Book Review-Definition of Suicide

It’s hard to address something that you don’t have a clear definition of.  That’s why Edwin Schneidman wrote Definition of Suicide.  He’s not the only person to tackle this definitional challenge, but he may be the person with the most experience.

A Rainbow of Colors

There have been numerous taxonomic approaches to suicide that often describe the lethality of the method chosen and the degree to which the suicide was intended.  The Neuroscience of Suicidal Behavior tackles the problem with these as well as the degree of planning involved.  However, as was highlighted there, there is invariably a continuum that things fall on that are difficult to distinguish.  For instance, what differentiates a parasuicide from a suicide?

More frustratingly, intent is very hard to infer and is therefore a dimension of great question, as Assessment and Prediction of Suicide reveals.  Schneidman’s own The Suicidal Mind explains that he believes communication of intent is a part of suicide.  (Since then, several others have questioned the percentage of people who do communicate their intent.  In particular, see Rethinking Suicide.)

Durkheim

Emile Durkheim is at the root of suicide research – but sort of accidentally.  His primary interest, it seems, was the application of statistics to public health concerns.  It turns out that one of the examples that he used was suicide.  As the first work of its sort, it is something that everyone comes back to – and unfortunately replicates.

Bacon’s Idols

Francis Bacon, whose scientific method helped to crystalize science, also wrote of philosophical works.  One aspect of those works that Schneidman calls out is the concept of idols – or sources of bias in our thinking.  Bacon’s idols, as explained by Schneidman, are:

  • Idols of the Tribe (Idola Tribus). These are fallacies that accrue to humanity in general.
  • Idols of the Cave (Idola Specus). These are errors peculiar to the particular mental makeup of each individual.
  • Idols of the Market Place (Idola Fori). These are errors arising in the mind from the influence of words, especially words that are names for such non-existent things as “mind” or “soul.”
  • Idols of the Theater (Idola Theatri). These are erroneous modes of thinking resulting from uncritically accepting whole systems of philosophy or from fallacious methods of demonstrating empirical proof.

 

These are perhaps some of the earliest views on cognitive biases.  It’s how we see things differently than they really (or objectively) are.  (See Why Are We Yelling and Thinking, Fast and Slow for more about cognitive biases.)

A Time for Dreaming

Death and sleep are often compared as relatives – sometimes as close cousins, and other times as siblings.  Sleep brings us relief, a chance to stall our pain and dream of happier times – either in the future or the past.  With the close relationship between death and sleep, it’s possible to see how some might desire death as both an ending of their current pain and, in a warped sense, how it might give them a chance to live the life of their dreams.  It’s possible to see how it seems more desirable.

The overlooked item, in the cognitive constriction of suicide, is that sleep returns to wake where death does not return to life.  While a decision to sleep is temporary, a decision to die is irreversible.

Not Quite Human

A challenge with some who die by suicide (or attempt) is that they feel somehow less than human and therefore undeserving of the grace and love that all mankind should show to one another.  In Moral Disengagement, Albert Bandura explains the need to make people less human to be able to inflict harm on them.  Phillip Zimbardo expresses a similar perspective in The Lucifer Effect.  What if suicide isn’t murder in the 180 degree, as Menninger suggests in Man Against Himself?  What if the thing that’s turned against someone is their belief in their humanity?  Schneidman shares one example where someone describes herself as an “it” or a “thing.”  Those sorts of descriptors minimize her own humanness.

The situation that created those feelings were stories I’ve heard before.  Pregnancies that were initially twins where one died in utero, and the parents told the surviving daughter that she killed her sister.  Another case where a father openly told his son that he should have peed inside his mother.  The list of these harmful parental responses to children is long, and unfortunately, the outcomes aren’t good.

Who Needs the Afterlife?

Sidestepping the topic of who God is, what our purpose is, and all of the religiously entangled parts, there’s an interesting question about who needs an afterlife if the life here is better.  Of course, whether you believe you’re coming back as a cow or you’re going to heaven, there’s no need to dislodge that belief.  But a more interesting question is one about what we can do now, regardless of our beliefs about afterlife.  What can we do to improve how we treat other humans such that we want them less harm?

Jonathan Haidt in The Righteous Mind proposes that we all have the same foundations of morality, the first of which is care/harm.  In short, we believe in more care and less harm.  However, despite this framework and the work of Robert Axelrod that confirms our cooperation isn’t an accident, and in fact is part of the Evolution of Cooperation, we find that too many people are suffering.

Improving someone’s condition even a little bit will help them make a different decision than suicide.  Instead of feeling hopeless, the improvement switches on The Hope Circuit and allows them to see that things can get better – since their degree of cognitive constriction may prevent that without a spark of hope.

Loneliness

In The Psychology of Hope, C.R. Snyder explains that hope is composed of two components: willpower and waypower.  There’s an aspect of this that he doesn’t address directly, which is the degree to which you believe the rest of the world is friendly or hostile.  In a hostile world, someone is always trying to prevent your success, while a helpful world is constantly trying to help you achieve your goals.  (This is the work of John Bowlby and Mary Ainsworth, and you can find more in The Secret Lives of Adults.)

However, even with a helpful view, you can get stuck in feelings of loneliness, which prevent the connection necessary to expect the world is helpful.  In Loneliness, it’s explained that loneliness is different than the state of being alone.  It’s about that sense of connection – and it can be critical.

The more we can help people who are feeling lonely feel more connected, the better off we all are – whether they’re suicidal or not.

Bankruptcy

Another way to envision suicide is that it’s declaring bankruptcy on life.  It’s the decision that you can’t make it better and you want to give up.  While this is tragic from the person’s point of view, it’s more complicated from the point of view of the others their life impacts.  Specifically, it means that people who knew the person feel as if their memories and experience with the suicidal person are somehow less important – at least less important to them.  They may even believe that the suicide invalidates their beliefs.

It’s easy to speak of the logical pieces of the situation.  Their pain.  The cognitive constriction that prevented them from seeing these memories.  However, that doesn’t help the hurting survivor who wonders what they could have done or why their perception of things was so different.

In the end, there may not be a suitable Definition of Suicide, it turns out we each may need to understand it in our own way.

Book Review-When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It

You never know how fate is going to deal a hand.  In the case of Rory O’Conner, he was going to be led towards suicide research only to find that the person who led him there would die by his own hand.  O’Conner wrote When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It to share his research and life journey around the topic of suicide.  In it, he covers some familiar ground – and some ground unfamiliar.

A Plane Full of People

It was said that the average number of people impacted by a suicide was six.  This ignores Robin Dunbar’s work, as I discussed in my post High Orbit – Respecting Grieving.  The research of Julie Cerel in 2018 places the number of people impacted by a suicide at about 135.  With this, we’ve moved from those who are most devastated to also include those impacted by the death.  However, everyone in this list will feel the impact of the death.

One hundred thirty-five people fit on a Boeing 737 aircraft with a little room to spare – but not much.  Every suicide impacts the equivalent of a plane full of people, people who are all in some way grieving the loss of someone who they feel died needlessly.

Trapped

Feeling trapped is one of the key indicators that someone may be suicidal.  Hopelessness, to express this another way, has a higher correlation to suicide than depression.  The tricky part is navigating the waters where someone feels trapped to understand whether the reason they feel trapped is real or simply perception.  Viktor Frankl in Man’s Search for Meaning explains the situations in the Nazi concentration camps.  He speaks of the atrocities that were committed and how simple things like the way that people approached their imprisonment and impending death has a remarkable impact on their outcome.

It turns out in suicide research that there is a difference between externalities and feeling trapped compared to an internal feeling of entrapment, which may or may not have external factors.  It seems that the walls that we build ourselves are more likely to trap us and lead us towards suicide.

Hope and Trust

Feeling trapped is the absence of hope.  That absence of hope leads to the conclusion that the pain will never end, and things will never get better.  (See The Psychology of Hope for more on what hope is, and The Hope Circuit for more on why it’s important.)  One of the aspects of hope that is interesting is not only our belief in our own personal agency and how we can power through what is necessary to change our results but also the impact of the relative benevolence of the world.

The more that we can believe the world will help us, the more hope we can maintain.  Our belief in a benevolent world in which we trust in others is a protective factor for suicide in a world of challenges.

Perfectionism

Perfectionism seems to lead to suicides – particularly the socially-prescribed perfectionism where we believe that others expect more from us than we’re capable of giving.  This is, for better or worse, a perception, and that perception may or may not match reality.  We can find that our boss really is demanding – or we can find that we perceive our boss as demanding.  From a psychological view, there is no difference.

At an organizational level, we create safety, like Amy Edmondson lays out in The Fearless Organization, by accepting people as they are – including their faults.  (See How to Be an Adult in Relationships for more on accepting.)

The tricky thing with perfectionism is teasing out whether it’s the environment that expects perfection or whether the person themselves is projecting their perfectionism on the environment.

Poor Sleep

One of the most overlooked aspects of daily life is the need for sleep.  It’s the time when our brains perform needed maintenance.  When we don’t get it, things start to fall apart.  Sleep is an undercurrent that flows through Why Zebras Don’t Get Ulcers and How We Learn and is key to The Organized Mind.  It’s the driver for PTSD – in that disrupted sleep prevents the integration and sense-making of the events.  Opening Up and Transformed by Trauma both speak to the need to make sense of our traumatic experiences, and that’s what sleep does: it allows us to make sense of our world.

The negative impacts of sleep deprivation have been used as torture and hazing rituals.  Unfortunately, when you just can’t sleep and no one is forcing it on you, it’s harder to resolve.  People often feel powerless to build better sleep if they only know that when they close their eyes, they’re failing to get rest.

In the context of this conversation, sleep disturbances seem to be correlated with higher rates of suicide.

The Power of Connection

We do know that there are things which help reduce the burdens and appear to reduce suicide rates.  Perhaps the simplest of these is to try to understand and accept another person.  Many stories exist about people who were yearning for a connection they couldn’t find, and therefore they decided to die by suicide.

As simple and powerful as connection is, it isn’t always that simple.  Learning to just listen for understanding and not try to problem-solve is a skill that must be learned and relearned repeatedly.  Even if you don’t connect with someone well, their decision to die by suicide isn’t your fault.  As I explained in The Psychology of Not Holding Children Accountable, you can’t be responsible for something you can’t control – and you don’t control others.

Not Escaping but Accepting

Ultimately, the ability to cope with the slings and arrows of life is more about finding ways to accept yourself rather than trying to escape yourself.  Certainly, there’s always room for all of us to grow, but that doesn’t mean we’re wrong, broken, or unworthy.  Finding the narrow path with being happy for where you are today while being willing to continue to grow is what Carol Dweck explained in Mindset.  The fact that you’re not perfect or the best isn’t a sentence, it’s an opportunity.  In a way, it’s a way to accept life’s unfolding.

It allows us to have positive future thoughts about the relationships and experiences as well as the prosperity and joy we’ll have.  We know that positive future thoughts are associated with lower suicide rates.

Low Effort, High Results

Some of the most promising aspects of our world are our ability to find low-cost, low-effort interventions that can have a profound effect.  Simple letters mailed on a predictable interval may be systematized and not very personal, but it’s a signal to the person who is struggling that someone cares about them and will notice when they’re gone.

It seems like these letters provide just enough time for people to ponder how much people care during the brief windows when suicide seems like an option – or the only option.  The tragedy and opportunity in suicidal moments is that they tend to be quick and fleeting.  If we can only find strategies that allow them to pause for a bit, we’re likely to help them When It Is Darkest.

Book Review-Rethinking Suicide: Why Prevention Fails, and How We Can Do Better

When you read a lot, you start to realize that many books fall into a common pattern.  They offer small enhancements on what you already know – that is, until you find the book that causes you to rethink what you know.  That’s what Rethinking Suicide: Why Prevention Fails, and How We Can Do Better does.  It questions what we know about preventing suicide, including how we identify those at risk and what we do to treat those who we believe are at risk.  Taking a slightly heretical view, Craig Bryan walks through what we know – and what we don’t but assume we know.

Heresy

I have no problem with heresy.  I know that sometimes it’s necessary to move forward.  As Thomas Gilovich explains in How We Know What Isn’t So, we often believe things that aren’t true, and those beliefs hold us back.  More recently, Adam Grant expresses the same sentiment in Think Again.  My friend Paul Culmsee and Kailash Awati wrote two books that are intentionally heretical – The Heretic’s Guide to Best Practices and The Heretic’s Guide to Management.

The need for heresy comes from our desire to think of the world as simple and predictable.  However, reality doesn’t cooperate with our desires.  The Halo Effect explains that we live in a probabilistic world – not a deterministic world.  That means we can’t expect that A+B=C – we can only expect that A+B often leads to C, but occasionally leads to D, E, or F.  Certainty is an illusion, and a rudimentary understanding of statistics is essential.

Douglas Hubbard explains the basics of statistics in How to Measure Anything in a way that is sufficient for most people to realize how their beliefs about the world may be wrong – and what to do to adjust them to more closely match reality.  Nate Silver in The Signal and the Noise gives more complex examples in the context of global issues.  Despite good resources, statistics are hard, and few people believe that the world is anything other than deterministic – and therefore believe understanding statistics isn’t important.

Suicide is Wicked

Wicked problems were first described by Horst Rittel and Melvin Webber in 1973.  I speak about it in my review of Dialogue Mapping, which explains the process that Rittel designed, Issue Based Information System (IBIS), to help minimize the negatives when working with wicked problems.  (I’ve also got a summary of wicked problems in the change models library.)  One of the ten criteria of a wicked problem is that there is no definitive formulation of the problem.  We have that with suicide, as we struggle to measure intent and categorize behaviors as suicidal, para-suicidal, or non-suicidal.

The conflicts in the space of suicidology are seemingly limitless.  Some believe that we must prevent all suicides – but others recognize that some lives aren’t worth living.  We struggle with the sense that people believe they are burdens, but we fail to accept that, for some people, they may be right.

Because suicide is a wicked problem, our objective can’t be to “solve” or “resolve” it.  Instead, we’ve got to treat it like a dilemma, seeking to find the place of least harm.

Misdirection

One of common attributes of science is the accidental discovery of correlations that don’t mean causation.  In Thinking, Fast and Slow, Daniel Kahneman explains the difference and how we often confuse them.  The first step to finding causation – or, more accurately, factors influencing the causation of the negative outcome – is to identify which things are correlated to the negative outcome.

We’ve got a long list of things we know are correlated to suicidality: low cholesterol, low serotonin, high cortisol, toxoplasma gondii infection, brain activation patterns as measure by an fMRI, and many more.  (See The Neuroscience of Suicidal Behavior for more on toxoplasma gondii.)  In most cases, the correlation rates are too low to be a possible causal factor.  However, they may point to the right answer that we’ve not yet found.

In Bryan’s studies, he considered that suicidal ideation might correlate with deployments.  However, it seems that this may not be the root issue, as he also identified other factors – including age and belongingness – that seemed to be important.  It’s possible, as others have suggested, that belongingness – not deployments – may be driving the suicide rates.  (See Why People Die by Suicide for support about belongingness and other ideas.)

Sometimes the misdirection that we find in suicide research is self-induced.  Confirmation bias causes us to interpret what we see in ways that are positive to our point of view.  I cover confirmation bias at length in my review of Steven Pinker’s The Blank Slate  (The first post of the two-part review covers more from the book.)  The short version is that you’ll find what you look for, and you won’t see important things when your mind is distracted trying to justify your decisions or process other information – as The Invisible Gorilla explains.

Which Way Do We Go?

Bryan raises an important philosophical question with, “If something isn’t working, doing more of that same thing probably won’t work either.”  Of course, as a probabilistic statement, he’s right.  If we have lots of experience that demonstrates that something doesn’t work, we probably don’t need to do more of it.  However, this is countered with the fact that many things need to build pressure, power, and energy to overcome inertia.  This leads to the key question about whether we should keep doing the same thing – or try something different.

I’ve struggled with this question for years.  Jim Collins in Good to Great calls it the Stockdale paradox.  It comes up repeatedly.  Entrepreneurs wonder when they should give up.  There are plenty of stories about how they had to hang on to the very last before they could succeed – however, we don’t hear the stories of the entrepreneurs who held on too long and lost everything.  Those aren’t the stories that “make it into print.”

So, I fundamentally agree that we’re doing things in suicidology that are proven to not work, and we need to stop doing them.  However, I’m cautious about giving up on unproven, new approaches that may not have had the opportunity to prove themselves yet.

With No Warning

Conventional thinking about suicide is that people send out warning signals – or at least we can devise some sort of assessment that results in a clear risk/no-risk determination for people.  However, it appears that this isn’t reality – and it’s certainly not true in every case.  Bryan walks through the math that indicates for every person who speaks about suicidal ideation and later dies by suicide, 17 discuss it but die by something other than suicide instead.  We pursue universal screening with the idea that if people describe themselves as struggling with suicidal ideation, they need to be treated immediately.  Best case, this will generate roughly 20 times the number of “false positives.”  In short, even the signals that we believe are the most compelling may be so buried by noise that they cause as much harm to system capacity as they do good.

But that’s people who indicate in some way that they have suicidal thoughts – what about the people who don’t indicate?  Surely, we should be able to determine their risk for suicide.  Surely, we’d be wrong.  First, the facts: there aren’t any tools that have demonstrated sufficient discriminatory capabilities.  Second, the statistics are heavily against the probability that we’ll be able to accomplish the goal.  With a suicide rate at roughly 1:7,000, the event is just too infrequent for our tools to detect it – even if it were persistent, but it doesn’t seem like it is.

There are countless cases where people had spent nearly no time considering suicide before attempting.  With the benefit of someone to interview, it’s possible to get direct answers about the timeline – as opposed to psychological autopsies that can only guess at what happened.  Clearly, there are some biases in self-reports, but too many cases of too many people who have nothing to lose by describing their planning indicates there was no – or very little – time spent planning.

If this is true, it makes the possibility of assessment accuracy even less likely.  In short, there’s no warning – and that makes it impossible to predict.  (Joiner expressed similar concerns about the lack of indication and planning in Myths about Suicide.)

Jumping

From the outside looking in, it appears that people jump from a normal state to a suicidal state without any warning.  This may be a strobe-light-type effect because we’re not sampling frequently enough, or it can be a literal truth that the transition between states is almost instantaneous.  In The Black Swan, Nassim Taleb explains improbable events and how things can move from one state to another rapidly.

Bryan’s view of this is expressed best in a figure:

Here, the risk of suicide can transition rapidly from low to high-risk – and vice versa.  Bryan makes the point that the velocity of and mechanisms for the transition need not be the same in both directions.  It’s possible to transition quickly in one direction but to have the opposite transition be much different.  Consider inertia.  An object in motion gives up very little of its momentum to friction until it stops.  Once it stops, it takes a considerable force to break inertia.

A different, less known, example would be the transition in a plane between lift occurring over the wings and a stall.  In a stall, the wings generate substantially less lift than the same forward motion not in stall.  Most folks think of a stall as the aircraft falling out of the sky, but in reality, the flow of air over the wings has been disrupted and is no longer generating the low-pressure region that creates lift.  I share this example because very small changes in the surface of the wing – or its leading edge – can create stall conditions in situations that would normally not be a problem.  Pilots pay attention to the angle-of-attack of the air moving across the wing, as they know that this is the most easily controllable factor that can lead to – or avoid – a stall.  When the angle of attack exceeds the tolerance, the resulting stall can be somewhat dramatic.

Bryan’s work here is reminiscent of Lewin’s work in Principles of Topological Psychology, where he created a map of psychological regions with boundaries.  Bryan’s work extends this to 3-dimensional space.

Sucking My Will to Live

Often, suicide is conceptualized as ambivalence.  It’s the struggle between the desire to live and the desire to die.  Unsurprisingly, those with a desire to die had a higher suicide rate.  Those with the highest desire to die and the lowest levels of wishing to live were six times more likely to die than everyone else.  However, even a small reason for living was often enough to hold off the suicidal instinct.

The problem is, what happens when the reasons for living collapse – even temporarily?  Consider that the reasons for living are a very powerful drive, as explained in The Worm at the Core.  Perhaps even low levels are powerful enough to hold off a desire for death.  But our desire for living and our desire for death are not fixed points.  Rather, they’re constantly ebbing and flowing as we travel through life.  The greater the normal state of reasons for living, the less likely that the value will ever reach zero.  Perhaps reaching zero reason for living requires hopelessness.  Marty Seligman has spent his career researching learned helplessness and our ability to feel control, influence, or agency in our world.  In his book, The Hope Circuit, he shares about his journey and the power of hope.

Certainly, there are life events and circumstances that invoke pain and lead us towards a desire for death.  When we experience loss and how we grieve that loss are important factors for ensuring that we don’t feel so much pain that our desire to die overwhelms our reasons for living.  The Grief Recovery Handbook explains that we all grieve differently, and it pushes back against Elizabeth Kubler-Ross’ perspectives that we all experience – to a greater or lesser degree – the same emotions.  In On Death and Dying, she records her perspectives on the patients that she saw in the process of dying.  In summary, the process of grief is the processing of loss – and we all do it differently.

Marshmallows and Man

When Walter Mischel first tested children at the Stanford Preschool, he had no idea that he’d find that the ability to delay gratification would predict long-term success in life.  His work recorded in The Marshmallow Test offered a variety of sweets – including marshmallows – which children could eat then, or they could wait while the investigator was out of the room for an indeterminate amount of time and get double the reward.  It’s a high rate of return, but only if you can defer the temptation long enough.  Those that did have self-control did better in life.

It comes up because, in Bryan’s map, one of the dimensions is risky decision-making.  Those who can defer gratification are less likely to make risky decisions.  Whether it’s the Iowa Gambling Task or other tasks, we can see that being able to be patient for small wins and identify winning strategies leads us to believe we can get more in the future – and seems to reduce our chances that we’ll take the suicide exit.  Evidence seems to show that tasks that are particularly difficult are those where the rules change in the middle and the things that worked before no longer work.

The research seems to say that those who are at increased risk for suicide may recognize that the rules have changed and therefore they should be using a different strategy – they just don’t seem to do it.  It’s not just that they don’t recognize the rule changes, they try to apply the old rules to the new situation, and it doesn’t work.

Rules for Life

Two key things can help people survive suicide.  First is just finding a way to slow down decision making to allow for things to recover and building braking systems to halt downward spirals.  Slowing decision making is familiar to anyone who has heard how to deal with anger.  The common refrain is count to ten, take a walk, and give it time.  Building braking systems to stop spiraling self-talk is trickier but is possible.

There are three proven effective strategies for suicide prevention – Dialectical Behavior Therapy (DBT), Cognitive Behavior Therapy for Suicide Prevention (CBT-SP), and Collaborative Assessment and Management of Suicidality (CAMS).  All the other strategies are unproven or disproven despite their prevalence.  As was discussed in Science and Pseudoscience in Clinical Psychology, people do a lot of therapies that aren’t proven and continue to hold on to therapies that have been disproven.  Tests like the Rorschach inkblot tests and Thematic Apperception Test (TAT) fail to meet the standard for federal evidence but are still routinely used.  The Cult of Personality Testing explains the fascination with these sorts of disproven (or mixed results) methods.

Changing the Game

The thing is, the message isn’t that all hope is lost and there’s nothing to be done.  There are a lot of things that can be done to reduce the prevalence of suicide – it’s just not the things we think or even the things that we’ve been doing.  Simple approaches like blocking paths by adding anti-suicide fences to bridges or adding locks to guns make a difference.  Rarely do people change their preferred method, and frequently it only takes enough time to unlock a gun for the feelings of suicidality to pass.  (Judged by the fact that the suicide rate decreases in the presence of gun locks.)

We may have to start thinking of suicide like we think of traffic accidents.  We know that they occur at a relative frequency, but we can’t say who will – or won’t – be involved.  The result is that we must work to make things safer through eliminating threats or instituting barriers.  Maybe the best way to make a change with suicide is to start by Rethinking Suicide.

Book Review-Critical Suicidology

Critical Suicidology can either refer to the critical need for people to become more versed in suicidology or being critical of suicidology’s progress – or both.  While suicide rates vary country by country and year by year, they’re climbing and globally are at about 16 per 100,000 people.  That’s a tragedy that generally lands suicide in the top ten list of mortality in the United States every year.  However, because of the stigmas associated with it, it’s often underfunded, poorly understood, and, in some cases, even taboo.

Rethinking Research

The research that is published in the various journals that cover suicide is woefully insufficient to move the study forward.  There are many quantitative studies but few studies of interventions.  Too many rehash the same associations that are already known.  People who abuse alcohol and those with depression are at greater risk of suicide.  There is the continued repetition of the sociological impacts to suicide.  Older white men beware, because you’re at the greatest risk – but, of course, that isn’t something you can directly intervene to change.

Critical Suicidology has a strong emphasis on the need for more qualitative research.  I agree in part but certainly not to the degree proposed.  The key isn’t in what there should be more of but rather what there should be less of.  It’s too easy to process the statistics available and translate them into risk maps based on useless, relatively unchangeable criteria.  The proposal for qualitative research is to increase understanding of what the drivers are – instead of just repeating an endless stream of numbers.

On this point I agree; however, I think that the better option is to find approaches to interventional testing to see if what we already know can be operationalized into solutions.  We know that Toxoplasma gondii reduces rats’ fear of cat urine, and that it infects 30-40% of the world population.  We have simple tests and treatment.  It would be great to know if we can reduce suicide by simply treating a parasite that causes us to lose our fear of death.

Maybe it’s a good idea to take the fMRI research that identifies activation patterns in the brain that seem to lead to suicide and convert them to be used with qEEG machines, which have a substantially lower cost both in terms of acquisition as well as the time to get to a result.  In less than 15 minutes, we should be able to identify the patterns that seem to lead to suicide.  If we can identify these people, we can get them into treatment.  If part of the problem is brain activation patterns, we can teach meditation and mindfulness to change those activation patterns.

We know that serotonin, cortisol, and are low cholesterol all are correlated with suicide – maybe we can use artificial intelligence to discover relationships with these three indicators that give us a good sense for who is at risk for suicide.

While I strongly support the need to get better ideas about what the root causes are and even agree that qualitative studies are the best way to get at these, I believe that the greatest need is interventional studies to see if we can apply what we already know more broadly.

What Answers

It’s true, as the book says, that we need to understand what our research goals are before we can choose appropriate methods to answer them.  I think we can always gain more clarity, but in general, we know that we must solve the problem of detection and the problem of protection.  We, of course, need to learn in more detail how we’re going to accomplish this.  However, I think we’ve got plenty of things queued up for appropriate interventional research.

The Negative Case

A key point that leads to wanting more qualitative research is the fact that many people with the identified risk factors – like depression and alcoholism – don’t die by suicide.  Many don’t attempt suicide.  If these are causal factors, then why do so few with the conditions go on to attempt or complete suicide?

It’s my belief that we’re talking about a recipe that needs to have certain ingredients that come together at the right times to end in a tragic result.  Consider making bread.  Most breads require flour, sugar, water, yeast, and salt.  If you have all of these – plus the special things called for in specialty recipes – then you can make bread.  You must have enough of all these.

Maybe depression is a key ingredient, but all of us have some degree of sub-clinical depression (without even accounting for the fact that depression diagnosis continues to rise).  Maybe having a clinical level of depression makes it easier to get the right ingredients – but the question remains what are the others?

Intolerable

What makes a situation intolerable?  Many people who struggle with chronic pain find ways to manage it and don’t fall into hopelessness and suicide.  Others who suddenly feel vulnerable for the first time – or the first time in a long time – find the situation intolerable and resort to suicide.  Certainly, the answer to tolerating the world is the development of coping skills.  However, what coping skills are they, and how do we ensure that people know how to appropriately deploy them?

If we want to reduce the rate at which people find themselves in intolerable situations, we can start first with coping skills.  But in the spirit of social justice, we should evaluate the situations under which we could prevent the situations that require coping skills.  We can’t prevent the tragic death of someone close to us through accidental or homicidal means, but we can address systemic persecution and victimization.

Suicide is the Solution

Suicide is often framed as a problem to be resolved – and appropriately so.  However, there’s a different conceptualization of suicide that may make it easier to work with.  What most people fail to realize is that suicide is a solution.  It is a solution to the problems the person believes they have.  It may be a bad solution, the wrong solution, etc., but for them, it appears to be a solution.  Understanding this framing gives us the opportunity to look backwards into the causes that make people’s life so unbearable that suicide seems like the right option.  In The Suicidal Mind, Shneidman describes suicide as an escape from psychache (psychic pain).

In some societies, however, suicide is a reasonable option.  When someone is elderly and feels as if they’ll become a burden to their kin, they can choose suicide as an option.  In some places in the United States – under strict regulation – there are laws which allow for others to support someone’s suicide.  We approach suicide as if every suicide should be prevented, but there are many cases where the alternative is worse than death.

Should I Say or Not

The tragic news is that 70-80% of people who die by suicide do so after having told someone about their intent.  Those people didn’t know how to respond in a way that helped the person survive.  We should better equip everyone to support others when they’re suicidal.  However, it’s equally tragic that 20-30% of people who are considering suicide never tell anyone.  They don’t help others understand their struggles so they can share it and help lessen the load.  They believe that they are alone and don’t reach out.

There’s certainly an aspect of this that is the impulsivity that some have when becoming suicidal.  There’s also an aspect, I’m sure, of how safe people feel to express their thoughts about suicide.  What might happen to them if they do share their thoughts?  All of that leads people to not share their thoughts of suicide and instead suffer alone.

Minimization

Of those who heard of the plans for suicide and weren’t able to help enough, there are some who will minimize the concerns or blow them off.  They think, incorrectly, that if people want to suicide, they’ll do it.  They won’t just talk about it.  (See Myths About Suicide for more.)  Even if they’re serious about the attempt, they may minimize the situations that lead the person to feel as if suicide is the answer.

Never having been trained in techniques like Motivational Interviewing, they don’t realize that it’s important to validate someone’s experience before convincing them that they can change the way they see it.  In short, the suicidal person who often believes they need to be heard feels even more disconnected.

Defining Moments

They’re called defining moments because they are the moment that define our lives.  The problem is that people are all too quick to call a death by suicide a defining moment.  Too many people who die by suicide have their suicide labeled as their defining moment instead of looking at the best they had done or the totality of their life.

For many, the tragedy of suicide follows a sense that they’re can’t ever be enough.  There is pressure to perform or to conform to other standards.  The result is an unsolvable stress.  Too many people who die by suicide are high achievers who have standards that they can never meet.  The result is they do amazing things their entire life and, in their desperation, end up believing suicide is the answer, and people then define them by their desperation instead of their achievements.

Diagnosis

A diagnosis – of any kind – feels like an inescapable label.  Someone stamped a label upon you, and it won’t peel off.  However, one of the insights from Critical Suicidology is that diagnosis exists not on you but in the space between you and the person that tried to apply the diagnosis.  While a great deal of progress has been made on repeatability of mental health diagnosis, they’re still rather subjective in most cases.

Furthermore, the implications of the label aren’t well articulated.  People believe that the diagnosis means something that it may – or may not.  When we’re considering how other perceive us – which is what a diagnosis is – we should consider that it’s their perception that will have some degree of truth and some degree of fiction about us, and the same goes for the person making the diagnosis.

Meaning in the Suffering

Everyone has suffering.  Buddhism and Christianity both share stories that comment on the fact that everyone has suffering.  They leave little doubt that there is suffering in every life.  However, what’s different is how people respond to that suffering and find meaning in it.  For some, the meaning is divine intervention, something that God has willed.  For others, it’s a newfound calling, something that becomes a new purpose.

In twelve-step programs, one of the keys is service so that people can leverage their pains to support the growth of others.  (See Why and How 12-Step Groups Work.)  If you want to help someone avoid suicide, the right answer may be to place them with others who are potentially suicidal so they can leverage their experiences to help others.

Responsibility to Heal

No matter what factors in life have led to your having been hurt, it’s your responsibility to heal yourself.  You must do whatever must be done to accomplish the healing, so that you’re not hurt as easily again.  (See Hurtful, Hurt, and Hurting for more.)  Perhaps one way that you can start healing is to get Critical Suicidology and to get critical of the ways that you think about suicide.

Book Review-Suicide: Understanding and Responding

Ultimately, what people want is to know how to respond to loved ones, colleagues, and community who are potentially suicidal in a way that helps them to recognize their value and allows them to make the decision to continue living.  Suicide: Understanding and Responding seeks to create a guide for understanding something that is largely not understandable and responding in ways that reduce the probability of a suicide attempt.

Positive Alternatives

Edward Shneidman in The Suicidal Mind said that “only” was the four-letter word of suicide – as in people believe that suicide is the only option.  Another way to think about the problem is that the positive alternatives to suicide have lost their credence.  Even if they’re able to see that there are options, they believe these options aren’t viable.  Maybe they perceive them as too difficult or too improbable.  In any case, the alternatives lose their salience.

Another problem with decision making and suicide is that people don’t really do rational decision making, as acknowledged by Gary Klein in Sources of Power and Irving Janis in Decision Making.  Instead, we evaluate alternatives until we believe we’ve reached a solution that’s good enough.  Barry Swartz in The Paradox of Choice explains that this is “satisficing” – and it’s often the best way to make decisions for future happiness.  This is obviously not the case with suicide, since there is then no future in which to be happy.

With satisficing, we make sequential evaluation of alternatives until we discover one that we believe is “good enough.”  If the limitations of suicide are sufficiently obscured from consciousness, it’s possible that suicide is perceived to be a valid alternative.  Perhaps this is one of the reasons why it’s important to restrict means of suicide from those who might consider it a valid option.  If you can delay the ability to act for a short time, it’s possible that the suicidal individual will decide that it wasn’t such a great option after all.

They may discover that the pain (physical or psychache) they are feeling is temporary, contextually dependent, and isn’t about them.  In this discovery, they realize that there are other options to end their pain than suicide.  In fact, the solution may just be to be patient.

Helping

One of the challenges in helping others, whether medically or psychologically, is to help at the right time, the right way, and in the right amount.  Many have explained that you shouldn’t do for someone the things that they can do themselves but should do those things they need but are not able to do themselves.  This simple framework allows for decisions based on how they’ll help the other person without enabling them.

There are two embedded challenges.  The first is understanding what they need.  How can you determine what someone needs in a general sense?  The answer may be that subjective experience leads to these decisions.  Of course, that’s not very repeatable.

The second challenge is in the form of what the other person can do for themselves.  Sometimes it takes pushing for people to enter into conflict or exercise in ways that are uncomfortable.  It’s not that people can’t do these things, it’s that they don’t naturally want to do these things, and as a result, they should be nudged or even pushed into doing what they can.  Unfortunately, this is generally uncomfortable for both parties.

Keen Why

Suicide, from the point of view of those left behind, is often a senseless act.  Though the person dying by suicide may have had their reasons and reasoning, this is often not available to the survivors.  The result is confusion on the part of survivors as they try to discover why their loved one could have possibly done such a thing.  Shneidman explains that there is never such a thing as a needless suicide.  In the mind of the suicide, there was a keen need that was withheld.

When assessing the risk of suicide, it’s important to consider what it is that people are missing in terms of their needs.  There are many answers to what people need that they don’t seem to get.  The key is understanding which of those things are the most important to the person, so that they can be given strategies to get what they need.

Four Factors

There are four psychodynamic factors that seem to have an impact on suicide:

  • Acute Perturbation – General upset
  • Heightened Inimicality – Hostility, particularly self-hostility
  • Sudden Cognitive Construction – A failure to recognize alternatives
  • Cessation – The idea that there will be an end to the pain, suffering, or struggle

The perturbation may be the intensification of the ambivalence towards death and suicide.  Specifically, it can be that the considerations for death that had been previously repressed may be coming more to the surface.  (See The Worm at the Core for how we suppress thoughts of death.)  Inimicality might also be described as thwarted or frustrated needs.

Intent

Intent is at the heart of whether something would be considered a suicide or not – and intent is hard to infer when the person isn’t available for questioning.  Intent ranges from the completely intended to predicable outcome and eventually arrives at completely unintended.  At the completely intended end, there are some indicators of that intent,  including a suicide note.  However, the low rate at which these notes are left behind (see The Suicidal Mind) makes it a poor indicator of intent.  Techniques like the psychological autopsy are retrospective reviews of artifacts and interviews with those whom the suicide interacted with and can often convey a sense of intent, but they too are difficult to get precision from, and their cost makes them prohibitive in most cases.

Some of the most difficult situations to infer intent from are those situations where the death appears to be an accident but may have been something different.  Consider the single-car auto accident where the car impacts a tree, an embankment, or hurtles off a cliff.  Who is to say whether the driver lost control, consciousness, or their will to live?  Undoubtedly, some deaths ruled as accidents are in fact suicides disguised as accidents.  In many of these cases, we’ll never know what the true cause is.

Some situations, like death through cancer or through freak acts of nature are safe from the possibility of intent because of their unpredictability.  It’s good that there need not be any serious consideration given to intent yet sorrowful for those who lost a loved one.

Relieve the Pain

There’s no singular approach to working with suicidal patients and friends that ensures they will disavow the idea of suicide.  It’s true that if someone really wants to die by suicide, they’ll eventually accomplish it.  However, conversely, if you’re able to reduce the pain just a little, you may be able to restore hope that their pain and problems will end and therefore life may be worth living.  As prediction machines, we’re quick as humans to project ourselves into the future when the small reductions in pain would continue until there’s no pain left.

Hope itself is an amazing thing, and Rick Snyder explains in The Psychology of Hope that it’s two pieces: waypower (knowing how) and willpower (willingness to try).  Often, the pain will drive a willingness to try, but without any sense for how to escape the current pain, they may be stuck and try nothing.  (See The Hope Circuit for more on learned helplessness.)

Bankruptcy

Suicide is, in essence, declaring bankruptcy on life.  There’s a sense that it will never be possible to be happy and therefore suicide is the only option left.  More than declaring bankruptcy in the present, the survivors can often interpret the suicide as in some way invalidating their memories of the person.  The memories of happiness and the joyful times shared seem as if they may be illusionary – as if, somehow, they weren’t enough to prevent the suicide.

This perspective is certainly understandable, but it simultaneously fails to recognize the cognitive constriction that face those who die by suicide.  It’s probably true that the people who die by suicide couldn’t recall the happy times that they had with the survivors.

Not Today

One of the bits of wisdom in 12-step programs is the decision to live life one day at a time.  You don’t have to make a decision to not suicide forever – it just has to be for today.  Related to this is that, for suicide, you don’t need to suicide today – it can be deferred.  Strangely, knowing that it’s a decision that never will expire as an option makes it less desirable.  (See Influence and Pre-Suasion for more on how this functions.)

Losing Your Mind or Death

What if you had to choose between losing your mind or death?  Which would you choose?  It’s an odd question, since both bring an end to consciousness, but it’s one that, strangely, suicidal people consider.  Some feel as if they’re slowly losing their mind.  They can feel as if crazy is creeping up on them, and they don’t know how long they’ll be able to hold out.  Then they’re left with an impossible choice.

Obviously, losing one’s mind doesn’t exactly work like this unless there’s an underlying physical cause, but at the same time, it’s a real fear that many face in fleeting moments or as a more serious consideration.  Maybe sometimes the solution to preventing a suicide is helping people understand that they’re not going crazy – no matter how much it may seem like that is the case.

Offspring

One of the factors that is sociologically associated with lower suicide rates is marriage.  Consistently, those who are married have a lower risk for suicide.  Many hypotheses for this have been put forth, including the closeness of the relationship, the time-to-discovery for an attempt, and others.  One of the more interesting considerations is sense that the desire to protect one’s offspring and relatives may remain even if it’s been subdued in the protection of oneself.  It appears that people will avoid suicide if they know that others are depending on them.  This may be the source of the marital protective force that’s been seen in the data.

Steven Pinker in The Blank Slate, Jonathan Haidt in The Righteous Mind, and Robert Axelrod in The Evolution of Cooperation all hint at an odd bit of genetic programming that allows us to sacrifice ourselves without violating Darwin’s evolution and survival of the fittest proposal.  The short version is that by saving our children, we’re ensuring the survival of our genes even if in doing so we ensure our own death.  This behavior extends to “like-groups” – presumably cousins and other relatives – who carry some percentage of genes that are the same as ours.  Obviously, genes can’t make you too willing to give your life, or there’d be no one to benefit from the altruistic act.

It seems like the complex web of protecting our genes may be able to be subverted for ourselves without subverting other aspects of the gene protection.  That may be at the heart of why people who are recovering for addiction are encouraged to serve others.  It may be the path back to restoring the protective forces for ourselves.

Loneliness

One of the factors that can drive people towards suicide as an option is the feeling of loneliness.  Loneliness the book makes the point that being alone and loneliness are different.  Loneliness is a feeling that can occur while you’re alone or while you’re in a room filled with people.  In fact, Sherry Turkle in Alone Together puts forth the idea that while we’re objectively less “alone” because of the connectivity that technology brings, we’re equally not connecting in ways that fulfill our needs – and therefore may feel more loneliness.

If you want to reduce the loneliness of someone – whether they’re considering suicide or not – the solution is simply to try to understand them, their perspective, and their situation.  When you feel like someone understands you, loneliness must take a back seat to the feelings of being understood.

Nothing Left to Lose

It’s a problem when someone with nothing left to lose, like a death row felon, is free.  The rules of morality and social convention have no hold over the person who no longer has anything to lose.  (See How Good People Make Tough Choices for more.)  Suicidal individuals no longer fear death and therefore must be approached cautiously.  (See The Worm at the Core for more about the fear of death.) There’s no telling what they might do.

Murder-Suicide or Suicide-Murder

Though murder-suicides are rare, they happen.  An interesting challenge comes from whether the person first considers murder and then acquiesces to suicide, or if they decide that they’re going to die by suicide and they need to take one or more people with them.  There’s obviously no one, simple answer.  However, it seems that though we call it murder-suicide because of the (required) order of events, perhaps it would be more accurate to describe it as suicide-murder if we consider the thinking process that happens.

If you’ve already decided on suicide, you can extract revenge on those who have tormented you through murder without concern for the consequences.  They’re not going to kill a dead person, nor are they going to imprison a corpse.

Worthlessness

Joiner in Why People Die by Suicide frames it in terms of burdensomeness.  That is, people feel as if they’re a burden to others and they’d be better off dead.  Here, the word goes less far and describes feelings of worthlessness leading to a desire for suicide.  Worthless is the sense that you can’t generate value to others or humanity – or perhaps not enough to offset the costs that you bring to the world.  Feelings of worthlessness are often a natural consequence of failure.

For some, they’ve picked up some sense that the love and protection that they get from others is performance-based.  That is, that they will only receive love and support from others as long as they perform.  Because of messages they’ve received from their family of origin (mother, father, siblings, etc.) they’ve come to believe that their worth to others is in what they can do for them.  Without any sense of inherent worth, a failure generates feelings of worthlessness and the fear that they’ll never be loved.

The degree to which this is truth or simply perception isn’t relevant.  What’s important is that the individual has developed a perception that they can’t fail if they want to be loved, cared for, and supported.

On Their Terms

At some level, those who call to a suicide help line are asking for help, and while the saying goes, “beggars can’t be choosers,” it doesn’t apply here.  They want to get help – but only the help they want and in the way that they want it.  In a suicidal person’s constricted vision, they may not be able to accept the communication approach and pattern used by the person on the other end of the line.  As a result, the person answering the phone line may need to deviate a fair amount from the official protocol to first form a connection with the caller and from that start to understand then persuade them.  (This is consistent with Motivational Interviewing.)

This extends into a general sense that if they can’t get life on their terms, then they don’t want it on any terms.  In other words, if they don’t get what they want, they’re taking their ball and going home.  In this case, that means suicide.  It’s an extreme sense of feeling as if you’re not heard and valued as you are and as a result, you’re not longer willing – or able – to bend, adapt, and change for the chance to be heard.

Self-Soothing

One of the learnings from having a child is that sometimes the right answer is to let the child cry.  It sounds cruel and heartless, and it’s clearly not the only strategy that can be used.  Sometimes, it’s important for a parent to establish that the child is okay and safe.  It’s even important to demonstrate warmth, compassion, and caring, so that the child can establish a perspective that the world is helpful not harmful.  However, there are times when the right answer is to allow children to cry.

The experience of resolving a sense of pain ourselves is critical to our development.  We can’t avoid all pain because to do so robs of us our experience with resolving it.  Chicks need to escape their shell on their own and sea turtle babies need to find their way to the sea.  (See The Psychology of Recognizing and Rewarding Children.)  Without a sense of efficacy in self-soothing and resolving problems – some self-efficacy – it becomes impossible for someone to face an adversity and believe that they can overcome it themselves.

Calm the Panic

If someone can’t calm the panic that they feel in themselves about their situation and the resulting psychological pain, then the people around them must find ways to help them calm the panic.  While not totally self-reliant, the ability of others to bring forth, encourage, and enable the capacity to shut down the pain that is being felt is perhaps the most important thing that one human can do for another.

Pain itself is, as was said above, a necessary teacher.  However, as Nassim Taleb explains in Antifragile, we need the right kinds of challenges at the right times and in the right amounts to be able to grow.  When we teach people to self-soothe or calm the panic, we’re enabling them to regulate the amount of pain they feel from the challenges facing them so that they can bring them into a range that encourages growth rather than feeling oppressive and crushing.

Overstrivers

One of the psychic pains that can drive suicide is the idea that you’re not “enough.”  That is, you’re not good enough to be loved and accepted as a human being.  While we all face the challenge of feeling like we’re enough at times, some of us are locked into a more persistent struggle.  The irony of the situation is that those people who are larger than life, who are more than enough by other people’s standards, are sometimes not enough in their own eyes.

Many people who are high performers became high performers because of a sense of drive.  They wanted to be more than they were.  While in the context of a growth mindset, this is good, it can be that the driver itself may cause a different kind of problem.  (See Carol Dweck’s work Mindset for more on a growth mindset and its benefits.)  What may be driving it isn’t necessarily a sense of acceptance of the current state and a striving for more but instead a longing to be something more than today so that they’re finally enough.

Some situations exacerbate these feelings and may even lead to suicidal ideation.  The overstrivers believe that that they’re not good enough – and can never be good enough – so the world is better off without them.  This isn’t true, but to them it feels true.

Somebody to be Loved By

There’s an innate need in people to be understood and even loved.  We long for acceptance in ways that convey that our existence matters.  We’re created as social beings having evolved with the primary advantage being our ability to have a theory of mind.  (See The Righteous Mind and Mindreading for more.)  When deprived of love, we find ourselves seeking it out in ways that may be self-destructive or ultimately harmful but that quench the immediate, burning need.

Sometimes, the suicidal individual can’t find a way to feel loved by others.  Whether they are or are not is immaterial.  Their capacity to accept the love that others are pouring into them is somehow blocked or thwarted.  To help a person who is considering suicide as an option, sometimes all that’s necessary is to be present and allow them to recognize that other people do care and that they love them.

Grass Must Not Be Greener

One of the challenges of the early Christian church was the attractiveness of heaven.  If today’s life is hard and the afterlife is all good, why not end the life part today and move on to the afterlife part immediately?  Unfortunately, more than a few people came to this realization, and suicide became a problem for the church, which was trying to increase its numbers.  (See A Handbook for the Study of Suicide.)  That’s why the church made suicide a sin.  By making suicide a sin, they could simultaneously maintain the psychic benefits of a glorious afterlife and remove suicide from the list of methods that could get you there.

Whenever we’re looking at ways to shape the decisions of others, the ultimate answer is easy.  If you can make the option you don’t want them to pick always undesirable, then few will pick it.  (It’s not all because some people have a rebellious spirit.)

Support Withdraw

A disproportionate number of suicides happen while therapists are on vacation.  This creates a struggle for therapists who need to find ways to recharge themselves and simultaneously don’t want to put their patients at greater risk.  There are solutions that therapists can take advantage of by having others that their patients can talk to in their absence.  However, the greater observation is the fact that the patients react to the perceived withdrawal of support.

It’s not that they believe that the therapist will be gone for good necessarily (though that is a possible thought).  It’s simply that they don’t know how to cope with today given the perceived withdrawal of support.  It’s like they’re literally leaning on the therapist when they suddenly disappear.

Interfering with Freedoms

On the opposite end of the spectrum are those situations where it’s believed to be necessary to interfere with the freedoms of suicidal individuals so that they are deprived of the chance to take their own lives.  There are, undoubtedly, situations where this is the right answer.  However, there are also times when depriving people of their liberties to save their lives may be precisely the wrong thing.

Suicide is driven, at least in part, through a feeling of helplessness and the involuntary loss of freedom encourages that feeling.  You necessarily reduce someone’s internal sense of personal agency when you restrict their freedom.  Thus, the short-term protection can come at a long-term cost.  You cannot hold someone indefinitely.  At some point, you’ll have to return them to their own freedom and sometimes at great peril.

So, it makes sense to involuntarily restrict someone’s freedom if there is no question about their intent to harm themselves, but when there is no clear indication, it may be a bad choice.

Patient Proactive

The ultimate goal of any therapeutic approach should be to empower the individual towards their own life separate from therapy.  It’s not appropriate or effective to keep patients in therapy indefinitely.  That means it’s necessary to continue to enable the patient to solve their own problems and, more specifically, learn to cope with life with progressively less external support.

Therefore, every patient interaction should be structured to enable them to solve their own problems rather than the therapist being seen as the expert to which the patient must always come.  (See A Way of Being and Motivational Interviewing for more.)

Separating Despair and Depression

Despair (hopelessness) is different from depression – and it’s more indicative of a situation that requires immediate care than depression.  While depression is a solid indicator for suicide, it’s less predictive than hopelessness, so it’s important to distinguish between depression and despair – with despair requiring more attention and faster intervention.  Depression, because of the diagnostic criteria, is a more long-term condition.  Despair (lack of hope) covers a person unexpectedly and profoundly.  It’s therefore difficult to detect with much advance warning – and it’s difficult for patients to muster defenses against.  It comes when people least expect it.

When encountering people who are in active despair, we must find ways to help them see that things will change for the better – even if it is difficult for them to see that at the moment.

Acceptance through Presence

Sometimes the things that need to be done are so simple and unremarkable that they’ve overlooked.  Often people believe that no one cares and that no one is listening.  Sometimes the intervention is just being present with people and listening.  By being present and listening you convey acceptance of them as a human being and an interest in who they are.  Sometimes this can help them recognize their own value and personal agency.

Often, the stories of those who have attempted or completed suicide are clear about their feelings that they’re not heard or even more explicit about aborting their plan should so much as a single person give them a hint that they’re not alone in the world – that someone cares and recognizes them as a human being.

Tread Water for Now

Being present is one way of treading water.  While you’re being present and listening, few people will actively attempt suicide.  Instead, they’ll be in the moment with you – and that may be all that’s necessary for the suicidal impulse to subside.

If you can point to the finality of a suicide as a solution and acknowledge that the option will always be available to them, they don’t have to choose it now.  For now, all they have to do is survive today.  They don’t have to solve their long-term happiness and the prevention of future pain.  They just need to make today livable.  (See Stumbling on Happiness for more about our lack of predictive powers for what will make us happy.)

No Control, Lots of Hope

Therapists have relatively little control over patients’ lives.  They may have powerful clinical prowess and amazing techniques, but these all pale in comparison to the other forces in a patients’ lives – the other 160+ hours of their week that they’re not with the therapist.  So, while it’s not possible for therapists to accept complete responsibility for the outcomes of a patient, that isn’t to say that they shouldn’t try to make the situation better.

Just because we don’t have control doesn’t mean that we can’t hope that our degree of influence is enough.  In many cases, it can be that the influence that the therapist has is sufficient to convert a tragedy into a triumph.  There’s no way to know which will be which.

The Liberty and Control Coin

Jonathan Haidt in The Righteous Mind calls one of the foundations of morality the strive towards liberty and away from oppression.  Here, the word used is control – whether it is perceived as oppressive or not.  What we realize is that the more liberty someone has, the less control we have.  Conversely, the more control that we exert over someone else, the less liberty they have.  They’re inseparable because they are opposite sides of the same coin.  This creates challenges when trying to limit access to potentially lethal means for suicide and the need to ensure that the person retains their sense of liberty.

Responsibility and Control

One cannot be responsible for something they don’t control.  That’s a truism that extends beyond the bounds of suicide and is a point of challenge, as we’ve taught parents that they are responsible for their children while fully admitting that parent can’t control their children.  This is particularly true as children get older.

Because parents often feel responsible for their children even if they don’t have control of them, they struggle when children don’t do what the parents expect.  This is particularly true of parents whose children die by suicide.  They have no way of accepting their responsibility for the death of their child – and they shouldn’t.  We collectively need to acknowledge and share that, most of the time, parents are no more responsible for their children’s suicide than a therapist is responsible for the mental illness of a patient.

Both can try to create conditions for better mental health and feelings of love and support, but neither can be responsible.

Things Worse than Suicide

While suicide is a tragedy, we can’t forget that sometimes there are fates worse than death.  Some situations are so laden with pain and suffering that we shouldn’t be so hasty to eliminate suicide as an option.  We show compassion to our animals to euthanize them when they’re in too much pain from which they can’t recover, yet we often are unwilling to allow humans even peaceful deaths due to natural causes.  Instead, we attempt everything we can to extend life – even if the person whose life we’re saving would say it’s not worth living.  Sometimes the best – and most difficult – thing that we can do is to allow someone the grace to decide that suicide is the right answer.  That’s one of the reasons why understanding and responding to suicide is so hard.

There are no clean answers.  No quick fixes.  No magic bullets.  However, there is some wisdom in Suicide: Understanding and Responding.

Book Review-The End of Hope

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

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

The Power of Placebo

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

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

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

Staff Emotions

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

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

Feelings of Control

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

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

The Temptation to Regress

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

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

Labels and Expectations

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

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

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

Doctor’s Orders

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

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

You’re Only as Sick as Your Secrets

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

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

Sick Cycles

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

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

Magical Responsibility

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

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

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

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

Book Review-Social Forces in Urban Suicide

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

The Test of Time

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

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

Individuals and Society

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

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

Societal Control

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

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

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

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

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

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

Craving the Control

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

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

Not Excessive Individualization

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

Settled but Not Settled

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

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

Alcoholism

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

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

Book Review-After Suicide

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

The Weight of Marriage

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

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

Insecurities

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

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

Strength

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

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

A Series of Deaths

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

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

Growing in the Same Direction

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

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

Stories

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

Sorrowfully, Suicide in Spring

It’s a time of life and rebirth – and it’s also a time to die.  One of the things I’ve learned over the last six months is that suicide peaks in the spring.  I would have expected the dark of winter or late fall when confronted with having to survive winter.  However, that’s not what the statistics say.

To recognize the spring peak and that next week is the start of spring, we’ll be posting a book review for a suicide book at 8AM EST every day next week instead of just Monday.

If you’re concerned about someone who has been struggling or you suspect may be struggling, my simple advice is reach out to them.  Send them a text or give them a call.  It may mean more than you know.

[The image accompanying this post is a sunrise – not a sunset.]

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

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

Proxy Relationships and Marriage

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

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

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

Mental Healthcare

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

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

Ten Step Assessment

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

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

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

Natural Negative Reactions

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

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

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

Incorrect Assessment

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

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

Peer Protection

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

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

More Reliable and Valid

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

Getting the Last Word

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

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

Safety Through Dying

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

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

Never Enough Beds

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

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

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

Documentation of Rationale

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

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

Limits

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