Book Review-Bruised and Wounded

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

Maps and Compasses

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

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

Kinds of Diseases

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

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

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

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

Desperate Attempt

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

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

The Rhythm of Recovery

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

Book Review-Comprehensive Textbook of Suicidology

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

It’s in the Water

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

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

Risk and Protective Factors

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

Only

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

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

Establishing Intention

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

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

No Switching

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

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

Short Term Protection, Long Term Problem

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

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

Loneliness and Isolation

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

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

Failure to Fire

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

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

History of Suicide

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

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

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

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

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

Mental Illness

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

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

Unbounded Optimism

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

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

Expected Burdensomeness

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

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

Escaping the Pain

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

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

Migratory Suicide Risk

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

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

Ultimate Alienation

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

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

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

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

Social Integration Failure

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

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

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

Magical Acts

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

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

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

Mostly Drunk at Death

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

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

Daredevils Entertain

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

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

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

Escape from Real Life

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

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

Self-Punishment and the Need for Compensation

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

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

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

Compensating for Safety

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

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

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

Good Death

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

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

No Blame and No Control

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

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

Book Review-The Neuroscience of Suicidal Behavior

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

The Pseudo Why

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

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

Degrees of Suicide

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

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

To categorize suicidal attempts, three dimensions are introduced:

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

Non-Suicidal Self Injury (NSSI)

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

Economic Uncertainty

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

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

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

Stress

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

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

Parasites

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

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

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

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

Impulsivity

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

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

Not All Indicators Are Created Equal

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

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

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

Normal and Abnormal

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

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

Constricted Thinking

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

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

Entrapment and Hopelessness

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

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

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

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

Epigenome

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

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

Specific Memories

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

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

Physical vs. Psychological Trauma

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

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

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

Book Review-Turning Points: An Extraordinary Journey into the Suicidal Mind

What better way to understand the suicidal mind than to hear the stories of those who attempted suicide, failed, and decided to share their experiences? That’s the heart of Turning Points: An Extraordinary Journey into the Suicidal Mind. The journey begins with an understanding of the researcher, Diego De Leo’s, story before proceeding through ten case studies of those who attempted suicide before concluding with two stories of those left behind. In the stories, there are clues to help discover what might be going on beneath the surface of the suicidal mind.

Continuation of the Unbearable

What if your view of life was that it was unbearable? What if you believed that you were being beaten up and knocked down by the slings and arrows of life that others seem to take in stride? What if you felt like there were no hope of that ever changing? This is the place that people find themselves in as they come to the precipice of suicide. They look at suicide as an escape or a way out from the unbearable pain that they suffer through.

What’s important here isn’t the objective reality of the situation. It can be that others would look at their burdens and think nothing of them. It’s possible that their friends and loved ones would look at their life and believe they’re blessed or charmed. What matters is the internal perspective of the person – how they feel about it. (See Choice Theory for more.)

It also doesn’t matter how long these feelings have lingered. They can be a fleeting thought or a drunken concept. What matters is that the thoughts, feelings, and beliefs exist at least for a moment. When the feelings are persistent, then suicidal ideation – or planning – can occur. If only fleeting, then there is an aspect of impulsivity to the suicide.

Sharks and Dolphins

When all you can see is a fin above the water, you have no way of knowing if you’re seeing a dolphin or something much more sinister – a shark. So, too, is it hard to tell the difference between emotionally and physically helpful versus harmful people. Many of the people who struggle with depression and suicidal ideation have had numerous adverse childhood events (ACE), including physical and sexual abuse. (See How Children Succeed for more about the ACE study.) Through these ACE, they begin to question their role in the events and often blame themselves for the harm that was inflicted upon them.

To determine the difference between a shark and a dolphin, you must see more of them. If you want to discover which people are safe – and those who are not – you’ll need to see more of them. The difficult place is that to discover their safety, you must make yourself or those you care about at least somewhat vulnerable. (See Safe People for some clues and Trust=>Vulnerability=>Intimacy, Revisited for tips on being appropriately vulnerable.) Unfortunately, there aren’t good ways to quickly determine the safety of a person. The best protection we have for our children and others is the kind of relationship that encourages safety and openness. (See How to Talk So Kids Will Listen & Listen So Kids Will Talk for more.)

Saying vs. Living

One of the ways that is recommended for discerning between those who are dolphins and those who are sharks is that dolphins don’t just say things, they live them. In my post, The Largest Gap in the World – Between Saying and Doing, I explain how saying things is easy and actually following through and doing them is hard. People who are safe – dolphins – are the kinds of people who are willing to do the hard work – to do what they say they’re going to do even when it’s hard.

Pupu Platter of Addictions

One of the hallmarks of an addict, or addictive personality, is that when you conquer one addiction, another one pops up. In The Gifts of Imperfection, Brene Brown talks about having the “pupu platter of addictions.” In other words, a bit of this and a bit of that. People are often confused by addiction thinking that the only “valid” addictions are drugs or alcohol. (See The Globalization of Addiction for much more on this topic.) However, what we find with many people is that they have a tendency to become addicted or nearly addicted to many things.

Before going further, I need to share perhaps the most helpful definition of addiction that I’ve ever heard. It’s coping skills that gradually take more and more control over someone until they become enslaved to it. In that context, the question of addiction becomes a broader question of what is it that the addiction is solving. In the case of many, the addiction is blunting some sort of pain.

Feelings Don’t Matter or Feelings Don’t Exist

If you were trying to write a recipe for creating problems down the road, teach them that their feelings don’t matter – or that feelings don’t exist. Make feelings – except perhaps rage – become unacceptable, and therefore if you have them, you’re not acceptable. The child learns that, to be loved, they must deny their emotions – or at the very least not share them with others.

The problem is that this traps the person into cutting off parts of themselves – and that harms them. (See The New Peoplemaking for more.) Some of the stories relayed the relatively unsafe nature of feelings in their families, and I’ve personally observed what happens when feelings must be denied in order to be okay. Eventually the feelings win, and the results can be a complete mental breakdown.

Arsenal of Thoughts

For the suicidal person, their thoughts are not their friends. Before an attempt, one author described their thoughts as an “arsenal.” Instead of nurturing and reassuring themselves, their thoughts created fear, anxiety, doubt, guilt, and shame. One of the big discoveries that led to cognitive behavioral therapy (CBT) is the fact that the way that we talk to ourselves about ourselves has a huge impact on our lives. Describing the thoughts as an arsenal pointed back at oneself is a tragedy from which there is no direct escape.

If someone else is putting you down or attacking you, you can get up and leave or defend yourself. When it’s your own internal voices, there is no escape, particularly if the thoughts interfere with sleep.

Sleep

Far from being wasted time, sleep allows us to integrate our memories and to make sense of the day’s events. (See How We Learn.) Sleep also serves a neurological/biological function by allowing the brain to remove the buildup of waste that makes it difficult for us to think. The challenge for many people who have attempted suicide is that they’re not able to sleep – to rest and restore themselves. In some ways, they’re not able to escape their self-deprecating self-talk even for a few minutes of rest.

That’s one of the reasons why sleep is such a key component of self-care, and poor sleep habits lead to a cornucopia of other problems, including burnout. (See Extinguish Burnout for more help on avoiding burnout and doing good self-care.)

Suffocating Anxiety

Immediately behind the arsenal of thoughts is suffocating anxiety. Most people aren’t clear about what anxiety is. Fear is when you know something may harm you and are concerned you may not be able to cope. (See Why Zebras Don’t Get Ulcers and Emotion and Adaptation for more.) Anxiety is when you don’t know what threat (stressor) may be coming. Anxiety is more troubling, because you can’t defend against an unknown problem.

The only solution to anxiety is to build more self-worth, self-agency, and belief in personal efficacy. With these, the fact that you can’t predict every potential stressor becomes less important as you worry less about what the threat is and instead focus on your capacity to weather the storms that do come.

The basic beliefs about the world – whether it’s helpful or hostile – lead to the degree to which the person must feel they have personal agency or the ability to get help from others – to be able to survive the day-to-day slings and arrows of life.

A Race Against the Clock

In an odd bit of logic, people sometimes report that they had to commit – or attempt – suicide quickly. Some undoubtedly want to get attention in their suicide attempts. The attempt is a genuine cry for help. Others, however, find themselves in a race against the clock. They must act hastily, because if they don’t, they’ll be discovered, and someone will put an end to their plans to end their life. The odd twist happens when someone who wants to commit suicide tries to accelerate their plans and make it happen now – so they’ll have a greater chance at success.

There are, I’m sure, times when this strategy is effective, and they’re successful in their attempt. This cannot, however, be universal, as those who attempted but failed to commit suicide have explained their attempts to hasten their demise. Clearly, it didn’t work.

Where some linger near the railing, pondering their thoughts of jumping, others leap headlong into the abyss – because being captured and returned to their lives is too unthinkable.

Death and Mutilation

Suicide is death for the person and mutilation for the family. They must suffer through the loss of a part of themselves. This is literally true from a neuro-cognitive standpoint. Every time we lose someone close to us, we lose someone who we depended on for a part of our collective knowledge.

Whether you know someone directly who has attempted suicide or you’re just peripherally aware of the problem, I hope that reading this will be your turning point so that we can prevent more stories like those in Turning Points.

Book Review-Myths about Suicide

I was surprised when Alex took his life. I thought we knew about what the warning signs were for suicide, but clearly, we’re wrong. Myths about Suicide explores some of the common myths about suicide – including myths that we still teach people who are supposed to identify risk for suicide in the people they work with.

Model

Joiner’s model was explored more fully in Why People Die of Suicide, but, in brief, he believes that factors related to the degree of connectedness, the degree of burdensomeness, and the ability to actuate self-harm are the three factors that make the difference between those who attempt suicide and those who don’t.

Perception is the Rule

The key with burdensomeness and connectedness is that they’re rather abstract concepts that are not about the reality of the situation but are instead about the person’s perception. Some may believe that they’re not well connected, yet show every indication that they are very connected to their families, friends, and communities. It’s not the objective measures that matter, it’s the subjective perception in their minds that matters – and that’s where things can get off track.

Similarly, people view the degree to which they’re a burden and decide that they are or are not a burden without verifying their perception with others. Instead of knowing what others think about whether they’re a burden or a help, they make their own evaluation, and the evaluation isn’t always good.

The World Will Be Better Off

There’s a Doctor Who episode, “The Wedding of River Song,” that culminates in a conversation where River Song tells the Doctor, “You’ve decided the universe is better off without you, but the universe doesn’t agree.” This is often the case for those who ultimately decide to commit suicide. They’ve decided that the world is better off without them – either because they need to relieve their pain or because they feel as if they’re a burden. I can tell you, personally and from the stories of others who have lost their loved ones from suicide, we don’t agree.

Agitation

Joiner asserts that one of the better indicators of potential suicide is agitation. If you believe, as Shneidman explains in The Suicidal Mind, that suicidal people are ambivalent, then it’s easy to see the relationship between agitation and suicide. Ambivalence isn’t a lack of energy towards something but rather the presence of competing forces. Agitation is a set of competing forces that create turmoil on the part of someone – those same conflicting forces that can lead to ambivalence. Superforecasting explains that we say the chances are 50/50 when we don’t know how to rate the probabilities. In agitation, the forces are fighting in the arena of the mind to get the upper hand.

Kurt Lewin in Principles of Topological Psychology explains that it’s these competing forces that once decided propel people from one area or perspective to another. There’s reason to be concerned when we don’t know which force will win.

Lunch Money

What sense does it make for someone who is planning on killing themselves today to ask for someone to write them a check and mail it to them? The answer is, of course, none. And yet, this is one of the scenarios described in the book. The only way to explain this is the conflict that exists in the mind about whether to live or die.

If you’re going to live, you’ll need to pay the rent next month; if not, less so. When the person asked for the money, they were intending to live, but it was the force propelling them towards death that ultimately won the war.

The fact that there are two processes – one for living and one for dying – that are battling it out inside the head of the suicidal person is a strange thing indeed. Most people assume as single train of thought and a predictable path, but that’s not the case.

Momma’s Hard Liquor

Speaking of predicting suicide, hard liquor does it. The big surprise is not that alcohol influences suicide. The big surprise is, in at least one case, it was only hard liquor. Beer and wine had no correlation to suicide – but the correlation to hard liquor consumption was clear.

Even more surprising than someone’s consumption of hard liquor driving suicidal tendencies is the fact that a mother’s drinking of hard liquor had an even higher correlation. The factors at play are a mystery. However, the fact is that there’s something about your drinking and your momma’s drinking of hard liquor that leads to suicide – but not your father’s.

Talking about Suicide

Most people are scared to talk about suicide. It’s a difficult topic that no one wants to bring up. (See Crucial Conversations if you’re struggling with hard talks.) The fear is that if you bring up suicide, you’ll give someone the idea that it’s something they might want to try. This fear is, thankfully, false. You can and should talk to people about suicide, because being open about it seems to reduce the chances.

There’s an exception to the rule related to the media and cases where suicide may be unintentionally glorified. In those cases, it’s better to rethink the approach or just skip the story all together – that is, if your goal is to stop suicide.

Stopping Suicide

Speaking of stopping suicides, what happens if you thwart someone’s attempt? Will they just try again at another time or in another way? The research says no. 95% of the people who were stopped trying to jump off the Golden Gate Bridge never committed suicide. Apparently, the fact that someone stopped them reset the thinking and disrupted the cycles that told them that the world really would be better off without them.

If you’re given an opportunity to take action to prevent a suicide, the chances are you’re being given a chance to save a life – if you’re willing to take it.

No Call Boxes

If we’ve got suicide prevention lines and we can place telephones on the bridge, it stands to reason that we can prevent suicides by simply adding the phones. The problem is this doesn’t seem to work. The impersonal call boxes don’t seem to get used. They’re an interesting sign about how the community wants people to live but the sign isn’t strong enough – or the suicidal person is able to ignore them well enough that they have no impact.

It seems like there must be some person reaching out to make it work.

Personally Known Impersonal

The funny thing is just the reaching out – whether it’s as simple as a smile or a computer-generated postcard – works. Sure, people acknowledge that they know the postcard wasn’t truly personal, but somehow the fact that there was a reach out is enough. We seem to be willing to give folks the benefit of the doubt. This fact opens the door for long-term care of suicidal patients and of people who are impacted by tragedy to receive automated responses that need to be only slightly personalized to be effective – that could be a good thing.

It’s not a compensation for the pain and suffering, but it does seem to help a bit.

Suicidal Nightmares

The relationship between mental health and quality sleep is well established. The better sleep we get, the more we’re able to function. The ability to clear the neurotoxins that our brain naturally creates while awake confers on us greater emotional capacity and better reasoning. It’s little surprise, then, that when we face nightmares, we see higher rates of suicide. The one last respite from the constant turmoil and stream of internal voices is removed from us by nightmares.

One of the biggest challenges with patients with post-traumatic stress disorder (PTSD) is the inability to completely process the trauma – which can be minor – that triggered the PTSD. Patients continue to replay the events over and over but never resolve them. Whether waking or sleeping, it’s the failure to resolve the situation or process it to the point that you’re able to make sense of it that keeps you stuck. In Opening Up, Pennebaker speaks of PTSD and techniques for helping free people from the cycle. I wonder how many people who die by suicide are really PTSD victims whose PTSD was never diagnosed – which may have been triggered by something very small.

The Myths

It’s important to list the myths that Joiner confronts in the book, since I could find no listing of them anywhere else. Again, these are all myths:

  • “Suicide’s an Easy Escape, One that Cowards Use”
  • “Suicide Is an Act of Anger, Aggression, or Revenge”
  • “Suicide Is Selfish, a Way to Show Excessive Self-Love”
  • “Suicide Is a Form of Self-Mastery”
  • “Most People Who Die by Suicide Don’t Make Future Plans”
  • “People Often Die by Suicide ‘on a Whim'”
  • “You Can Tell Who Will Die by Suicide from Their Appearance”
  • “You’d Have to Be Out of Your Mind to Die by Suicide”
  • “The Death Scene Shows that the Cause of Death Was Not Suicide”
  • “Most People Who Die by Suicide Leave a Note”
  • “Suicidal Behavior and Contagion”
  • “If People Want to Die by Suicide, We Can’t Stop Them”
  • “It’s Just a Cry for Help”
  • “Animals Don’t Die by Suicide”
  • “Young Children Do Not Die by Suicide”
  • “Young Ones (and Others) Should Be Lied to about Deaths by Suicide”
  • “Breast Augmentation Causes Suicide”
  • “Medicines Cause Suicidal Behavior”
  • “Suicidal Behavior Peaks around the Christmas Holidays”

I don’t know about you, but I’m glad that I was able to discover some of the Myths about Suicide.

Book Review-The Suicidal Mind

After someone close to you commits suicide, the nearly universal response is to try to understand what they were thinking. How did they come to view suicide as the only (or best) option? That’s the question that The Suicidal Mind seeks to answer. What is it that makes people commit suicide? Shneidman’s description is robust, but it all comes down to psychological pain that he calls “psychache.”

Psychache

We know from our neurology that our minds and bodies make little distinction between physical and psychological pain. While there are distinctions, it’s important to recognize similarities first. Basically, all the same brain regions light up in the same general way. The body, on the direction of the brain, responds to psychic pain in the same way that it responds to physical pain.

Consider, for a moment, that when you watch a scary movie – or just an action-packed one – your heart races. Obviously safe in your home with locked doors, you’re in no real threat. However, because your brain is simulating what is happening on the screen, adrenaline and other chemicals are released, and the body responds.

Similarly, when you’re in psychic pain, your body responds as if it’s in real pain. The stress response is activated, including adrenaline and cortisol. The net result is both risk for long-term, stress-induced complications (see Why Zebras Don’t Get Ulcers) and a cognitive narrowing of options, as described in Drive. We’ll come back to the narrowing of options soon, as it’s called “cognitive destruction” or “cognitive constriction,” and it plays a major role in the risk of suicide.

The biggest difference between psychological pain and physical pain is that we’ve got pharmacological and other pain management solutions that are effective – or at least partially effective – at managing physical pain. There are not a similar set of solutions for psychic pain, and as a result, psychic pain is often seen as something that will continue to plague a person for years. Few people are taught how to manage their psychic pain.

Cutting

Someone cutting themselves doesn’t make sense on the surface. Why would someone intentionally harm themselves? That answer comes in two parts. First, some people cut because they want to feel alive. The physical pain punches through the numbness. Sometimes, that numbness is the response from the intense psychache.

The other reason for cutting (and other forms of self-harm) is because the physical pain can temporarily distract the mind from the psychache. For most people, our conception is that our brain processes all pain equally, but that’s not exactly right. There are factors that cause the brain to process pain more or less intensely. It’s possible, for instance, to “confuse” the brain into decreasing pain in an extremity by distracting it with physical contact closer to the core. (See The Gate Control Theory of Pain for more) Similarly, new inputs for pain are treated with a higher degree of attention than chronic pains. Thus, an acute physical pain can temporarily overwhelm a psychache.

To be clear, this isn’t a good coping strategy for psychache – but it can explain why people start down the road of self-harm.

Lethality

While psychic pain is the fuel that drives suicide, it needs something to ignite the fire. That fuel comes in a capacity to be lethal to oneself. This is like Joiner’s concept of capacity for self-harm. (See Why People Die by Suicide.) Plenty of people are in psychache but don’t have the lethality necessary to complete a suicide attempt.

Self-harm techniques like cutting are problematic, because they move us closer to lethality. They normalize self-harm, and through habituation, it takes more and more physical harm to mask the psychache. This natural escalation makes it harder to see how you’ll continue to cope. The psychache remains, and it takes more and more self-harm to keep it at bay.

The Dialogue

Self-awareness is a gift – and at the same time, it can be a curse. (See The Righteous Mind for why it’s a gift, and The Worm at the Core for more about how it can be a curse.) Suicide is largely a drama of the mind. It’s how we speak to ourselves, our stream of consciousness, that leads us towards or away from suicide. When we look for our options for relieving our pain, we briefly float over suicide and quickly dismiss it. However, in our constrained decision making, we find ourselves coming back to it as a solution. (See The Paradox of Choice, Sources of Power, and Decision Making for more about how we really make decisions – rather than the way we believe we make decisions.)

As I mentioned in my review of The Satir Model, alcohol is often the solution to the psychic pain that exists in a family system. Similarly, suicide is the solution to the psychache that can’t be blunted. I’m not saying it’s the right solution or a good solution, but rather, in the mind of the suicidal person, suicide is seen as the solution not a problem. One could reasonably wonder how suicide could possibly be seen as a solution. The answer comes down to cognitive constriction.

Cognitive Constriction

One of the problems with alcohol use is what Al Lang from FSU calls “alcohol myopia.” That is, your perceived options and situation are severely constrained. This is like the kind of constriction that we encounter in people who are under stress – in a much more powerful form.

Cognitive deconstruction is a different way the process of suicidal constriction of thinking is termed. Perhaps it’s because our ability to make rational decisions is deconstructed and we’re only able to investigate a few options that are immediately upon us. We tend to not look for new alternatives and instead focus on a very narrow list that we already have. Like the professional game of confirmation bias, we see only those options that we’ve already considered. (See Thinking, Fast and Slow for more on confirmation bias.)

This constriction prevents suicidal people from realizing that self-immolation (setting yourself on fire) would hurt. As difficult as it may be to accept, people who are in a suicidal state of mind can’t process the impact of their own pain, much less the devastation that they’ll be leaving behind when loved ones are forced to live with the worry about what has happened to them or discover their lifeless body. It’s not that they don’t care, it’s that the thought literally doesn’t come to them about how their actions will impact others – or themselves.

Reports from suicide attempters include those who’ve jumped from the Golden Gate Bridge who suddenly realized that they wanted to live and that every problem in their life was solvable – except, of course, having just jumped. These are not isolated reports of a single individual but rather a repeatable pattern of remorse that takes place before the impact but after the jump.

Only

The most dangerous word in all suicidology is the word “only.” As in, “suicide is my only option.” Only is the word that signals that someone has become cognitively constricted and they’re unable to identify new opportunities. They’ve become locked onto the idea that suicide is the only option – whether it’s really the right option or not.

In attempting to help suicidal people, one of the most important aspects is to help them realize that suicide is not only not the only option but that it’s not even a good one. Gary Klein in Sources of Power, Irving Janis in Decision Making, and Barry Swartz in The Paradox of Choice all explain that people don’t develop exhaustive lists of all the potential options. Instead, they often satisfice, picking the first option that seems acceptable. The key is helping people see other options, so they see that suicide isn’t an acceptable option.

The Impact of Explanatory Style

Work going back four decades speaks about the value in the way we talk about our situation to ourselves. The work, which was contributed to by Aaron Beck, Christopher Peterson, Martin Seligman, Rick Snyder, and others, explained the benefits – and limitations – of the way that we explain things to ourselves across three dimensions. (For more background on this, see The Psychology of Hope and The Hope Circuit.) The three dimensions have been given different names, but the labels used more recently are:

  • Personal – Is it about me or things that are not under my control?
  • Permanent – Is the situation permanent or temporary?
  • Pervasive – Is this situation global in nature or unique to this situation?

The more that we describe negative things as personal and under our control, temporary, and isolated to the current situation, the better off we are. (See Why We Do What We Do for our perception of control that Deci describes as internal locus of control.) It’s relatively well established that optimists think better of themselves than those suffering from depression, and though the perceptions are slightly distorted, that this has a positive effect for the individual – if they aren’t distorted too much into narcissism. (See How We Know What Isn’t So for more.)

Ambivalence

In the mind of the suicidal person, there seems to be a conflict. On the one side is the desire for death. It’s the desire to end suffering and pain. It’s perhaps the desire to relieve current or perceived future burden to others. On the other side, there’s the powerful force that drives everyone to keep living, the fear of death that The Worm at the Core claims drives us all. These two forces are in opposition, constantly applying pressure and creating a place of confusing behaviors as the conflicted struggle to work through the conflict as one or the other of the desires gains the upper hand.

As the result of this constant pushing and tugging, most suicidal people are termed to be ambivalent. They’re not apathetic – they do care, they’re just stuck in a conflict. It’s a conflict that they can’t escape from until they see that there are options other than death.

Hopelessness

Marty Seligman and his colleagues first described learned helplessness about 50 years ago. The idea that animals (dogs specifically) would sometimes not escape discomfort when they should. While we call it learned helplessness in animals, we call is hopelessness in humans. Seligman’s colleague more recently used fMRI technology not available 50 years ago to discover that it wasn’t learned helplessness but a failure to learn control – or a degree of influence – that caused the dogs to freeze. In The Hope Circuit, Seligman explains this transition and his personal journey to optimism and positive psychology.

It’s the work of another scholar, C.R. (Rick) Snyder, in The Psychology of Hope that begins to expose how we might develop hope instead of hopelessness. He explains that hope isn’t an emotion – it’s a cognitive process with two components. The first component is willpower – or our willingness to do things even when it may be uncomfortable. (See Willpower and The Art of Learning for more on willpower and its impact.)

The other component, waypower, is much less recognized. Waypower is the knowledge about how something will be accomplished. It’s the map, guide, or path that leads someone from their current situation to the situation that they want.

Both aspects of hope can be encouraged. Willpower explains how willpower is an exhaustible resource, but with repeated work, it can be developed like a muscle. (See Antifragile for more on developing and improving under strain.) The problem with building willpower isn’t that it cannot be done, it’s that it takes a long time to accomplish. The other aspect, waypower, is relatively easier and quicker to influence.

Waypower is simply about knowing how to move. However, the kernel of waypower is found in the ability to explore options that may lead someone to where they want to go. There doesn’t need to be a guarantee of success, just a possibility – and even a possibility that you’ll just get closer. One of the real challenges with cognitive constriction is that it prevents options from being seen and thereby harms our ability to hope.

The good news about waypower is that we can influence the options we see both by creating places of greater perceived safety. (See The Fearless Organization for more.) We can also teach approaches and techniques that are intentionally designed to generate more options. (See The Art of Innovation, Creative Confidence, and Unleashing Innovation as examples.)

Hope is the most powerful force in the world. Whether you start with the idea of Pandora’s box and how hope helps keep all the demons of the world at bay, or you consider how hard we must work against the placebo effect because hope is so powerful, it’s a force to be reckoned with. (For more on the placebo effect, see Warning: Psychiatry May Be Hazardous to Your Health.)

To Disagree Slightly

Building therapeutic alliance is essential. (See The Heart and Soul of Change for more.) In non-therapeutic settings, it’s important to establish rapport. You’ve got to help the other person know that you hear them – but you don’t necessarily have to agree with them. Motivational Interviewing is a great approach for helping transition addicts to better modes of thinking. The tools, techniques, and approaches create an environment where, frequently, the addict realizes that their addiction is the central problem in their lives. However, with suicidal people, it may not be possible for them to see that their beliefs about suicide are problematic. That’s why it may be necessary to disagree slightly.

At some point, the conversation has to turn to the fact that the suicidal person believes suicide is an option – or their best option – and the other person thinks it’s a really bad idea. Rushing into this confrontation to early or too strongly can destroy the rapport and make it impossible to change the person’s mind – conversely, doing it too late, well, may be too late.

The key is to find a way to affirm the person and to disagree with their conclusions in a way that opens up their interest in alternative perspectives and additional opportunities to solve their problem.

Burn as Brightly

It was Louis Terman who converted Binet’s work from French and brought to the English speaking world the Stanford-Binet Intelligence Test – commonly known as the IQ test. While the limitations of the test and its applicability to future performance has been called into question, it has had profound effects on our ability to understand intelligence. (See Emotional Intelligence for a discussion of the limits of IQ.)

Despite this, Terman’s work helped us to understand that those who were highly intelligent weren’t maladapted or physically weak. In fact, he found lower incidence of divorce, alcoholism, and mental health issues while finding that the most intelligent were taller, healthier, and better developed social leaders.

The problem comes, however, when suicide rates are considered. Of the 1,528 subjects of his study, 28 of the highest performers committed suicide – well above the 12 per 100,000 rate that occurs normally. It seems that their higher intelligence made them more susceptible to suicide. As a group, they were socially and professionally successful, but something in the drive put them at risk.

In the 1970s, Herbert Freudenberger was running a free clinic in lower Manhattan, and he discovered that his clinicians were struggling. Eventually, he’d call these struggles burn-out. His 1980 book, Burn-out, explains how he saw the syndrome play out. Even in these early writings, it was clear that his clinicians weren’t feeling effective, as people kept coming through the doors asking for help. (We’ve developed a wealth of materials at https://ExtinguishBurnout.com that are designed to help you recover from burnout if you need that help.)

Inefficacy is at the heart of burnout – despite some of the missteps that the discussion has taken since Freudenberger’s work. It’s that same perceived inefficacy that may have doomed Terman’s subjects. While they were by all accounts very successful, it can be that their expectations of success exceeded their actual success, and therefore the gap caused them to feel like they’d never be enough. They were hopeless that they’d ever achieve the level of success that they expected they should.

Loneliness

Loneliness is a powerful predictor in someone’s interest in attempting suicide. Joiner’s model (as explained in Why People Die by Suicide) contains only the ability to commit self-harm, a sense of burdensomeness, and a lack of connectedness. However, as the book Loneliness explains, the experience is different than the objective reality. I can be in a room full of people at a party and experience loneliness. Conversely, I can be alone on a mountaintop and not experience loneliness. It’s not the objective reality that matters, it’s my subjective reality of how I feel.

Emotional Processing

One of the largest challenges, I believe, in suicide today is the inability for people to process emotion – theirs or other people’s. We’ve simply not been taught how to decompose our emotions to understand what’s behind them. Both How Emotions are Made and Emotion and Adaptations explain that our emotions are based on unconscious perceptions, and it is possible to explore these foundations and ultimately to shape how we feel. (See Hardwiring Happiness for practical examples of how to do this.)

Jonathan Haidt’s perspective is a bit different in that he encourages a better relationship between the rider and the elephant. (See The Happiness Hypothesis and Switch for more on the rider-elephant-path model.)

Ten Commonalities

Shneidman explains that he believes there are ten commonalities of suicide, which are:

  • The common purpose of suicide is to seek a solution
  • The common goal of suicide is cessation of consciousness
  • The common stimulus of suicide is unbearable psychological pain
  • The common stressor in suicide is frustrated psychological needs
  • The common emotion in suicide is hopelessness-helplessness
  • The common cognitive state in suicide is ambivalence
  • The common perceptual state in suicide is constriction
  • The common action in suicide is escape
  • The common interpersonal act in suicide is communication of intention
  • The common pattern in suicide is consistency of lifelong styles

This is just one way that Shneidman believes that we can peer into The Suicidal Mind.

Book Review-Why People Die by Suicide

I never claimed to be an expert on suicide, but I had been trained with some screening criteria. It wasn’t much more than, “Here are the things to look for, and here’s what you do,” but it seemed like enough. I found out it wasn’t enough when our son, Alexander Hedlund, committed suicide. He didn’t have any of the markers I was told to look for. He was facing the loss of a shipmate and was sad because of it, but nothing indicated that he would end his life.

Through the process of understanding what happened, I was pointed to Thomas Joiner’s work, Why People Die by Suicide. It was eye opening and confusing at the same time. A lot of what he says makes sense – and it still doesn’t explain Alex’s suicide.

Three Components

The key to Joiner’s work is the theory that, for suicide to occur, you must have three components in place. The first is an apathy towards self-harm. Having trained to be a rescue diver in the Coast Guard, he had been trained to do painful things in the service of the mission. The second component is a belief that you’re a burden to others. We had no indication that Alex felt this way, as he was mentoring others, completing schooling, working on his house, etc. In short, we didn’t see anything leading us to believe he would think that he felt like a burden. The final component is a lack of connectedness. Alex was one of seven children. He spoke to several of his siblings the weekend before taking his own life. He spoke with both his mom and I multiple times on the date of his death.

He confided in us that he had recently started drinking – as a result of the shipmates’ death – after 11 months of sobriety. He knew we wouldn’t approve but felt safe enough to tell us and to reach out to get some help processing how he felt.

It would be easy for me to dismiss Joiner’s theory for the causes of suicide except for two key things. First, his work is well researched. He points to numerous studies that he and his colleagues have performed as well as the research of others. He ticks a major credibility marker for me, because too few people do solid research.

Second, while his theory doesn’t explain Alex’s death, it feels like it’s possible that Joiner is materially correct in his theories of suicide, but that it’s not exactly right.

The Prevalence of Suicide

The statistics aren’t good – but they’re not bad enough to garner focused attention. The round number for suicide is 10-15 people per 100,000 per year. Some countries have more and some less. Men are three times as likely to commit suicide than women, while women are more likely to attempt it unsuccessfully. Men’s attempts are more lethal – due in not so small part to the use of firearms as a more lethal approach to suicide.

Suicide lands around 10th in terms of top causes of mortality in the United States and other countries. It’s enough to make the top ten list but not necessarily enough to create a focused effort to address it. Part of that, however, may be a result of the stigma against mental illness.

Mental Health Stigma

For centuries, suicide was a major sin in Christianity and Islam. While Islam maintains the prohibition against suicide, the Catholic church – and many other forms of Christianity – recognize suicide as a mental health illness. Despite the redefinition of suicide from a sin to an illness, it’s not dramatically changed the overall feelings about mental health.

Mental health isn’t something that people readily accept. While it’s okay for us to have high blood pressure, high cholesterol, diabetes, and a host of other comorbidities, we do not, from a societal standpoint, accept people who are struggling with depression – much less those who attempt to take their own lives.

We know that 80% of our healthcare costs are driven by behavioral issues, but we don’t want to acknowledge this fact. (See Change or Die for more.) It’s easier to believe that our lack of willpower is a weakness rather than accepting it as a skill that we must master. (See Willpower for more.) So instead of people getting our compassion and support when they manifest a mental illness, we shun them and avoid them.

Joiner believes that nearly all those who commit suicide could be diagnosed with a mental illness. Whether this is true or not misses the point that mental health is implicated in suicide.

Death

Complicating matters in the case of suicide is our prohibition against speaking of death. While a fear of death seems embedded in nearly all we do, we actively avoid thinking about it, as The Worm at the Core so thoroughly explains. We feel uncomfortable when we face our own mortality – something that having compassion for suicide survivors – both those who attempted and their families – forces us to confront.

For me, being willing to confront death as a potentially better choice than living can occur only in situations of extreme pain when it’s believed there’s no hope of relief or that the world is better off without them. The second reason aligns squarely with Joiner’s concept of burdensomeness.

Hopelessness

On the other side, Joiner explains that hopelessness isn’t enough. If everyone who was momentarily hopeless committed suicide, we’d have a lot fewer people on the planet. I believe strongly that hope is the most powerful force in the universe. It drives the placebo effect, and if you believe Greek legend, it can survive all the evils of the world. (See Warning: Psychiatry Can Be Hazardous to your Mental Health for more on the placebo effect and Pandora’s Box for the role of hope in Greek mythology.)

Hopelessness drives Martin Seligman’s learned helplessness concept and can be a major source of depression. (See The Hope Circuit for more about learned helplessness.) On the other side, researchers like Snyder explain how to generate hope in The Psychology of Hope. He explains that hope is a cognitive function – not an emotion – and that it’s created from waypower and willpower. Waypower is understanding how to move forward.

Mind the Gap

It started with anger, a passing comment that anger is disappointment directed by the Dali Lama. The ball started to unwind, and it became apparent that one of the biggest sources of emotional distress was the gap between expectations and observed reality. Disappointment is the judgement that the experiences you’re having don’t meet your expectations. It became apparent that it wasn’t just anger that could result from the disappointment. It could also lead to burnout. These ideas are at the very core of what we teach in the Extinguish Burnout materials.

The problem isn’t the disappointment but what can happen in a mind when that disappointment is seen as personal, global, and forever. In these conditions, the gap becomes a psychological pain – one that too many people try to escape through a suicide attempt.

Time Horizon

The problem with suicide is often the time horizon – or how people see time. It happens along two dimensions.

First, with any kind of pain or stress, our thinking is constrained to what can be done to alleviate the immediate pain – regardless of long-term impacts. In intense pain – of any kind – it doesn’t matter what the costs are later if it solves the immediate issue. This isn’t a bad thing per se. It allowed our ancestors to survive in a world where long-term planning was a luxury they couldn’t often afford. However, it does mean that all of us struggle to maintain a broad perspective both in terms of scope and time whenever we’re in pain.

Second, we tend to believe that the pain we’re feeling will continue into the infinite future. We believe that we’ll always feel loss and grieve at the same intensity as we do today. However, this simply isn’t true. No number of studies about how we adapt to pain will convince us that pain, in many if not most cases, does really get smaller over time. This is certainly true of psychological pain and often is true of physical pain as well when we take actions to resolve it.

Constrained Thinking

The primary actor in the “Who done it?” of suicide may be constrained thinking – this idea that the person considering suicide doesn’t consider all the options. Instead of looking for all the alternatives and deciding which is best, they stop when they discover that suicide may solve their immediate pain.

Gary Klein in Sources of Power makes it clear that we make sequential decisions. We don’t evaluate everything; we often pick the first thing that works. Barry Swartz in The Paradox of Choice explains that, often, choosing an option that satisfies the criteria is adaptive. However, when it comes to a decision as final as a suicide attempt, a different, more deliberate, and broader strategy would be more appropriate.

This is exactly the kind of decision that Daniel Pink’s work in Drive explains that we’re unable to do. Stress constrains our thinking and makes it harder for us to break free of cognitive fixedness. That is, we tend to believe that things are the way that we see them, and they can’t change. Quoting an old experiment, he explains that if you tell folks to affix a candle to a wall given only the candle and a box of tacks, they can discover that the box the tacks are in can be fixed to the wall with the tacks, and the candle can be set in the box. But if you give them even a mild incentive for quick completion (thus creating mild motivation to complete the task quickly), they take substantially longer – if they can complete the task at all. The problem was, at the core, the person defined the box for the tacks as the container for the tacks and therefore not useful in holding a candle.

The suicidal person’s box is that suicide is the only answer. There is no way to address their psychological pain, and therefore suicide is the only viable solution. This is, of course, not truth, but it’s their truth. It’s the belief system that drives them towards self-harm.

Depressive Views

The correlation between depression and suicide is well established. However, the mechanisms of that correlation are not clearly known. There are many theories, but no single, well-defined answer. One of the known factors in depression is that depressed people continuously rate themselves lower than their non-depressed peers.

One of the challenges is that depressed people may be rating themselves more accurately, but it’s not an accurate rating that is important. What’s important is what’s useful. Thomas Gilovich in How We Know What Isn’t So
explains that we all believe we’re better than we are. However, this perception may be far from getting us in trouble. It may be that our optimistic bias of our own capabilities protects us from the damages of depression.

Free Medical Care

There’s a problem with our medical system that isn’t immediately apparent but can be seen when you begin to look at the system itself. (See Thinking in Systems for more about how to view things this way.) What most people don’t know – but those who are struggling do – is that you can’t be turned away from an emergency room. If you wait until a problem is life-threatening, you’ll get the help you need – regardless of your ability to pay.

It’s an important safety net, but it comes as a cost. Those who are unable to access preventative care – either in medical or psychological terms – get caught by this safety net. Emergency rooms are swamped with people who are unable to pay and therefore have no other mechanism to get the life-giving care they need. It often frustrates the workers as they see the same people over and over again. If those people simply got the right preventative care, a great number of resources would be saved.

Emergency rooms are necessarily expensive to operate. They require professionals who are highly skilled, access to expensive diagnostic equipment, and other resources that are simply expensive to maintain. Thus, when people access the emergency room when they don’t need to, they drive the overall cost of healthcare up.

This shows up in suicide as a problem, because people are unable to get either the medical or psychological care they need prior to a suicidal event. It’s only after a failed suicide attempt that medical and psychological care will be forced upon the suicide event survivor. That’s great for them, but simultaneously a tragedy for those whose suicide attempt was successful.

Of course, making free medical and psychological care available pre-suicide attempt doesn’t solve the whole problem. We still must persuade those who struggle with suicidal thoughts to pursue care, but at least it would be available if they could be persuaded to get it.

Death as Life Giving

One of the curious comments contained in the book is that suicidal people begin to see death as life giving. While literally this cannot be the case, it creates questions about how suicidal people might feel more in control of their destiny because they’ve initiated their own death.

Another idea that may generate the perception that death is life giving is that it’s not life giving directly, but the freedom from pain may cause them to feel as if they could be more alive – paradoxically, by dying.

Belonging

Joiner’s model focuses on connectedness; that I’ll cover shortly. It’s necessary to introduce the concept of belonging as a larger, overarching concept. We have a fundamental need to feel like we belong. In The Deep Water of Affinity Groups, I share how our need to feel like a part of a group causes us to make decisions that may be costly to us but help shore up areas of our self-esteem that may not be what we want them to be.

Ideally, we want people to feel personally connected. We want one-on-one intimacy that makes us feel truly seen and heard. However, we can’t ignore the fact that we often use belonging as a proxy for these connections.

Connectedness

The degree to which people are connected isn’t something that’s easy to quantify. On the one hand, David Richo explains in How to Be an Adult in Relationships that we should receive no more than 25% of our emotional needs from one person. On the other, you have Intimacy Anorexia, where people seem incapable of connecting with others in a deep and meaningful way. While marriage conveys a variety of health benefits, it can be challenging too. John Gottman explains in The Science of Trust how “sliding door” moments can make the difference.

Some of those “sliding door” moments can help us form friendships that last a lifetime, as we step in to help someone at just the right time. They’re eternally grateful, and at some point in the future, they step in to help you. The result is a connection that lasts over time.

The impact of these long-term connections creates challenges and opportunities. Challenges because the loss of someone whom you care deeply for can lead you to intense grief, and because we’re rarely able to articulate those people for whom we have these deep connections when pressed for a quick list. They may be the people for whom you have deep respect, admiration, and connection – and at the same time, they are likely not the people you speak with every week.

Self-Worth

You can call it self-worth, self-esteem, self-efficacy, or self-concept. Though these concepts are slightly different, they all amount to the way that you see yourself. It’s about the value that you see in yourself and what the world will lose when you’re gone.

Joiner frames the conversation in terms of burdensomeness, but I wonder if the real core of this isn’t the balance of self-worth and perceived burdensomeness.

Burdensomeness

Everyone leans on others at times. When I’m sick, my wife takes the brunt of my relative helplessness. I know this and that, at times, I’ll support her when she’s ill. I don’t perceive myself as a perpetual burden to her or the family – though if I did, that would be a problem.

There are, of course, different ways that we can feel like we’re a burden to others. It could be a financial drain, an emotional drain, or a physical one.

Strangely – supporting my argument above – children, and particularly college-age children, rarely see themselves as a financial burden – at least not to the point of committing suicide. The belief that, ultimately, they have value or will generate value or simply have internal self-worth seems to provide at least some buffer against suicide. Despite this buffer, the changes in life situation make suicide the second leading cause of death for college-age students. (Studies vary on specific ages but cluster around 18-22.) Even buffered by self-worth, this time of fundamental transitions is dangerous.

Self-Harm

The final aspect of Joiner’s model is self-harm, which includes tattoos and piercings up to cutting and previous suicide attempts. What’s harder to quantify is those people who have learned to push themselves into and through pain. High performers who have learned to allow themselves to feel some pain so that they can achieve peak performance. (See The Art of Learning for an example.)

Reconstituting a Model

I don’t have a formulation for a suicide model that makes Alex’s death make sense. I don’t think Joiner’s model covers it. However, I can say that it went a great way towards helping me understand Why People Die by Suicide.