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.

Book Review-Helping the Suicidal Person: Tips and Techniques for Professionals

They want to help; they just don’t know what to do.  It’s a tragic fact that most psychology and sociology programs don’t have a single class regarding suicide in their entire academic career.  So therapists and social workers encounter a suicidal person and they feel – as they are – completely unprepared for what to do next.  Helping the Suicidal Person: Tips and Techniques for Professionals is a way of addressing the gap in knowledge –and coming to a better place of nurturing and support to help people move away from suicide as the only option.

Note: Throughout this post, I’ll be using “client” as shorthand so as not to distract from the readability.  I don’t intend to imply that everyone with whom you’ll encounter is a client, nor that you can’t use these techniques if you’re not a therapist.

Research Power

While the tips are research-informed, they are often offered with limited support in research.  There’s a simple reason for this.  The research is hard to come by.  Sometimes, research can show a reduction in attempted suicides but not in completed ones.  In fact, to show a 15% difference in suicide rates (with an appropriate confidence interval), researchers would need to enroll 13 million people.  That’s a relatively impossible challenge.  As a result, we have to accept the research that we do have and attempt to make the best of it.

Sometimes, the problem isn’t scale.  Sometimes, the problem is the ethics of the situation.  Consider that there is no randomly-controlled trial about the use of parachutes reducing death when jumping from an airplane.  Obviously, they work.  So obviously that no one would subject someone to the control condition of death to demonstrate that people without parachutes jumping from planes die.

This is a case where even though there is no research supporting the efficacy of the approach, it doesn’t mean the approach isn’t (or can’t be) effective.  It just means that the research hasn’t been done for a myriad of reasons, including time, money, and ethics.

Disclosure of Suicidal Thoughts

In some ways, it’s as if clinicians are practicing “Don’t Ask, Don’t Tell” as an approach toward suicide prevention.  Many clinicians don’t ask – and, particularly, don’t ask directly – if someone is considering suicide.  There was a historic concern that this might “plant” the idea of suicide in the client’s mind, but research has proved this to be incorrect.  Even without this defense, it’s still a hard thing for most clinicians to ask, so it’s frequently swept aside and forgotten about.

On the other side, the probability that a client will volunteer their thoughts of suicide are very low.  Despite somewhere between 1:5 to 1:6 people having thought about death by suicide, it’s unlikely that they’ll bring it up.  Instead, they’re more likely to believe that if the therapist doesn’t ask them, it’s not important – secretly knowing that it is.

The Loaded Question

Some questions cause people to become defensive, because they’re not sure how the person asking the question will respond.  The underlying challenge is that the question is related to something you think is – or may be – related just to you.  The Kinsey Institute found that asking the question “How old were you when you first started masturbating?” got a much better response than “Do you masturbate?”  Embedded inside the first question is the assumption that it’s something everyone does, and therefore the question of “when” isn’t particularly disturbing.  Of course, the small percentage of people who don’t – or won’t admit it – will respond that they can’t answer the question.  In working with people who are thinking about suicide, questions like “What are some of the ways that you’ve thought about killing yourself?” gets better answers than “Have you thought of ways to kill yourself?”  The presumption embedded into the question makes a difference to the way that people respond.

Similarly, you can intentionally stay ahead of where the person is likely to be by asking the question leading to an overly extreme – but not absurd – level.  For instance, you could ask “Do you think of killing yourself 20 times a day?”  The answer may be 15 – but the person will start by telling you “not that much” and giving you an answer that’s more likely to be accurate. 

Fear of Commitment

One of the barriers that clinicians must overcome is the client’s fear that if they say the word “suicide” or admit to suicidal thoughts, they’ll be involuntarily committed.  Involuntary commitment is a sometimes necessary but always troubling challenge.  People who are involuntarily committed experience a loss of freedom and control that can further exacerbate their reasons for wanting to die and simultaneously can destroy and therapeutic alliance and trust that might have been created.  (See The Heart and Soul of Change for more about the importance of therapeutic alliance.)

One of the challenges is that the client’s goals and the professional’s goals may be different.  The professional wants the person to stay alive, and the client wants the pain to stop.  As a result, there can be a gap through which clients become concerned about how their therapist will react.  They’ve likely heard stories about an involuntary hold – and they don’t want to experience it themselves.

Neither Lecture nor Pep Talk

Motivational Interviewing calls it the “righting reflex.”  It’s the tendency to directly correct a person’s perspective by telling them how they’re wrong – and it’s powerful.  It was Carl Rogers who insisted that client was the expert – in their lives.  We may, from a few minutes of conversation and some notes provided by others, believe their pain is manageable and their problems are all solvable, but from their perspective, they’re not.  Until they believe you truly understand, they won’t listen to suggestions; even after they believe you understand, they’ll not listen unless you tread gently by asking careful, somewhat leading, questions.

Lectures about how someone’s behavior, feelings, or perspective isn’t right has never worked – even when you were a child.  It induces guilt, shame, and invalidation, which further pushes them away.  It also causes them to become more entrenched in their positions.  They start looking for ways to defend their position and they find them.  They ultimately have invested more in their perspective and become less likely to change it.  (See Influence for more on these effects.)

Pep talks don’t work because they’re hollow.  Letting people experience joy and happiness is a good strategy to fight depression that seeks to convince them they can’t find joy or happiness.  However, these must be experiences they want.  One useful technique that I’ve used is to intentionally set a positive event out several weeks out so that anticipation can build.  The actual amount of time that you set the event in the future is dependent upon the client, but the point is to build an idea in the future.  Do be prepared that depression will try to convince them they won’t have fun.  The response is “Didn’t you have fun in the past?”

Rank and File

One strategy for assessing the importance of various reasons for dying is to ask the client to list them, and then rank them in order of importance.  This has a focusing effect that allows you to focus your energies on the most important items.  Sometimes, it’s possible to carefully walk them through strategies that break down the barriers preventing them from overcoming their reasons for dying.

For instance, if they’re struggling because they can’t find a job, you can work with them on ideas to get a job.  Care must be exercised here, because you’re likely going to move quicker than the client. You’ve seen these problems and solutions before and so you know the landscape and you’re likely to rush ahead. However, helping people work through problems is directly addressing the problem-solving challenge and cognitive constriction that seems to be found with most suicidal people.  It’s worth the time.

Reasons for Living

It’s an awkward conversation to ask people why they want to be alive.  It’s awkward when suicide isn’t a consideration and can be even more awkward when it is.  Often, you’ll need to start with the reasons why people want to die before getting to their reasons for living.  It’s important to recognize that people who are struggling with thoughts of wanting to die may have trouble enumerating their reasons for living.

You may need to prompt them to explain who would miss them when they’re gone or what they do to support others.  You might suggest they go through their recent calls and texts and make a list of those people who would miss them or their support.

They Can Move On

A somewhat typical response to reasons for dying may be that so their loved ones can “move on with their lives.”  This is the quintessential comment of burdensomeness.  (See Myths About Suicide for more on burdensomeness and its relationship to suicide.)  In many cases, however, the others that the client believes will “move on with their lives” are the recipient of the pain that the client is trying to displace.  Suicide and Its Aftermath says it plainly.  Suicide transfers the pain from the person who dies to those who survive.

Certainly, there are some situations where a person’s health is such that they are, in some sense, a burden to others.  However, one of the things that all people tend to misunderstand is that burdensomeness should be measured by the person who is (perceivably) burdened.  It’s possible that the other person doesn’t perceive it as a burden and may even believe it’s an opportunity to replay the kindness and support they’ve received.  Encouraging a more realistic perspective of the degree of burden is a good idea.

No Warning Sign Is Particularly Meaningful

One of the problems that exists in suicidology is that we believe things that aren’t true.  Thomas Joiner wrote a whole book about Myths About Suicide.  Craig Bryan in Rethinking Suicide challenges us to realize that the screening tools that we use don’t work.  Some still insist that most (or all) people who die by suicide sent warning signs.  Joiner addressed this directly and Bryan indirectly, but the myth persists.

The simple fact of the matter is that we have no way of knowing who will die by suicide or not.  We know statistics and probabilities – but not people.  There are lists of warning signs that cause concern, but it takes judgement to decide who is at the most risk of immediate harm to themselves and who isn’t.  It’s recommended that clinicians record the reasons for their assessments in their notes so, if there is any question in the future, there’s a record of why they assessed the risk the way that they did.

All that to say that while there are key indicators – like directly stating that they want to die – none of those indicators in isolation is a direct prediction of short-term risk.  It’s only by looking at all the factors in the situation that someone could assess risk.

The Tips and Techniques

The listing of tips and techniques are:

1. Reflect on Your Biases about Suicide
2. Take Stock of Your Experiences with Suicide (or Lack Thereof)
3. Confront “Suicide Anxiety”
4. Be Alert to Negative Feelings Toward the Suicidal Person
5. Reject the Savior Role
6. Maintain Hope
7. Face Your Fears
8. Directly Ask about Suicidal Thoughts
9. Turn to Techniques for Eliciting Sensitive Information
10. Embrace a Narrative Approach: “Suicidal Storytelling”
11. Ask about Suicidal Imagery, Too
12. Uncover Fears of Hospitalization and Other Obstacles to Disclosure
13. Recognize that, for Some People, You are an Enemy
14. Avoid Coercion and Control Whenever Possible
15. Resist the Urge to Persuade or Offer Advice
16. Understand the Person’s Reasons for Dying
17. Validate the Wish to Die
18. Acknowledge that Suicide is an Option
19. Gather Remaining Essentials about Suicidal Thoughts and Behavior
20. Learn about Prior Suicidal Crises: The CASE Approach
21. Cautiously Use Standardized Questionnaires
22. Privilege Warning Signs Over Risk Factors
23. Screen for Access to Firearms
24. Inquire about Internet Use
25. Probe for Homicidal Ideation
26. Collect Information from Family, Professionals, and Others
27. Examine Reasons for Living
28. Identify Other Protective Factors
29. Pay Attention to Culture
30. Investigate Religious and Spiritual Views of Suicide
31. Solicit the Person’s Own Assessment of Suicide Risk
32. Estimate Acute Risk for Suicide
33. Estimate Chronic Risk for Suicide
34. Document Generously
35. Know When and Why to Pursue Hospitalization
36. Know When and Why Not to Pursue Hospitalization
37. Do Not Use a No-Suicide Contract
38. Collaboratively Develop a Safety Plan
39. Encourage Delay
40. Problem-Solve Around Access to Firearms
41. Discuss Access to Other Means for Suicide, Too
42. In Case of Terminal Illness, Proceed Differently (Perhaps)
43. Seek Consultation
44. Make Suicidality the Focus
45. As Needed, Increase Frequency of Contact
46. Treat Chronic Suicidality Differently
47. Involve Loved Ones
48. Suggest a Physical Exam
49. Recommend an Evaluation for Medication
50. Continue to Monitor Suicidal Ideation
51. After Safety, Address Suffering
52. Look for Unmet Needs
53. Target Social Isolation
54. Use Grounding Exercises
55. Assume Nothing: Does the Person Want to Give Up Suicide?
56. Tap into Ambivalence
57. Compare Reasons for Living and Dying
58. Invite the Person to Look for the “Catch”
59. Search for Exceptions
60. Frame Suicide as a Problem-Solving Behavior
61. Help Brainstorm an “Options List”
62. Teach the Problem-Solving Method
63. Nourish Future Plans and Goals
64. Incorporate a Hope Kit
65. Highlight Strengths
66. Connect Suicidal Thoughts to Other Thinking
67. Educate about Cognitive Distortions
68. Help Challenge Negative Thoughts
69. Elicit Coping Statements
70. Rescript Suicidal Imagery
71. Discourage Thought Suppression
72. Foster Acceptance of Suicidal Thoughts
73. Enhance Coping Skills
74. Cultivate Mindfulness
75. “Broaden and Build” Positive Emotions
76. Pair Behavioral Activation with Values
77. Differentiate Between Suicidal and Non-Suicidal Self-Injury
78. Determine the Person’s Reaction to Having Survived
79. Conduct a Chain Analysis
80. Evaluate Where the Safety Plan Fell Short
81. Take Advantage of the “Teachable Moment”
82. Attend to the Therapeutic Relationship
83. Address the Trauma of the Suicide Attempt
84. Explore Shame and Stigma
85. Warn about the Possibility of Relapse
86. Review Lessons Learned
87. Complete a Relapse Prevention Protocol
88. Propose a Letter to the Suicidal Self
89. Follow Up

Maybe it’s time for you to learn the tips and techniques that you can use to start Helping the Suicidal Person.