among others to try to determine who was a better suited parent.  I found out later that the TAT is prohibited from expert testimony in federal court cases because of its lack of reliability.  (See Science and Pseudoscience in Clinical Psychology and The Cult of Personality Testing for more on the challenges with this test and others.)  It’s at that time that I picked up the book Love’s Story Told, because I was curious about Murray and how he created a test like the TAT.

I learned that many of his contemporaries were cautious about the lack of rigor and science in his work; despite that, the TAT became a widely popular test.

Around Suicide’s Bend

The real reason for making a point of reading the book was because of suicide.  Edward Shneidman was a student and fan of Henry’s who went on to lead the Los Angeles Suicide Prevention Center for many years and became an accomplished, well-respected suicidologist and author.  In The Suicidal Mind, he spoke about his appreciation for Expressions in Personality, and I knew I’d want to read it – but I decided I wanted to do that after I had a chance to learn more about the man behind the book.

What I didn’t realize was that it was Shneidman who would be entrusted with the letters and items for the dyad, nor that there would be so much suicide in and around the couple.

The Suicides in Murray’s Life

While Will and Jo died normal deaths, many around Murray weren’t apparently so lucky.  Other “friends” of Christiana’s, like Ralph Eaton, died by suicide.  At least 6 of Henry’s preparatory school class of 29 died by suicide as well.  There are questions about whether Christiana’s death was a suicide.  Suicide, it seemed, surrounded Murray’s life.

It’s Hard Work

The dyad wasn’t for everyone.  Even if it wasn’t the power-control fight that it appears to have become, with Christiana pulling for more of Harry and more sexual exploration and him longing for zestful thought, it would be hard work.  Both decided that it wasn’t going to be successful, but perhaps they glimpsed the kinds of relationships that folks like John Gottman would journey to discover years later.  (See The Science of Trust, The Relationship Cure, and Eight Dates for some of his work.)

It seemed as if both were so afraid of losing the dyad that they were in a constant battle to see who could control the other.  In the end, Love’s Story Told may have been more about control than love – but you should decide for yourself.

Book Review-Theory of Suicide

In suicide, man uses his power and intelligence to destroy that power and intelligence.  In doing so, he removes his sadness and desperation and replaces it with the suffering and grief of those who cared for him.  So starts the journey into Theory of Suicide.  It’s a journey to understand how people ultimately decide that suicide is the right answer.

The Environment

Two relatively small Western European countries, separated only by Sweden, have radically different suicide rates.  At the time of the book, Denmark lost roughly 20 per 100,000 people to suicide, where Norway only lost 7.  How is it that there could be such a remarkable discrepancy between two countries that are so close?  That set up Maurice Farber’s study of the two nations and the differences that might explain the radically different rates.

Hope

Farber was a student of Lewin’s who participated in a study of prisoners that revealed that their suffering was inversely related to hope and related to the structure of their future outlook.  The more hope they had, the less suffering they experienced.  Viktor Frankl explained in detail how hope and outlook were related to surviving the concentration camps in Man’s Search for Meaning.

The short version is that hopelessness shows up time and time again as a key predictor of suicide – even more than depression.  That makes finding ways to generate and sustain hope a key part of preventing suicide.  On this, C.R. Snyder has ideas in The Psychology of Hope, which are summarized in the ability to develop willpower and waypower.  Willpower is its own discussion that Roy Baumeister covers in his book, Willpower.  Waypower is Snyder’s way of saying know-how.  (See Kate Pugh’s book Sharing Hidden Know-How for more on that subject.)

Stress

Farber conceptualizes an equation where hope is a sense of competence over a sense of threat.  However, it’s my experience that Snyder’s representation of hope is more accurate.  What Farber expresses as hope, I frequently flip over as stress – and expand a bit.  First, we have to recognize that though the environment around us contains stressors, it’s our assessment and reaction that generates stress.  (See Emotion and Adaptation for more on our assessment being critical, and Why Zebras Don’t Get Ulcers as a comprehensive guide to stress.)  Flipped over, there are two aspects of a stressor that increase the likelihood and degree of stress.  The first is the probability of the stressor having an impact, and the second is the size of the impact.  These two factors are divided by our ability to cope.  Coping itself comes in two forms: internal coping that we provide ourselves, and external coping, which is provided through others as support.

It’s important to understand that stress negatively impacts our ability to see alternatives.  (See Drive for more on this constriction.)  It’s well understood that suicidal people often experience the same kind of cognitive constriction we see in people experiencing stress.  (See The Suicidal Mind.)  It shouldn’t be a surprise, because suicidal people are also described as ambivalent.  That is, they are caught between conflicting desires to be alive and to be dead.  They are caught in a conflict in their assessments of what the best alternative is.

Wounds that Won’t Heal

Perhaps the most concerning bit in the theory of suicide is the gradual buildup of emotional debris that eventually pulls people under.  The theory is that people commit suicide after a long period of continued chipping away at their natural resilience.  Instead of becoming stronger like in Antifragile, they’re slowly beat down.  That is, they learn to be helpless, and their one final act of desperation is to demonstrate that they do still have one act they can take that is impossible for others to prevent.

An aspect of this build up may be the labels that people initially hear from others and ultimately begin to accept and apply to themselves.  If you hear that you’re worthless enough, you’ll eventually internalize it and begin to believe it.  (See Mindset and I Thought It Was Just Me (But It Isn’t) for more.)  The problem is that these labels continue to work their way into your psyche and weigh on you long after those who initially applied the labels are no longer in your life.

Sometimes it’s not even a label that is applied, instead it’s just the sense that you’re defined by your wounds.  You’re not a person with diabetes, you’re a diabetic.  Your weaknesses begin to define your self-image and what you believe.  You think about what you can’t do more than you think about the things you can.

Ultimately, this may cause you to become a victim.  Everyone is victimized at times.  Everyone can feel like they’re a victim.  It’s called victimhood, and it’s an okay place to visit, but you shouldn’t build a house there.  Defining yourself as a victim necessarily takes away your power and makes it difficult to move forward.  (See Hostage at the Table for more on victimhood.)

Just After the Depths of Despair

There’s a general awareness that there’s a relationship between suicide and depression.  However, what’s not well known is that the riskiest time for suicide is when someone is recovering from depression and their lack of drive (technically called psychomotor suppression) that comes with depression releases sooner than their feelings of gloom.

First, it’s important to note that the rise of interest in SSRI medications has led to a preponderance of people who have some degree of depression diagnosis.  Any statistical relationship between depression and suicide may have been obliterated by the propensity to open the medicine cabinet any time anyone feels the slighted bit down.  (See Choice Theory and Warning: Psychiatry May Be Hazardous to Your Mental Health for more.)

Second, few people realize that depression is accompanied by a lack of drive.  Some depressed people, in the bottom of their depression, just can’t become active enough to be bothered to work up the energy to attempt suicide.  This is one of the reasons why it’s important to limit access to lethal means for a suicide, because depressed people are unlikely to work too hard to make the attempt.  This is perhaps one of the reasons why if a desired suicidal approach is thwarted, few people convert to a different form.

The Parent Trap

The power imbalance between children and parents can be a trap.  If parents aren’t giving children what they need, it can be difficult for the children to speak up directly to explain how their needs are not being met and instead they may act out in a variety of ways.  The most tragic is, of course, to commit suicide.

Human children require the most support of any mammal.  If they fail to get the support they need during their early development, they’ll experience problems later in life.  Whether the study is about the impact of rat mothers licking and grooming their kids or not (see The Globalization of Addiction), how fetal development can lead to adult disease (see FOAD in Why Zebras Don’t Get Ulcers), or even how Adverse Childhood Experiences (ACE) impact a child’s outcomes much later in life (see How Children Succeed), there are plenty of indicators that children need the support of their parents.  When they don’t get it, there are bad outcomes throughout their lives.

Indirect Causes of Suicide

The process of cause and effect is easy.  It’s easy, because it’s simple.  It’s easy, because it’s what we expect.  If we do A, then we get B.  Unfortunately, our world isn’t like that.  The Halo Effect explains that we live in a probabilistic rather than deterministic world.  That is for the most part because there are no straight lines between A and B.  It’s better to say that A leads to B in 99% of the cases but rarely leads to B when C is present.  We often fail to see the hidden systems that are operating that move A towards B – and what can break in these systems.  (See Thinking in Systems for more on systems thinking.)  More problematic is the law of unintended consequences.  The Diffusion of Innovations recounts the story of steel axe heads introduced to Stone Age Aboriginal people and the resulting disintegration of society and rise of prostitution.

What we realize as we look for causes of suicide is that the “causes” are rarely direct.  Instead, there’s a continual rolling of dice, and eventually snake eyes comes up through no particular fault of anyone – it just happens.  There are, of course, causes, but they’re obscure and nuanced.  They’re impossible to identify beforehand.

Depravation and Abandonment

There are some factors that seem to clearly lead down a path that may mean suicide.  Deprivation of attention and care during childhood seems to set people upon a road of believing they’re never good enough or that they’re unlovable.  This perspective on life leaves them constantly wondering whether they’ll be abandoned or not.

Abandonment, as I mentioned in The Deep Water of Affinity Groups, was historically a death sentence.  There’s an irony that the thing they seek to avoid is the very thing they pursue by their own hand, but the irony is lost.  As many have said, often people believe that to control the ultimate fate is the last grasp a power.

It seems like everyone has their ideas about what causes suicide.  Maybe by reading you can develop your own Theory of Suicide – and discover a way to stop it.

Book Review-Pathways to Suicide

What if the act of suicide isn’t a moment of desperation but is instead the result of a lifetime of wounds and hurts that just don’t seem to heal quite right?  What if we could see these hurts, and, in doing so, approach a sense of intervening before it’s too late?  This is the heart of Pathways to Suicide.  For some situations, there is a definite path that leads to someone feeling so much pain that they believe the only answer is to stop living.  However, this isn’t a complete story, as there are many others for which the path isn’t clear – if it’s there at all.

Alternatives and Coping

The first stop on the journey towards understanding suicidal pathways is to look at the conditions that seem to be present when we find suicide attempts and completions.  There are some expected answers, such as a life that has been harsh or when suicide is glorified.  Other factors, such as the lack of love and support, are present as well.  However, in the list are two related factors that bear highlighting.

If suicide is the “only” option (as Edwin Shneidman says in The Suicidal Mind), then it is the option to choose.  We find if the perception is that the “only” solution is suicide, many people take it – before finding other options.  The reality of the situation and the other alternatives that may be available disappear in the collapsed view of the cognitively constricted.  Therefore, it’s important to present the suicidal person with a set of options.  If there are options, then there’s no “only.”

Similarly, suicide represents a lack of alternative coping skills that would be more desirable.  In short, the person who attempts suicide is faced with a situation for which they have insufficient or no coping skills.  They decided that they couldn’t cope with their situation and therefore death seemed like the only option.  The key here in helping people avoid suicide is increasing their coping skills and ensuring they have support when their coping skills may fall short.

Why Can’t We All Just Get Along

It’s the cry of Rodney King, a man who was beaten by the cops, whose video caused their trial and whose acquittal caused the LA riots.  “Why can’t we all just get along?”  Much has been made of connections and social support.  What is often overlooked is that negative interpersonal interactions may create more suicidal drive than simply not having deep relationships.  In other words, it’s not the number of relationships but their quality and their valence.  (See High Orbit – Respecting Grieving for more on numbers of relationships.)

Negative relationships don’t necessarily mean conflict.  Conflict itself isn’t bad.  However, relationships that put another person down are at risk for reducing someone’s self-esteem to the point where suicide seems like a worthy option.

Drowning in Theories

Pathways to Suicide admits that we’re drowning in theories with too little hard data.  The book was published in 1981, so one should expect that we’d have more research, and we’d know what better to do about suicide.  Unfortunately, while we’ve made progress, it’s not nearly enough.

I’m particularly disturbed by the lack of research that teases out whether things are correlational or causational.  (The topic comes up all the time in my research.  See The Nurture Assumption for some coverage.)  We’ve got data sets and statistics about all sorts of things, including the impact of age and gender on suicide risk but precious little about detection, assessment, prevention, and training.

It’s like we’re in a time before Mendeleev’s Periodic Table of Elements organized chemistry in a meaningful way.  Until then, things seemed random and chaotic; only after organization did things start to make sense.  We need that for suicide research – but we don’t have it.

Hope and Alcohol

Pathways to Suicide confirms that hopelessness has an even higher correlation to suicide than depression but adds that hopelessness is negatively correlated with alcohol.  That makes the relationship between alcohol and suicide very complex.  On the one hand, alcoholism and the related implications are correlated with suicide.  However, alcoholism normally implies trouble with relationships and work leading to unstable home situations.  It can be that the correlation we see with alcoholism isn’t the alcoholism itself but is instead the impacts to home life.

Alcohol, however, is a short-term tool for coping with difficult situations and one that seems to have a positive effect towards reducing suicide.  Obviously, the question becomes when does the use of alcohol become alcoholism – and the impacts associated with it.

Role Transitions

There are transition points in our lives that separate one part from another – when we become a parent and when our children (finally) leave home for instance.  During our adolescent development, we’re trying to figure out who we want to be and to learn how to separate from our parents.  It’s at these sorts of times, it seems, when we’re at a heightened risk for suicide.

Maris refers to Erik Ericson’s work on developmental stages and how transitioning between stages is an unsettling time.  (See Childhood and Society for more.)  Maris also refers to Piaget’s work, which precedes Ericson’s and is derivative of Emile Durkheim’s.  Durkheim wrote the first substantial work on suicide.  How Good People Make Tough Choices is a slightly different look at the moral development of an individual, which creates a similar set of disruption as the old decisions are no longer necessarily the right, new decisions.

Even more challenging than the role transitions is what happens if you’re not able to make the cognitive changes that each stage calls for.

Stuck Stages

The more that we learn about our development as humans, the more that we realize that our early development has very serious, long-term effects.  The Adverse Childhood Experience (ACE) study showed how our health as adults was driven by the stressors that we faced as a child (see How Children Succeed).  More than that, we discovered some of the problems we face as adult may come from in utero development.  Fetal Onset of Adult Disease (FOAD) is a real thing, and it gives rise to the spooky world of impacts that happen well before our consciousness (see Why Zebras Don’t Get Ulcers).  Even in rats, licking and grooming produces more well-adjusted rats – if there is such a thing.  (This is also discussed in How Children Succeed.)

When we’re unable to complete some part of our development in a stage we leave a part of ourselves behind and we end up dragging it through the rest of our lives.  It takes energy and creates dysfunctions that are hard to shake.  Those undeveloped parts of ourselves can become progressively burdensome to the point where suicide seems like the only option.

Compensating Support

Just like how rats who received proper licking and grooming as pups go on to be more “well-adjusted,” we, too, can recover from, repair, heal, and move past our broken aspects of development with sufficient, consistent love, support, and encouragement for self-image.  Maris asserts that most suicides have lives that are in shambles – presumably where they’re not getting the kind of support they need.

I’m careful to acknowledge that some suicides’ lives are in shambles, but the important piece isn’t the objective reality of their situation.  What matters is how they feel about their situation – and in the moment where they encounter a suicidal thought.  People who are objectively in quite good condition commit suicide over the most trivial or fleeting of things.

Similarly, it’s not the actual tangible support that people are receiving that matters, it’s how they respond to and accept or reject that support.  Joiner believes that burdensomeness is a factor in suicide – and that comes from a feeling that you’re weighing down others.  (See Why People Die by Suicide.)  It’s possible to receive and accept support while not perceiving yourself as a burden – and conversely someone who receives almost no support can believe that they’re a burden.  It’s truly all about how the person perceives the support that is happening.

Separation and Grief

Separation is different than loss – real, permanent loss.  With separation, we can try to regain what we’ve lost.  But the grief that is left for survivors of suicide is permanent and unchangeable and is therefore categorically different than something that seems lost only for a time, like a relative going on a vacation far away.  (See The Grief Recovery Handbook and On Death and Dying for more about the grief process.)

Perhaps the most difficult thing for survivors to accept is the reality that their loved one is gone.  They can know it to be true, and still at some level not want it to be true, and thus are caught in a powerful conflict between their knowledge and the feeling that “it just can’t be.”

Punishment

Maris quotes other researchers that draw a connection between punishment – both physical and verbal – and subsequent suicide, while also noting that punishment and closeness often come from the same parent.  I’d propose that perhaps it’s not the punishment itself that is the problem but rather the child’s inability to predict which they’ll get from a parent that may be the root cause.

I’m strongly in favor of holding children accountable – as my post, The Psychology of Not Holding Children Accountable, explains.  In fact, I believe that a failure to hold children accountable based on Benjamin Spock’s book, The Common Sense Book of Baby and Child Care, has created a world of confusion for children who don’t understand why the “real world” is so much different than the coddling that they received at home.  (See The Coddling of the American Mind for more.)

Put together with other research, I’m skeptical that punishment is the issue.

Societal Influence on Suicide

In trying to determine what leads some people to suicide and others away from it, it becomes obvious that some cultures have higher suicide rates and others lower – sometimes dramatically lower.  It seems that more individualistic cultures seem to have higher rates, and more socially integrated cultures have lower rates.  This is what one might expect when they look at the kinds of powerful bonds that Francis Fukuyama describes in Trust: Human Nature and the Reconstitution of Social Order.  When a society has tight bonds, the individual is less able to dispose of their lives so easily.

Important Occasions

Viktor Frankl in Man’s Search for Meaning explains that planning on dates for rescue can be challenging as a prisoner.  If the date comes and goes and you’re not rescued, your hope will be dashed.  The opposite seems to be the case for suicide.  Suicidal people seem to wait until after special days like birthdays and holidays before attempting suicide.  It’s like they want to be around for one last special moment before finally giving up hope.

This seems to hold true even if the special event isn’t necessarily a special event for them personally.  They need not expect gifts or a big party, just the fact that there’s something special seems to be enough to pull at least some people along life’s journey a bit further.

Power to the People

Another interesting but not totally unexpected finding is that when people live with others, their likelihood of suicide is suppressed.  There may be two factors at play here.  First, it can be that they don’t have the time and space that they need to make the attempt.  This, however, stands against many examples where people killed themselves while others were close by.

Second, it can be that the higher density of people necessarily creates the probability of warm relationships that nurture people.  Much has been said about the need for positive relationships and closeness; perhaps physical closeness encourages the emotional closeness that protects people from thoughts of suicide.  It can, of course, lead to uncomfortable relationships as well, but that seems to be a less powerful factor.

Other People Don’t Matter, Then I Don’t Matter

People who attempt suicide seem to decide that other people don’t matter more than those who die by natural causes.  For some reason, they decide that it’s no longer worth maintaining or continuing to develop relationships with others, because some part of them is already on a journey towards suicide.

Who knows what part of the person makes this decision – consciously or not – that other people don’t matter, because they don’t intend to be around long enough to get value from the relationship.  Or perhaps it’s that they feel disconnected and alone, so their behavior starts to match how they feel.

Don’t Get Dead, Get Even

For some, it may be that there isn’t a way to get even with someone who has wronged them except through suicide.  There’s often little that a child can do to harm a parent, but certainly taking their own life is a way to accomplish that.  Some 47 percent of suicide completers conceived suicide as a way to get even with someone else.

This is an odd paradox.  You get the final word, because it’s your final deed.  Somehow the hatred and malice boils to a level where it’s even worth your own life.  It’s the final power that you can wield even if you feel like you have no power in a situation.

Performance-Based Love

Sometimes the end of suicide comes from a lack of love or perceived abandonment.  Other times, what a person learns about love is a performance-based love that is only present when you’re doing something for the other person.  (See The Four Loves for more.)

The real problem is that this isn’t love.  It’s not love – the commitment – when it’s performance-based.  (See Love, Acceptance, and Forgiveness for more about love as a commitment.)  It’s hard to live in a world where your support is from those who love you but that love stops when you can’t do something for them.  Learning that people take care of other people and that love isn’t dependent upon what you can do for the other person makes the world a lot better place to be in.

Socio-Economic Suicide

Another rock that is overturned in search of the causes of suicide is socio-economic status (SES) and employment status.  In short, it’s how stable a person’s finances are.  The mechanisms for testing this statistically aren’t very good, and it’s no surprise that there are no consistent results between SES and suicide rates.  Nor does there appear to be any employment relationship to suicide rate.

The problem with identifying SES’ relationship to suicide is that the amount of assets one has and even their current income has little to do with how stable, respected, or valuable they feel.  In Thinking, Fast and Slow, Daniel Kahneman shares the research he did with Tversky how people adapt to their current conditions and how they are impacted more by losses.  Between these facts and the idea that people can live at the edge of their means, we’re led to understand that a loss is still a loss no matter how much money you make.

Change Isn’t Good for Your Health

High levels of change in your world may lead to the kind of conditions that encourage suicide.  It’s been noted other places that immigrant populations have higher suicide rates, and those rates appear to be directly related to the degree of change that they’ve encountered – not their community.  However, Pathways to Suicide goes further and explains that high levels of change in someone’s life leads to both emotional and physical health problems.  These problems can, in turn, create challenges for suicidal ideation and attempts.

It’s not necessarily the change itself though.  It’s how the person responds to that change that seems to have a great deal of impact.  In the research for the Confident Change Management course, we discovered great discrepancies between those people and organizations that prepared well for change and those that felt as if they were being tossed like waves in an ocean.

Responsive, Not Responsible

For women who attempt or complete suicide, there seems to be an underlying current related to problems with their children.  Rarely are marriages mentioned; more frequently, there are concerns about children.  This may be a result of the belief that parents – and particularly mothers – are responsible for their children.

We use the word “responsible” for our children in the legal sense and fail to separate the word when we’re referring to their behaviors, which invariably will deviate from what the parents believe they taught and what they desire for their children.  Instead, in our Extinguish Burnout work, we encourage parents to be responsive to their children’s behaviors, because they can’t be responsible for something they can’t control, and children haven’t been controllable since they could be contained by a playpen.

Dulling the Pain

There are many ways that people dull the emotional pain that they feel.  Alcohol is a perennial favorite, but others are used as well.  Some use food to temporarily blot out their feelings, while others rely on the dopamine hit from a new purchase.  Whatever the mechanism, the goal is the same – to reduce the psychological pain to a tolerable level.

What is tragic, however, is that we become habituated to these coping mechanisms and require more and more of them to be able to sustain the same wall against our pains.  The key realization that too many people miss is that alcohol isn’t the problem – alcohol is the solution.  It just so happens that after sustained use and addiction, it becomes its own problem.

If and Only If

Suicidal individuals want to live more than they want to die if – and only if – something in their life will change.  Their marriage, their job, their relationship with a sibling, or dozens of other things.  If it could only be fixed, then life would be worth living.  They could finally put away the thoughts of suicide, because all of their problems would be solved.

Of course, this is fantasy.  When one problem is resolved, others pop up to take its level of importance.  However, suicidal individuals believe that they can hold on, they can cope, but only if their circumstances change.  What they fail to realize is that they don’t have control of those external factors.  They only have control of how they respond.  (See Choice Theory and Emotion and Adaptation for more.)

Unable to Articulate

Sylvia Plath was a poet who knew her way around words.  She could articulate her points clearly, succinctly, and passionately.  Her command of the language and her willingness to plumb the depths of her emotion made her uniquely qualified to write about suicide – having attempted it several times.  However, not all those who struggle are so gifted.  (See The Savage God for more about Sylvia Plath.)

Too many people who end up dying by suicide are never able to fully articulate how they feel, their depression, isolation, and hopelessness.  Part of helping is creating better understanding of others – even when they can’t help.

Reasoned not Rational

It’s important to point out that all suicides are reasoned at some level.  There’s some reason for pulling the trigger or jumping.  If there were not, it would be accidental.  However, just because something is reasoned doesn’t mean that others will find the response rational.  Too often, outsiders see the problems that the suicidal individual is facing and recognize that it’s not that bad.  However, that’s not the view from inside their head.

From the inside, everything appears to make perfect sense, and the negative consequences don’t matter because they won’t be around for them anyway.

Worn Down

In the end, Pathways to Suicide is about the long road that everyone travels and how some of those roads lead to suicide.  While it’s impossible to predict who will take their own life and who will conquer the world, it is possible to sometimes see how the roads sometime lead towards suicide.  The worn down, oppressed, depressed, and hopeless feelings are the Pathways to Suicide.

Book Review-Suicide and Its Aftermath

They don’t know what to say.  My friends, colleagues, and acquaintances are at a loss for words when I tell them of our son’s death by suicide.  While suicide ends the suffering of the person completing the act, it transfers that pain to those who survive.  Suicide and Its Aftermath isn’t focused on assessment and prevention of suicide.  Instead, it focuses on the impact to those left behind and their experience.

Blame

With any tragic situation, there are natural tendencies.  The first, and one we experienced, was a curiosity about what happened.  Even as open as we’ve been with our loss and how it happened, we paused before sharing some of the details.  Some of that was for us to make sense of it, and some was to try to find a way to honor the situation.  The second tendency is to try to find people to blame.  We fought back our own thoughts of blaming people.  Often in the case of a suicide, the family themselves is blamed for the loss of a friend, a colleague, or acquaintance.

While we’ve not heard directly from anyone that they blame us for our son’s death, we’ve heard from others for whom the story is different.  They meet with extended family or friends and find themselves attacked as people lash out, because they’re hurting in their own grief experience.

This is tragic.  The people who are hurting the most are being attacked, because others are in pain and don’t know what to do with it.  There are two things that my suicide research has made crystal clear.  First, there’s no one path to suicide.  Rarely is there something that is done that causes someone to decide suicide is the answer.  In The Savage God, A. Alverez blames himself for Sylvia Plath’s final successful attempt.  He felt he failed her in some final way – but this is after she had a long career of attempts.  Because there’s no known ways to cause it, it’s impossible to know how to prevent it.  In fact, it’s generally accepted that if someone wants to die by suicide, we’re powerless to stop it.  In Suicide Inside and Out, we hear the opportunities that were presented to someone who was in an inpatient program, and they’re ample.

Second, blame is pointless.  What are we going to do?  How could we possibly punish the survivors any more than losing their loved one?  While as a society we attempted to discourage suicide by desecrating the body and denying families inheritance, we’ve largely realized that this is cruel and unnecessary.  It only causes more suffering, and we’ve all had enough of that.

The truth is that the only person to blame for a suicide is the person themselves.  It was their decision.

Postvention

Shneidman in his work with the Los Angeles Suicide Prevention Center discovered something important when working with survivors (to perform psychological autopsies).  That is, survivors had a need to discuss their grief.  They needed a way to connect about their experience so they could process it.  (For more on psychological autopsy, see Review of Suicidology, 2000.)

“Postvention” was thus devised as a word to speak about the care for the survivors, which critically reduced suffering – and was supposed to prevent additional suicides triggered by the first.  Once suicide is experienced, it becomes somehow more real and acceptable.  This makes it more likely that someone close to another who has suicided will consider or attempt it.

It Can’t Be

Perhaps the most challenging aspect of surviving a suicide is to survive the cognitive restructuring that happens.  When we lose someone close to us – particularly in an unexpected or tragic way – we have to change our perspective on the world.  Something that could never happen has just happened, and it means that we must reconsider our perspective on the world.

The recurring thought is that “it just can’t be.”  Our experience of the world keeps fighting back the reality of the situation.  The thought is so incompatible that as we try to reorganize our perspectives on reality, we continue to question the fact that we know all too well.  We know it to be truth and simultaneously can’t bring ourselves to fully accept it.  We’ll get there.  We know it’s true.  But accepting it emotionally is more than can be borne initially.  It will take time.

The Silence

Those around the family are at a loss for words – appropriately so.  However, for some, their own discomfort disconnects them from the people they most want to support.  Most survivors experience material support – often in the form of meals.  However, one of the curious things that happens is how some people can’t bring themselves to reach out and communicate their care and concern.

Countless folks have responded to my messages by saying that they didn’t know what to say – so they didn’t reach out.  The disconnection from friends and colleagues may not take the form of a complete lack of communication – it may be much more focused.  They’ll connect, but only in a superficial way that avoids the elephant in the room.  They’ll not bring up the suicide for fear of triggering more pain.  For many, this results in an awkward conversation as everyone seems to be craning their neck around the obvious barrier to real connection.

My simple advice for those who have friends or acquaintances suffering from loss is don’t be afraid to bring up the topic.  Creating space for the conversation is sufficient.  You don’t need to be eloquent or witty.  You don’t have to find the “right” words – because they don’t exist.  Something as simple as “I don’t want to bring up ‘the situation’ if you don’t want to talk about it, but we can if you want to.”  This creates space for the survivor to engage at the level that is appropriate for them.  Of course, this presumes that you’re willing to walk through uncomfortable conversations if that’s what they need.

Acceptable Anger

Somewhere, we got this idea that we shouldn’t “speak ill of the dead.”  Our ability to be angry with the person who deserted and abandoned us is harmed if we can’t express it.  Desertion and abandonment are the feelings that many people have as they face the cold reality of the suicide.  They didn’t “have to” do it.  No one “has to” die by suicide; it’s a choice.

As The Grief Recovery Handbook explains, grief isn’t a linear process – but anger is often a part of it.  Elizabeth Kübler-Ross in On Death and Dying predicts that anger is a part of the process as well.  We shouldn’t be surprised that we’re angry with the person who chose suicide.  The feelings of desertion and abandonment are predictable.

Suppressing the feelings of anger because others can’t accept that you’re angry with someone has died causes more suffering.

But, why?

Another natural question that follows a suicide is “Why?”  There is very rarely any one reason.  While suicide can be reasoned, it’s not likely to be rational to others.  Like many things in life, suicide rarely follows a cause-effect pattern.  Instead, there are countless factors that pull people away from suicide and some that push them precariously close to the cliff of suicide.

We want to understand the why, because, for most survivors, the suicide answer was never an expectation.  The person who died violated our expectations, so we want to correct our mental models.  (See Resilient.)  The problem is that some things have no “why.”  In the case of suicide, even when a psychological autopsy has been performed, we may not know the real reason.  We may never know the final straw that broke the camel’s back and caused the person to decide death was the best option.

While it’s absolutely expected and natural that you’ll try to find the “why” for the situation, it’s important to accept that there may be no reason that you can understand or that you’ll find a mixture of psychological forces that moved the person to both life and death.  (See Principles of Topological Psychology for more on psychological forces.)

What Next?

Loss of a loved one is such a disruptive process it often lifts people up from their social moorings and makes them question their worlds.  Like any death, one is forced to confront their own mortality.  (See The Worm at the Core for more about confronting our mortality.)  This alone encourages people to reevaluate their world.  If they watch a friend fall victim to a heart attack before they retire, they’ll wonder if they’re putting off their retirement too long.  After all, what good is a savings when you’re dead?

However, the challenges with suicide are more complex.  One must also invite the question about what it is they really want out of life.  Not only must we consider whether it’s time to take it easy, but we also must question what we’d do if we were taking it easy.  The grief of the loss may be short in comparison with the existential crisis it triggers.

Out of Order

Because of the bimodal distribution of suicide – having a peak in the twenties and then much later in life – there’s the very real possibility that the person who dies by suicide will be much younger than those who survive.  This creates a more intense feeling of reorientation, as it violates the natural order of things.  We accept that old people die.  We think that they’ve lived their life, and it’s their time – even if they die by their own hand.  However, when someone younger than you – particularly a child – dies, it shakes your belief in the way that things should be.

Tragedy strikes everyone in different ways, and while most of the time it’s older people dying before younger people, we can’t eliminate the occasional situation where someone significantly younger does die.  We do, however, need to cope with the reality that they did, and it “isn’t right.”

Tell the Truth

In the case of an adult who is close to a child dying by suicide, there’s a natural inclination to protect the child from the truth.  The idea that it’s too painful for a child to process the fact that their loved one abandoned them is pervasive.  However, the research shows that those children who are told the truth – in a caring way – have fewer problems in adulthood.  It seems that the lying about the situation sets them up to have a general distrust of everyone when they discover the truth.  That isn’t healthy for them as an adult.

Additionally, the lie which must be kept creates further distance between the child and the remaining loved ones due to the need to suppress the thoughts of sharing the truth.  (See White Bears and Other Unwanted Thoughts for more.)

Magical Thinking

Magical thinking has a role to play in survivors just like it does in suicide itself.  (See Comprehensive Textbook of Suicidology for more on magical thinking in suicide.)  Some children (and adults) believe that somehow their thoughts and feelings may have caused the death.  While this occurs in any kind of death, it’s particularly frightening when combined with the sense of rejection that can be felt when someone close commits suicide.

Despite evidence or any indication, children (and adults) feel guilty for their feelings and thoughts, somehow believing that they are responsible.  While we can rationally argue that this could not be the case, the feelings are often persistent as people feel that they “had” to have some role in what happened.

While this may seem narcissistic – even for a child – our general tendency is to ascribe more belief about the circumstances we find ourselves in are a result of something we did or did not do rather than recognizing them as the randomness that happens.

Sibling Survivors

Siblings are often considered the forgotten survivors.  The attention and resources are focused on the parents coping with the loss, but too often, siblings are left feeling left out and perceived to be unimportant in the recovery process.  This process doesn’t require that others are unkind or tease them.  There’s no additional pain needed than the pain of losing a sibling.

In addition to the loss of future associated with a suicide, siblings can feel as if they’ve been deprived of a part of their childhood.  They can feel as if their memories of the happy times with their now departed sibling were untrue, or not enough, or unimportant.  These feelings don’t quiet quickly.

The Decision

Survivors get no choice in having their lives changed.  They do, however, get to choose how they respond.  (See Choice Theory for more on the importance of decisions.)  The choice can be to remain stuck and a victim or to decide that victimhood is a poor place to build a house.  (See Hostage at the Table for more.)

If the decision is made to move forward, it will require that emotions and the grief process is allowed to fully express itself rather than being suppressed, hidden, or accelerated.  The process takes its own time and attempts to suppress it or accelerate it can backfire and make the process messier, longer, and more severe.  However, actively looking for ways to heal, grow, and change are healthy.  (See Antifragile for more on growth.)

Helping Others

In Being Mortal, Atul Gawande explains that mortality of people in senior care drops when they are responsible for something as simple as a plant.  Helping others is wired into our DNA, and as we seek to help others in their struggles with surviving suicide, we help ourselves.  This creates a positive cycle that helps all those who are suffering – not just those being helped.  Gawande’s not alone.  Flourish and The Dalai Lama’s Big Book of Happiness also express that we’ll find the most joy when we’re helping others.

We won’t have to hide, drown, or attempt to compartmentalize our feelings of sorrow if we’re completely immersed in our desire to help others.  However, this presumes that you’re giving to others and that they’re not trying to take solace through you.  (See Give and Take for more on giving and taking.)

Others Using You

Others struggle with their feelings and may attempt to become closer to you to assuage their own feelings – and it ends up making you feel used.  It doesn’t help you and is of limited use to them.  Unfortunately, there is little to be done in these situations except to establish appropriate boundaries.  (See Boundaries for more.)

First Responders

Suicides don’t just impact just those who make the choice and their loved ones.  There’s another group that is impacted by suicides.  First responders – police, fire, and paramedics – are often the first to find the bodies and must face their own struggles.  Invariably, the suicide will resemble a friend, child, parent, or sibling from time to time.  First responders are remarkably adept at encountering the situations that others wouldn’t be able to tolerate.  They are, however, often restricted in their ability to communicate about their feelings; thus, while they have a higher tolerance for such events, the events build over time and lead to their psychological distress.

We have to find ways to make it safer for first responders to talk through their feelings and release the psychic pain that others’ suicides inflict upon them.

Prescription Pads

While first responders are also often the first people who must speak with the survivors, physicians often must support their patients who are survivors.  The natural impacts of stress, anxiety, trouble sleeping, and other health problems – including broken heart syndrome – lead patients to physicians for help.

Physicians have the power to prescribe and thereby relieve their patients’ pain.  While tempting – and invariably what the patients ask for – it’s likely not the right answer.  Survivors need to cope with their pain – and that’s not always possible when medicated.  (See Warning: Psychiatry Can Be Hazardous to Your Mental Health.)

Physicians should remain in contact with their patients and opt for more frequent interactions and evaluation before defaulting to a medical answer to a psychological problem.

Warning Signs

One of the nagging thoughts that suicide survivors must face is whether there were warning signs and what they should or could have done to prevent the suicide.  In some cases, there were warning signs, but in others, there are none to be found.  Even if there were warning signs, it’s not possible to stop someone who is intent on the act.  While we all want to do as much as possible – as we should do – sometimes there is nothing to be done.  Sometimes all we can do is live in Suicide and Its Aftermath.