Book Review-Suicide and Scandinavia

It’s a curiosity.  The suicide rate in Denmark is very high.  The suicide rate in Norway is low.  At least they were in the early 1960s, when Herbert Hendin was doing his research.  The rates today are substantially similar to each other.  Back then, Hendin wanted to know why, and the results of his search are found in Suicide and Scandinavia.  There weren’t definitive answers, but there may be clues as to why one culture may have a high rate of suicide vs. a low rate of suicide given a similar set of weather and history.

The Hypothesis

Hendin ultimately proposed that the difference in suicide rates was due to the parenting styles of the two countries.  He proposed that, collectively, the aspects of the parenting difference could drive suicide rates higher – or lower.  Shortly after the publication of the book, a research study was performed.  That study tested the various aspects of Hendin’s hypothesis regarding the differences between rates and their causes.  Fundamentally, these aspects are all about how children are raised.  These aspects and what the study, “A Test of Hendin’s Hypothesis Relating to Suicide in Scandinavia to Child-Rearing Orientations,” found was that some aspects of his hypothesis were supported, and some were not.  The child-rearing aspects, and whether the study indicated that they were supported, are:

• Competition (Supported)
• Maternal Authority (Supported)
• Physical Freedom and Autonomy (Supported)
• Teasing (Supported)
• Tolerance for Aggression (Not Supported)
• Expression of Affect (Not Supported)
• Dependency (Not Supported)

The reasons for these categorizations are nuanced and may be an artifact of the study design.  However, they provide a good framework for Hendin’s ideas, and they offer an opportunity to reevaluate how these factors may have changed and what impact that might have had on bringing the suicide rates closer between the two countries.

It’s important to note that there are many factors beyond the influence of parents in the development of children.  Judith Rich Harris in No Two Alike and The Nurture Assumption explains how small changes and lots of external factors shape children in unexpected and sometimes unexplainable ways.  The culture that individuals reside in shapes the way that they trust.  (See Trust: Human Nature and the Reconstitution of Social Order for more.)  Our basic moral perspectives are also shaped by the broader context in which we live.  (See How Good People Make Tough Choices for more.)

Dependence

Mothers in Denmark encouraged their children to be more dependent than their American counterparts.  This may no longer be the case, as we hear more about helicopter parenting and the kinds of cancel culture behaviors that are discussed in The Coddling of the American Mind.  The question is, what possible mechanism could a greater dependence on mothers have to suicide?  Are the same factors that were driving high rates in Denmark in the 1960s impacting the US and the rest of the world today?

Hendin doesn’t propose any effective mechanism himself, but one could postulate that dependence on their mother reduces the problem-solving skills in the children, and this lack of problem-solving skills – particularly in interpersonal matters – has been linked with suicidality.  Perhaps the dependence that’s being instilled deprives them of the experience and practice necessary to become good at solving problems on their own.  (See Peak and Sources of Power for the role of experience on performance and decision making.)

The Discussion of Death

Hendin remarked that the discussion of death was just as taboo in Denmark as in the United States.  It’s not a surprise given the work on how the fear of death drives us.  (See The Worm at the Core and The Denial of Death for more.)  Jonathan Haidt in The Blank Slate explains that we’re all driven by the same foundations of morality, so any differences tend to be more surface level rather than a change in the acceptability of death discussions.  Contrasting this, Hendin explains that, in Denmark, they were relatively less closed-off and disturbed with the discussions of death than in the United States.

Death as Relief to Deadness

Owing to the relative confusion or fantasy of death that is often encountered with suicidal people, one person remarked that death would be an escape from the feelings of deadness.  In a sense, the cessation of consciousness would, in fact, end the feelings of deadness – of course, replacing it with actual deadness.  Such are the odd twists that seem to occur in the mind of someone in severe pain.

In the end, Suicide and Scandinavia is more a commentary on the parenting practices and general cultural approaches to aspects of their lives than it is a specific study of suicide.  As a short book, it may be worth spending a few minutes to see differences between then and now, overall and at a country-by-country level.

Book Review-Cognition and Suicide: Theory, Research, and Therapy

Of course, the way that you think about things leads towards or away from suicide.  So, how do we find ways to lead people away from suicide as a valid option?  That’s what Cognition and Suicide: Theory, Research, and Therapy is all about.  How do we take what we know about cognition and apply it in ways that saves lives.

Connections

I explained in my review of Choosing to Live that I rarely post negative reviews.  However, I didn’t explain why I read the book in the first place: it’s referred to from Cognition and Suicide.  The editor of this volume, Thomas Ellis, is one of the authors on Choosing to Live.  I realized that some of the factual errors that I saw there made their way to this volume – or vice-versa.  As this is an academic volume rather than a consumer volume, the errors are substantially more constrained.  In some cases, they have references for their statements – but when you get the referred to article or paper, you realize it says nothing about the item it’s cited for.  This is concerning but not enough to eliminate the value produced by the authors in the volume.

High Expectations

As I began to explain in my review for American Suicide, higher expectations may be a factor in why people die by suicide.  In 1971, Shneidman did a study where he saw a substantially higher number of suicides in the group with higher IQs – and therefore higher expectations.

The research on maximizers started in 1957 by Herbert Simon and was covered extensively in Barry Swartz’s book, The Paradox of Choice.  Maximizers are those people – or, more accurately, those situations – where a decision has to be the absolute best.  People who are maximizing are looking for the best sale price and will be disappointed if next week there’s a better sale, and they missed out on an insignificant discount.  The goal ceases to be about getting a good deal or a fair deal and becomes competitive – it must be the best.  The research that has continued along the lines that Simon started has indicated that people who are maximizers are more depressed – less happy.

The truth is that we’re neither pure maximizers nor the opposite, pure satisficers.  We find ourselves alternating between the two depending upon the situation and our mood.  That being said, there are people who tend to do more maximization – and they’re less happy.  If we were to extend this into suicide potential, it follows that someone who is focused on maximization will frequently fall below their expectations.

High IQ

One of the notes are Shneidman’s analysis of 30 cases of people with high IQs – a disproportionate number of which died by suicide.  How can this be?  The answer may fall in the tendency for those with high IQs to have been told of their results and therefore expected more of themselves.  After all, if you’re smarter than the average bear, your life shouldn’t be average.  You shouldn’t have the same challenges that everyone else does – except that you do.

With high IQ, they got high expectations and a propensity to maximize in themselves and in others.  From other research we could assume that they’ll be less happy and more susceptible to suicidal thoughts.

Bias Towards Action

Humans are wired with a bias towards action.  If there are two equal probabilities of success with a passive strategy and an active one, we’re likely to choose the active one, because we believe we have more control.  Control is an illusion, to be sure.  (See Compelled to Control for more.)  However, what’s more interesting is our relationship with regret and guilt.  We regret the things that we didn’t do – the actions that we didn’t take – substantially more powerfully than we regret the things that we do.

The sayings go, “It’s better to have tried and failed than to have never tried at all,” and “You miss 100% of the shots that you don’t take.”  It’s clear that we’re wired to do.  It’s this complicated relationship with action that may explain, as Shneidman observed, the bias that suicidal people have towards action.  One of the most dangerous times for someone is the time when they’re recovering from depression.  Depression has a psychomotor retardation that prevents action – and therefore an attempt at suicide.  During recovery from depression, this psychomotor retardation sometimes wanes before the feelings of hopelessness and despair.  The result is people take action on the suicidal act they never had the energy to do before.

Viewed from the lens of helplessness, the action is an attempt to control or influence their situation and thereby avoid helplessness, so their action can be seen as them desperately fighting against it.  If they can demonstrate influence over their pain, they’re not truly hopeless.  That’s why suicide itself is sometimes seen as a final act of control.

Reduce Depression, Reduce Suicide

One of the difficulties in dealing with suicide is that actual completions are rare – while a good thing it represents a challenge in directly addressing the rate.  One of the side effects of this is that we start to look for indirect (proximal) effects.  Instead of researching the reduction in suicide directly, we look at a covariate like depression and try to reduce it with the belief that this will lead to a reduction in suicides.  Unfortunately, this hasn’t turned out to be the case.

Economists once tried to stabilize the economy through increasing home ownership, because it seemed like this was a good thing and would lead to more stability.  After all the two were covariates – change one and you change the other.  At least, that’s the story.  The manipulation led to the meltdown of the financial system in 2008.  (See The Halo Effect for more.)  Sometimes, what seems to make sense doesn’t actually.

Perturbation

It’s Shneidman’s word for emotional disturbance.  It’s one of his key factors for suicidality, and I mentioned it in my review of Suicide: Understanding and Responding – without attributing it to Shneidman (oops).  However, I didn’t address a conceptual underpinning often missed with the concept.

Perturbation is a discomforting.  It’s a feeling of things being wrong – and it’s something that we seek to minimize.  Quiet Leadership says that, in fact, much of our society is set up to minimize discomfort.  If we look objectively at the drug problem, we see that it’s a solution to a variety of other problems.  In most cases, drugs start out as a solution to some inner pain.  It’s a way of coping with pain that progressively takes control over the person.  (See Chasing the Scream, The Globalization of Addiction, and Dreamland for more.)

Michell tested children at the Stanford Bing Nursery Center and ultimately learned that those who could delay gratification did better in life.  (See The Marshmallow Test.)  These children had already learned how to address the distress of not being able to have a sugary treat right now.  They learned that their struggle against the desire was okay.  Many of the most successful children were using their own distraction techniques to allow them to get the reward – double the treats.

Josh Waitzkin in The Art of Learning explains how he came to make peace with discomfort.  A chess wiz turned martial arts guru knows a thing or two about both mental and physical discomfort.  Anders Ericsson and Robert Pool in Peak explain that people need to be pushed outside of their comfort zone by someone they trust.  A coach is an essential ingredient of peak performance.

Coping with perturbation is about learning to tolerate distress long enough to find strategies that resolve it.  When our distress can’t be tolerated, we’ll start to seek risky or far reaching solutions to problems that we should normally not be inclined to accept.  Sometimes, distress tolerance is a set of distracting skills like those children used for The Marshmallow Test.  Sometimes, distress tolerance is a coach or mentor assuring you that there is value to your suffering.  Sometimes, it’s just a sheer act of willpower.

Willpower

Willpower is an exhaustible, renewable resource, as Roy Baumeister explains in Willpower.  He recommends exercising it at appropriate levels – but not relying on it.  Invariably, if we are relying on willpower, we’ll eventually exceed our capacity, and bad things will happen.  Willpower as distress tolerance is “I’ll make it through.”  While noble, this places an immense demand on our willpower and thereby depletes it quickly.

Hope

The problem with depleted willpower is we need it for hope.  As Rick Snyder explains in The Psychology of Hope, hope isn’t an emotion.  It’s a cognitive process.  That process needs both willpower and waypower.  If either are lacking, hope will be flagging or gone.  Waypower, by the way, is knowing the path forward.  It’s a plan or an approach, or even just a visionary direction.  Often, immediately after an intense loss in the moments of perturbation, we’ll not know how to move forward – we’ll have little waypower – and as a result, depleting our willpower is especially dangerous.

The Embarrassment of an Attempt

For some people, it’s impossible – or very difficult – to discuss a prior suicide attempt.  What seemed to make sense in the moment suddenly seems stupid in the light of day.  They don’t know how they reached the point where an attempt made sense, but they don’t expect that admitting it is a good idea.  In an ideal world, we’d want people to feel comfortable sharing their thoughts, particularly those leading up to the attempt, to detect the weaknesses in thinking that led to the attempt, but that requires a degree of safety that may be difficult to generate.  In my review for The Fearless Organization, I explained that safety is a perception, and safety has as much (or more) to do with the person as it does the environment that someone creates.

The wisdom of 12-step groups says that “You’re only as sick as your secrets” or, less judgmentally, “Any load shared is lightened.”  (See Why and How 12-Step Groups Work for more.)  Critical Incident Stress Management (CISM) is a common debriefing tool for first responders who encounter potentially traumatic events on a regular basis.  As I explained in my review of The Body Keeps the Score, CISM can be effective, but often first responders reject it, because it feels forced, artificial, and unsafe.

Unconditional Self-Acceptance (USA)

For most people, there are aspects of their personalities and their being that they struggle to accept.  In my review of No Bad Parts, I explained one theory of consciousness that posits that we have multiple parts – not all of which are the same or present in every situation.  We have parts of ourselves that are protecting other parts – sometimes in maladaptive ways.  The fact that we have some aspects of ourselves that we’re not accepting can be problematic.  It can lead to shame and its corrosive effects.  (See I Thought It Was Just Me (But It Isn’t) for more.)  That isn’t to say that people can’t desire to be better.  Rather, it says that they should accept where they are now and recognize their capacity to get better.  (See Mindset for more about this kind of growth mindset.)

Unconditional Other Acceptance (UOA)

At the heart of acceptance is a lack of judgement.  We can accept ourselves without judgement, but we can also accept others without judgement.  (See How to Be an Adult in Relationships for more on acceptance.)  Unconditional Other Acceptance (UOA) is about accepting others where they are.  We often judge people without accepting their circumstances led to their behavior.  Daniel Kahneman calls it “fundamental attribution error” in Thinking, Fast and Slow.  Lewin’s perspective is that all behavior is a function of both person and environment.  (See A Dynamic Theory of Personality.)  Therefore, we shouldn’t discount that the behaviors we observe may not be about the other person but rather about being in the environment they’re in.

Steven Reiss’ work focused on different basic motivators and how two people with different motivators will struggle to accept one another.  (See Who Am I? and The Normal Personality for more.)  By learning about how other people don’t see the world the same way we do, that their perspective is different and how their motivators or values or different, we can come to accept others more easily.  (See The Difference for more about differences of perspectives.)

Unconditional Life Acceptance (ULA)

Moving from self to other to overall, unconditional life acceptance (ULA) acknowledges that there are some bad things in life, but those bad things are aren’t the only things.  They are a part of the broader context that is often quite positive.  It’s hard to accept the negative aspects of life.  However, by accepting that they’re a part of life, you can also accept that there are good things in life, too.  If we attempt to deny any part of life, we necessarily make it easier to discount the positive things as well.

Achievement

Getting things done, achieving things, seems like a good thing – and it is.  However, achievements can hide an unwillingness to accept who we are.  If our self-worth is connected to our achievements, then what happens when we’re no longer achieving great things?  Instead of accepting ourselves, we find that we’re judging ourselves – and generally being negative.  So, while we should encourage achievement in ourselves and others, we shouldn’t do it at the expense of our feeling worthy of love and respect – even if we’re not achieving anything.

The Downward Spiral

Sometimes, there’s a downward spiral that starts with simply becoming upset.  Then judgement sets in, and we judge that we shouldn’t be upset (or the other person shouldn’t be upset).  Then we’re upset because we’re upset (or they’re upset).  This cycle, once started, is hard to stop.  Frustration and judgement build until there’s a problem, and we’re thrown out of the cycle.  The best solution is to simply know that being upset, or frustrated, or angry, or whatever is a normal part of life.  We’ll feel things that may or may not make sense on the surface, but these feelings are normally short-lived.  In How Emotions are Made, Lisa Feldman Barrett shares a story how she once confused getting ill with falling in love – and how easy it is to forget how transitory our feelings are.

Missing the Positive

Depressed people do see the world more accurately than non-depressed people.  (See Superforecasting and The Signal and the Noise for more.)  But just because they see the future more accurately doesn’t mean that it’s better – or that they don’t have gaps.  Severely depressed people don’t foresee negative events with greater frequency or intensity than non-depressed people as much as people who are depressed fail to correctly anticipate positive events.

They require more prompting, more proof, and more persistence to see that there are, in fact, good things that can – and will – happen in the future.  Of course, we’re no more able to make an accurate prediction of the ratio of good to bad things than they are – but to exclude the possibility of positive things happening in the future is a unique characteristic of depression.

Gaslighting

One of the most damaging forms of invalidation is when the victim is made to believe that they deserved the abuse they received.  This exists in a malicious form, where a villain intentionally deflects blame from themselves.  However, it also exists in a form where a random tragedy happens, and people accept responsibility for its occurrence when it’s not possible for them to have known or prevented the tragedy.  Too often, parents of children that die by suicide are haunted by the idea that they could have prevented it.  Unfortunately, most of the time, the way of preventing it requires magical premonition to understand the degree of challenge their child faced.

Similar situations are faced by those who have lost love interests.  They ask the question of why they weren’t enough for their partner to stay.  They believe if they had been present at the moment or if they had been more attentive or loved them “better,” they’d still be around.  Of course, this transfers the responsibility from the person who died by suicide – whose responsibility it is – to another person who could not have possibly controlled the situation or prevented it from occurring.

Another variation is where someone is gaslighted – that is, made to believe that whatever it is that they’re talking about never happened.  There are some rather ludicrous claims like that the Holocaust never happened, but most gaslighting is much more subtle.  In the context of suicide, persistent gaslighting of someone would naturally cause them to question the accuracy of their memories and feel less connected with reality.

Mind Control

One of the greatest “tricks” of humanity is the ability to read the minds of others.  Theory of mind allows us to anticipate what others are thinking and thereby work more cooperatively with them.  (See The Blank Slate and Mindreading for more.)  These skills do not extend to detailed knowledge of someone else’s innermost thoughts.  In Telling Lies, Paul Eckman explains that even micro-expressions, which are detectable “tells” of emotion, don’t help you understand what triggered the emotion.  Nor do our powers of mind-reading cross over into the realm of mind control.  We cannot force someone else to think a particular way.  However, this doesn’t stop some people from exerting as much control as possible – sometimes in the form of a suicide attempt.

Suicide attempts are sometimes cries for help.  (See The Cry for Help for more.)  While this isn’t to say that a suicide attempt should ever be taken lightly, it’s a recognition that sometimes people don’t believe they’re getting enough attention.  Much like delinquent children, they’ll take any attention – even bad attention.  (See Delinquent Boys for more on delinquency.)  Ultimately, it’s hard to predict how others will respond, so a suicide attempt is a bad way to try to get attention.

Depersonalization

In response to overwhelming emotional stress, people learn to depersonalize.  Often, this skill is learned as children, when their skills for processing emotions are overwhelmed by some life event.  How Children Succeed explains in detail the work in the Adverse Childhood Experiences (ACE) study and how adverse childhood experiences shape people’s long term success.  The study doesn’t say whether the children develop depersonalization as a coping strategy, but we do know that trauma patients often experience depersonalization.  (See The Body Keeps the Score for more on trauma-induced depersonalization.)

Overgeneralization

A curious finding separates those who have attempted suicide from a control population.  It’s much like what was found when real suicide notes were compared with notes written by a control group told to write a suicide note – but much less specific to suicide notes.  (See Clues to Suicide for more.)  When suicide attempters were asked to recall a specific memory, they more often responded with an overgeneralized memory rather than a specific memory.  While a matched control group responded with specific instances, the suicide attempters did not.  Since the original study, the overgeneralization of memory has been studied frequently and often indicates a disorder, where recall of specific memories does not.

Burdensomeness

One of the factors that Joiner’s model of Interpersonal-Psychological Theory of Suicide posits as a causal factor is burdensomeness.  Atul Gawande in Being Mortal explained that even taking care of a plant was enough to help the elderly live longer.  The belief that they needed to be there to care for another life – even a plant – can be powerful.  One of the powerful ways that people can fight suicide is to fight people’s feelings of burdensomeness, and that can be done by having those who are suicidal helping others.  This service to others puts a finger on the scales and starts to bias it in a way that is more positive, where people don’t believe that they’re a burden to others – in the big picture.

There’s no way to totally eliminate the feelings of burdensomeness – but a little bit of service, as 12-step groups have learned, can go a long way.  (See Why and How 12-Step Groups Work for more.)

Fluid Vulnerability

As I mentioned in my review of Brief Cognitive-Behavioral Therapy for Suicide Prevention, the fluid vulnerability theory of suicide posits that suicidal crises are time-limited, and therefore it’s often a good thing to be present with someone until the feelings of dying by suicide have passed.  While this may sometimes require handoff and won’t work for those who believe they’ve rationally decided that death is the best answer, it can be important in most cases.

Understanding how most people who are considering suicide will only ponder it for a short time is important – even if there are exceptions.  In the end, the more we know about Cognition and Suicide, the more lives we can all save.

Book Review-The Cry for Help

One of the things that people often say about those who attempt suicide is that it’s just a cry for help.  While this isn’t true – every attempt should be taken seriously – The Cry for Help covers suicide attempts and death by suicide as it was known in 1965.  It was a time of serious condemnation for those who attempted or died by suicide.  Society was even quicker to blame parents, siblings, and spouses for a death by suicide – or an attempt – than today.

The Presuicidal Phase

As Joiner points out in Myths about Suicide, you can’t tell who will die by suicide by looking at them.  There aren’t tell-tale signs that anyone can pick up.  Joiner’s position (at the time of that writing) was that there are signs that predate a suicide attempt.  He challenges the research with attempters that they hadn’t considered suicide more than a few hours before their attempt.  The challenge – a fair one – is that attempters and those who die by suicide are an overlapping but distinct group.

Increasingly more research is added to the pile that, while some people who die by suicide have a presuicidal phase where they’re considering it and sending signals, some do not.  The latest research puts well over 50% of people not considering suicide prior to a few hours before the attempt.  That research wasn’t available in 1965 so the perspective is one where all suicides have a presuicidal phase with detectable signals that suicide is eminent.

Our experience today with the predictability of screening and assessment tools shows the same challenges.  We simply can’t use these tools to predict who will attempt suicide or not.

To add further challenge is the fact that even if signals are sent, they may be too low to be detected.  They may fall into the category of normal variations that people don’t detect.  Behavior changes are often cited as a suicidal signal; however, people change their behaviors every day in a variety of ways based on reasons to numerous to count.  Thankfully, few people who change their behaviors are truly suicidal.

Should we ask people if they’re going to harm themselves or attempt suicide?  Absolutely.  However, that isn’t to say that we’ve got to develop absolute prediction skills.

Suicidal or Accidental

The coroner’s job in determining what is – and what is not – a suicide is a challenging one to say the least.  There are some situations that are clear cut, but many more where it’s not possible to peer into someone’s intent after the fact.  This is why Shneidman started working with the coroner to help tease out the difference between accident and suicide.  (See Assessment and Prediction of Suicide.)  Even with advanced techniques for interviewing those who knew the deceased, there are still many errors that can be made, such as whether the car that crashed into the tree slid on an icy road or whether the driver intentionally pointed the car at the tree.

We may never know whether some deaths were accidental or suicidal – but in the individual case that may not matter.  It certainly will not bring them back.  The value in the distinction lies in our ability to potentially prevent the suicide.  However, as Bryan points out in Rethinking Suicide, suicides are like car crashes in that you can’t predict them at an individual level.  Our goal is to make things safer and in that way we’ll reduce suicides.

Secondary Benefits of a Psychological Autopsy

If we can’t see with clarity someone’s intention, the process of gathering the information in the psychological autopsy may be beneficial as postvention to those left behind.  Postvention is the process of caring for those left behind after a suicide.  (See Suicide and Its Aftermath for more on postvention.)  Many have reported that telling the story of their loved one is therapeutic.

The truth is that we need stories to make sense of our experiences.  Rich Tedeschi explains in Transformed by Trauma that PTSD is really our inability to process something we’ve seen or done.  By helping the family members formulate their story about their loved one, they get a chance to process the experience.  This is similar to the techniques that are explored in Opening Up and The Body Keeps the Score where the story process is encouraged.

Irredeemable

In some cases, the underlying drivers for suicide may be an unshakable sense of shame.  That is, it’s not that something that they did was bad (resulting in guilt) but rather that they are bad.  This sense of shame may be persistent if the person believes that they’re irredeemable.  The sense that everyone can be saved from their current state – no matter how bad – creates the window for hope to hold on and to keep people trying to find ways to better themselves – and survive.

No one is irredeemable.  Don’t let The Cry for Help go unheard or unaddressed.

Book Review-Clues to Suicide

If I presented you with a selection of genuine suicide notes and a set of manufactured suicide notes from a matched set of individuals, would you be able to tell the difference?  This is at the heart of Clues to Suicide.  Edward Shneidman famously got interested in suicide by stumbling across suicide notes.  (See Definition of Suicide.)  He and Norman Farberow started the Los Angeles Suicide Prevention Center and edited Clues to Suicide in 1957.  It’s a part of an initial set of research and writing to start the modern period of suicide research.

Mortality

Even in the 1950s, it was clear that suicide was more prevalent than murder – but that the public didn’t know that.  Even today, mass shootings are far more newsworthy than suicides.  We focus on gun violence as if it’s only murder.

Real or Imagined Loss

The fluid vulnerability theory of suicide (developed decades after this book was published) explains that people have a baseline risk for suicide, and then are driven by triggering events into a different stratum of risk.  (See Brief Cognitive-Behavioral Therapy for Suicide Prevention.)  Often, that trigger can be classified as a risk.  Sometimes, the risk is a relationship, and sometimes the loss is a sense of safety.  Clues to Suicide makes the important point that the loss that triggers ideation about suicide need not be real.  It can be either real or imagined.

Consistent with Sapolsky’s work in Why Zebras Don’t Get Ulcers, we as humans have the capacity to predict the future.  That allows us to experience stress that hasn’t happened.  Instead of being confined to immediate threats to our survival, we can predict a loss of job or a loss of love and experience a stress response immediately.  The problem is that our predictions are notoriously bad.  (See Superforecasting and The Signal and the Noise.)  This is particularly true of our happiness, as Gilbert explains in Stumbling on Happiness.

Less Trouble to Everyone Concerned

Sometimes, people believe that they’re a burden; consistent with Joiner’s Interpersonal-Psychological Theory of suicide, burdensomeness is a predictor of eventual suicide.  To be clear, there are probably two different modalities of suicide.  One is planned and the other impulsive.  In both cases, the cognitive processing may consider the degree to which someone is a burden to others.

The challenging aspect of this burdensomeness is that it’s measured from the perspective of the person and may or may not reflect the actual degree to which others perceive them as a burden.  However, in some cases, the concept of burdensomeness shows up as a desire to minimize the amount of pain those left behind will feel.  As a result, they may choose to attempt suicide in a way that they believe will be the least painful for those they leave behind.

Of course, most of this is fallacy, because the loss will be immense when someone dies by suicide, and people rarely perceive their burdensomeness to others equitably.

Socioeconomic Status and Suicide

Even in these early times, it was clear that suicide was occurring at higher rates in those who were privileged.  Today, we think about this in terms of socioeconomic status (SES).  Certainly, suicide occurs in all levels of SES, but there seems to be an odd concentration of suicides at higher levels.

As I’ve suggested in previous reviews, this may be due to maximization and/or the expectation gap.  (See The Noonday Demon.)  When people constantly have higher expectations than are possible, they are necessarily disappointed.  This disappointment can lead to burnout.  (See ExtinguishBurnout.com)  Sometimes this disappointment doesn’t find an outlet or develops into hopelessness, and suicide seems like a good solution.  (See The Psychology of Hope for more about how hope is built, and The Hope Circuit for more about its impact.)

Many of the threads that research has followed for decades are laid out in Clues to Suicide.  Despite its age, it may be a good place to start to see where we’ve been.

Book Review-Choosing to Live

A long time ago, I was told that no one is interested in a negative review.  I was reviewing technology at the time, so a few of the products I set out to review never got a story.  I’ve mostly carried that through in my book reviews.  However, Choosing to Live: How to Defeat Suicide Through Cognitive Therapy is different.  There are some good things to learn, but more importantly, there are some commonly repeated myths that need addressed – so let’s do that.

Myth: Treatable Psychiatric Disorder

There’s often quoted statement that most people who die by suicide are mentally ill or have a diagnosable and treatable psychiatric disorder.  There’s some variation to the myth, with people adding rates like 90% or 95% to make it seem more real.  However, the problem is that there’s no root research to support this.  In fact, modern research and thinking doesn’t believe this at all.  Certainly, some percentage of people do have a treatable psychological disturbance – but the number isn’t 90-95%.  There’s no credible research I’ve seen that even supports the idea that it’s a majority.

It seems to be a holdover from the idea “you’d have to be crazy to kill yourself.”  Of course, Shneidman and others have demonstrated that people die by suicide for a variety of reasons, but often because there’s some sort of psychological pain that is unbearable (see The Suicidal Mind) or because they’ve become hopeless (see The Noonday Demon).

Myth: Invariably Clinically Depressed

The exact quote from the book is, “Studies also show that suicidal individuals, terminally ill or not, are almost invariably clinically depressed.”  Except there is no research that says that – and the author didn’t respond to a request for him to clarify this statement.  Is there a correlation between depression and suicide?  Absolutely.  There’s a stronger correlation between hopelessness and suicide.  There’s an even stronger correlation with substance use disorder.  It is true that some are depressed?  Yes.  Here’s the real problem: that says very little, since a non-trivial amount of the population meets criteria for depression – at least to the level of being given a prescription for an SSRI.

Myth: Self-Destructive Behaviors Are Suicidal but Won’t Admit It

Another direct quote: “Indeed, some suicide theorists have proposed subintentioned suicide to explain such self-destructive behaviors in people who may not be depressed and who deny that they wish to die.”  There’s a long distance between self-harm and suicide.  Again, a correlation exists.  However, it’s too much to say that all self-harm is a desire for suicide.  For instance, we know that people who do self-harm are often trying to achieve a pain they can experience and control due to emotional disconnection or suppression.  One can be inflicting self-harm and not be suicidal.  Admittedly, the ability to do self-harm makes it easier to die by suicide later – but it doesn’t mean that’s where they are now.

Myth: Half the Population Has Had Suicidal Thoughts

Another direct quote: “Some studies have indicated that half of the population has had such thoughts at one time or another.”  The problem is that these numbers far exceed the accepted research that places the number at somewhere between 1 in 5 and 1 in 6.  Yes, people think about suicide much more frequently than we admit they do – however, it’s not 1 in 2 people unless the incidence rate is substantially under reported.

It’s appropriate to acknowledge that many more people consider suicide than we believe, but it’s too far to say that it’s half the population.

Myth: One in Six Untreated Depressed People

This quote is, “Left untreated, one depressed person in six will commit suicide.”  Not only is there no research support for this, but there’s no effective way to do this research.  How do you find untreated people who have depression?  If you found them, no review board would let you leave one group without “treatment as usual,” which is probably CBT or DBT.  As was mentioned above, people who die by suicide are more likely to have depression—but there’s no way to know how many would die by suicide.

Retrospective studies and psychological autopsies don’t have the precision to make these kinds of determinations.

Myth: The Drugs Made Them Do It

Here, the quote is, “Abuse of drugs and alcohol can lead people to become so chemically addicted that they develop another problem (the addiction) that they are unable to beat.”  This is the pharmacological view of suicide.  It’s been disproven but remains popular.  (See Chasing the Scream, The Globalization of Addiction and Dreamland for more.)  The truth is that substance use disorder (SUD) is a result of a coping strategy that has taken control over the person.  They leaned on the coping strategy in the first place, because there’s some aspect of their lives that is unsatisfying.  Much of what we were taught about drugs was simply false.  The programs, like DARE, didn’t work – they made things worse.  And we’re still fighting our way out of it.

Myth: Surfacing Subconscious Can Be Brought to Consciousness Easily

The direct quote is, “Depressive thinking patterns, while usually outside of a person’s awareness, can be brought into awareness fairly readily.”  Most professionals would say that subconscious thoughts can sometimes be easy to surface but some are more difficult to surface.  In fact, in Immunity to Change, we discover how persistent some beliefs can be.

Long String of Failures

With the list of myths out of the way, it’s time to highlight some of the good that the book has to offer.  One of those is the recognition that suicidal people can come to see their lives as a long string of failures.  Whether this is due to unrealistic or perfectionistic perspectives about what they should be able to accomplish, the disappointment is tangible.  It’s also, of course, possible that they’ve encountered a long string of difficult circumstances beyond their control.  However, in either case, when someone believes it’s hopeless that they’ll start meeting expectations, it can mean a suicide attempt.

Not Selfish

Suicidal people are, most frequently, not being selfish in their death.  In many cases, the person dying by suicide is so focused on their situation, their pain, and their circumstances that they don’t consider other people.  It’s not that they’re inconsiderate in general but rather the cognitive constriction (see The Suicidal Mind) and the intense pain make it difficult for them to consider the impact to others.

A Permanent Solution to a Temporary Problem

The research seems to indicate that most suicidal crises are short-lived.  Said differently, the decision to die by suicide is a permanent decision that’s made in a rather short moment of pain.  What we know is that even small deterrents that block their chosen means can make a large difference in the rate of suicides.  If we’re encountering someone who may be suicidal, the best thing we can do is just keep them talking.  Between the benefit of the connection and the probability that you’ll be speaking with them beyond their period of suicidality, it’s a great strategy.

Struggles and Love

No one has a perfect life.  We’ve all got things that we struggle with – things that we believe are difficult and challenging.  However, just because life is difficult doesn’t mean that there aren’t positive aspects, and it doesn’t mean that we’re not loved.  For all of the bad information in Choosing to Live, a reminder that you can be loved while struggling or being imperfect is a pretty important way to end.

Book Review-American Suicide: A Psychocultural Exploration

Every country seems to have its own unique quirks as it relates to suicide.  Some have higher rates and some lower, but more than that, each culture views suicide just a bit differently.  American Suicide: A Psychocultural Exploration (originally printed under the title, Self-Destruction in the Promised Land: A Psychocultural Biology of American Suicide) walks through the changing American beliefs about suicide and how they related to other beliefs across time.

It’s Not New News

At some level, we might believe that suicide didn’t exist, or it didn’t exist in the distant past at the same levels it does today.  Because our records aren’t incredibly accurate past the last 100 to 150 years, there’s very little way of knowing the actual prevalence of suicide in society – nor its drivers.  While there are historic studies of suicide, getting to accurate numbers is hard.  There were very real criminal, shame-based, and financial reasons to hide suicide.  Many suicides were likely categorized as accidents.  In fairness, suicide numbers are hard to get today as well, as stigma still surrounds the death certificate that says “suicide.”

However, perspectives were a bit warped as well.  For instance, the 1845 American Journal of Insanity warned against the dangers of “protracted religious meetings, especially of those held in the evening and night.”   It seems that they may have viewed any degree of passion or rapture as a mental illness – or insanity.  They believed that those who had mental illness needed to be controlled like beasts.  Perhaps it’s no wonder that we evolved from this thinking to warehousing those who were struggling in state-run institutions.

Our Immortal Soul

Earlier thinking was that, somehow, the way we interacted with others, our behaviors, and our thoughts related to our immortal soul.  That left little room for biological challenges to influence our behavior.  In short, if you were behaving poorly, it was your fault.  It wasn’t that you were struggling, healing, or hurting, it was believed that you had some sort of character defect.

It’s not exactly unheard of, as people used to shun those who had cancer because of the belief that somehow the person must have brought it upon themselves.  It’s a natural progression.  When things are mysterious, we assign mysterious causes.  We believe the Devil did it when we can’t point to the process that caused it.

As we improved our diagnoses and treatments for cancer, it became both less of a death sentence and less of an indictment about someone’s poor character.  We acknowledged it as a tragic reality of modern life.  Similarly, we had discomfort around HIV and AIDS until it became treatable as a chronic condition instead of something unknown and untreatable.

Reticular Activating System and What You See Is All There Is

Our reticular activating system (RAS) is responsible for our sleep-wake cycle as well as for what we pay attention to.  It’s why when we buy a new car, we see many more of that type of car on the road than we ever did.  It doesn’t mean that the car is more prevalent – it means that we’re suddenly paying attention.  (See Change or Die for more on RAS.)  Daniel Kahneman in Thinking, Fast and Slow spoke of a related tendency in humans, which is to believe that what we see is all there is.  The more that we research a topic or the more it’s reported, the more prevalent it is.  Anthro-Vision explains that murders aren’t more prevalent than they used to be.  Rather, there’s simply better coverage of them in the media.  This creates the perception that they’re more prevalent.

If you’re new to researching suicide, you may think that it’s a new thing.  However, the more you look back into the past and the odd perspectives that people had – and the rituals that evolved around the bodies of those who died by suicide – the more you realize that this isn’t new at all.  We can go back to the statistics of the 1800s, or we can look at the news stories that warned of epidemics of suicide – in the early 1900s.

There’s little argument that suicide statistics are increasing – and probably the rate is increasing.  However, there are questions about the limitations of the statistics we have.  With a history of criminalization and church condemnation, there’s little question that suicides were frequently under reported.  Is some of the climb in suicide rates that we’re seeing today the result of better statistics and greater reporting?  We don’t know.

The idea comes from the work of Amy Edmondson and is recounted in The Fearless Organization.  It’s the paradoxical finding that medication errors increased after psychological safety training that was designed to make it safer for people to report issues – and therefore be able to address the root causes.  When the rates on the unit rose, it got everyone’s attention until they realized that the rates didn’t rise – the reported occurrences did.  In the pre-safety culture, some events were simply not being reported.

Pathological Condition of the Brain

The first five editions of Medical Jurisprudence of Insanity (1838-1871) claimed that suicides were the result of “those who have been affected with some pathological condition of the brain.”  This with the circular logic that only someone who was insane would attempt suicide has led to a persistent – and incorrect – belief that people who die by suicide have a mental illness.  Frequently, this is quoted at 90%.  The number ends in a zero, so we know it’s an estimate (since statistics are rarely so clean).  However, it’s still widely cited as fact or research supported.  (Complicating this are “research” articles that seem to back this up but have substantial methodological issues.)

Shneidman in The Suicidal Mind puts forth the idea that suicide is a solution to solve psychache – psychological pain.  This makes sense in the broader context, because people in pain often behave in ways that are difficult to understand – and our brains make very little distinction between physical and psychological pain.  (See The Neuroscience of Suicidal Behavior for more.)

Social Capital

Robert N. Reeves wrote in Popular Science Monthly (June 1897), “Where the population is dense and the law of health neglected, where dirt is common and vice flourishes, where the poor are concentrated, and where fortunes are made and lost in a day will always be found the highest rate of suicide.”  Reeves has a point.  The point is that in places where there is the least stability, there will be more opportunities for loss, and that loss can drive suicidal behaviors.  Some of the aspects of this are obscured.

“Where population is dense” leads to a variety of situations that can lead to loss.  Competition is greater with higher density – and that can itself lead to loss.  More broadly, however, the social glue that causes more altruism in smaller settings begins to give under the intense strain of larger groups.  We stay together for our own survival.  If we can begin to release a few people, they’ll experience loss while the broader group may not.

If we want to reduce suicide, one aspect of this should certainly be the development of safety nets that catch people when they’re the most vulnerable and help them to make their way through difficult situations.

The Gap Between Statistics and the Individual

One of the challenges that exists in any sociological challenge is that the statistics that power identification of opportunities fall short of the capacity to predict outcomes on an individual basis.  Research has demonstrated a correlation between alcoholism and suicide.  A percentage of people who are alcoholics will die by suicide.  We can say that the percentage is greater than in the general population.  What no one can tell you is whether Bob or Suzi or Jim will die by suicide because they’re alcoholics.  This represents a problem for suicide prevention.

We amass more research that explains the variations, and we still end up with screening and assessment tools that do little better than chance at correctly identifying those people who are going to die by suicide.  That’s a problem.

Pathways

In Pathways to Suicide, Ron Maris attempts to lay out a set of transitions that the suicidal person goes through.  Ideally, it’s a pathway from sane, mentally-healthy living to making the decision to take their own life.  There are numerous problems with the approach, no matter how valiant the attempt.  Not the least of which is the data that says that more than 50% of suicides are impulsive.  That is, they weren’t considered more than a few hours before their act.  (See Joiner’s Myths About Suicide for a discussion about this controversial idea.)

However, if the other group was on a suicidal path, then we’d expect to see that those who walk further down the path become progressively more likely to die by suicide.  It’s not clear that this is the case.  Of course, one can accumulate risky factors, but the degree of overlap between different factors and the direction of the causal arrows between them is such that it’s impossible to say with certainty that one person is – or isn’t – more or less likely to die by suicide.  We simply don’t have the predictive capacity in any of our tools to say for sure.

In Extreme Productivity, Robert Pozen explains the random path that his life has taken – and he’s not alone.  We can’t say that one path leads towards death by suicide, because even if we could, there’s no one path.

Statistical People

The problem that leads to the unpredictability of personal experiences is in an assumption that breaks down at the level of the individual.  Statistics and the math behind it make a fundamental presumption that all of the data is the same.  Statistical Process Control (SPC) was a boon to quality control inside of manufacturing.  The idea is that you can predict when parts are going to start to go outside of tolerance and intervene when they do – or right before.  If you have a machine that cuts widgets, and the machine has a tool that can dull over time, then you can predict when it will fail and thereby learn to replace it at precisely the right time.

This operates at the level of homogeneity.  All the tools are the same, and all the parts are the same, therefore the failure is predictable.  Individual differences will arise due to small fluctuations in the tool itself, but they will be sufficiently small as not to matter.

Humans, on the other hand, are immensely diverse.  Two humans that appear the same may end up on radically different trajectories, as Judith Rich Harris beautifully explains in No Two Alike.  Reiss explains these differences based on motivators in Who Am I?, but others have had other ways of identifying differences as well.

Because humans are fundamentally complex and not the same, the neat models of statistics break down.  (See also How to Measure Anything for more about where statistics work and where they fail.)

The Expectation Gap

In Extinguish Burnout, Terri and I expose the challenge of expectation gaps.  We share that burnout is those feelings of inefficacy we get when we have high expectations that we can never meet.  We begin to feel hopeless that we’ll ever achieve them – rightly so – and in the end, we’ll end up in burnout.  We see this same expectation gap in suicide as well.  Suicide seems to separate into two different groups along the dimension of performance.  I believe that it’s the averaging of these two different groups that sometimes leads to results that aren’t actionable.  (See The Innovator’s DNA for an example of the problems of averaging when there are two different fundamentals in the data.)

Group 1 are those who have low performance drives.  In this group, the conditions lead to a desire for suicide.  There are endless reasons why people in this group are unfairly treated, and how the conditions that lead to their desire to die may be caused by events outside of their control.

Group 2 are the curiosities.  When you look at their lives, they seem to have it all together.  They have high expectations, and for the most part, they meet them.  Consider celebrities in this category.  They are, by definition, popular.  They’re making money and enjoying a life that most people will never get a chance to fully experience, yet they want to die.  What can explain their desire?

The answer may live in the gap between their expectations of their performance and their actual performance.  They expected their album to be double-platinum, and it only became a platinum seller.  With no expectations, this is amazing – but from the expectations, it’s a let down or a loss.  It doesn’t have to be a celebrity.  We’ve seen civic leaders and experts within their field die by suicide.  Sometimes, it’s possible to track their expectation gap, and other times not so much.

What if you bought a house you could afford, went to a job you liked, had a primary relationship that was good, a new dog, and plenty of social connections?  You were recognized for your contributions to others, thereby mitigating any concern that you’re a burden.  (See Why People Die by Suicide.)  In short, it looks like all is going well.  Then, a small disturbance, like the death of a friend, creates ripples on the water of your life.  What could explain your desire to die?

The loss creates an altered trajectory of your life.  That person will no longer be a part of the future.  This may cause you to take stock of your current situation.  With high expectations, it might be that you’ll decide that you’ve not measured up to the standards you had for yourself.

Serotonin

There’s been a great deal of interest in serotonin in recent years.  We’ve built chemicals to prevent its reuptake in the synaptic gap, and they’ve had some degree of success in helping people with depression.  (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for a countervailing view.)  What we’ve learned about the neurotransmitter may explain why we like Thanksgiving so much.

Tryptophan – found in turkey – is a precursor to the development of serotonin, and it’s something that our bodies can’t naturally synthesize.  Serotonin is manufactured in the brain, and therefore we need to get tryptophan from our digestive system through the blood into our brain.  It turns out that the blood-brain barrier is a very competitive space, with many molecules trying to make the transition at the same time.

It also turns out that an increase in insulin – which is the natural response to a large number of calories eaten – makes it easier for the tryptophan we eat to make its way into the brain and to be used in the construction of more serotonin.  It’s a complex, convoluted process, as biological systems often are.  But it’s a pathway that can help us understand why we can feel so good after a big turkey dinner – even if we feel bad that we ate so much.

Depression and PTSD

Konrad Lorenz noticed an odd behavior in geese and ducks.  They’ll search for a missing partner for days.  It seems they can’t seem to make sense of the loss, and therefore they keep at it.  This is not unlike depression, where our brain struggles to accept a truth that it cannot fathom.  This is no different than the challenge of PTSD patients who are seeking to integrate a memory that they cannot accept.  (See Transformed by Trauma for more.)  In the end, it seems that depression and PTSD are both attempts to integrate information about a world that doesn’t match the way we see it internally – or the way we want to see it.

The story of American Suicide is one of change, depression, and trauma that is well worth the read.