Book Review-Suicide: Understanding and Responding

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

Positive Alternatives

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

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

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

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

Helping

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

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

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

Keen Why

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

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

Four Factors

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

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

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

Intent

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

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

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

Relieve the Pain

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

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

Bankruptcy

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

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

Not Today

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

Losing Your Mind or Death

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

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

Offspring

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

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

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

Loneliness

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

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

Nothing Left to Lose

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

Murder-Suicide or Suicide-Murder

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

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

Worthlessness

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

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

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

On Their Terms

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

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

Self-Soothing

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

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

Calm the Panic

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

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

Overstrivers

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

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

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

Somebody to be Loved By

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

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

Grass Must Not Be Greener

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

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

Support Withdraw

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

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

Interfering with Freedoms

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

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

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

Patient Proactive

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

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

Separating Despair and Depression

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

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

Acceptance through Presence

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

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

Tread Water for Now

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

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

No Control, Lots of Hope

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

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

The Liberty and Control Coin

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

Responsibility and Control

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

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

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

Things Worse than Suicide

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

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

Book Review-The End of Hope

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

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

The Power of Placebo

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

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

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

Staff Emotions

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

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

Feelings of Control

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

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

The Temptation to Regress

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

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

Labels and Expectations

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

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

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

Doctor’s Orders

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

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

You’re Only as Sick as Your Secrets

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

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

Sick Cycles

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

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

Magical Responsibility

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

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

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

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

Book Review-Social Forces in Urban Suicide

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

The Test of Time

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

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

Individuals and Society

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

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

Societal Control

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

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

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

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

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

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

Craving the Control

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

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

Not Excessive Individualization

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

Settled but Not Settled

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

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

Alcoholism

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

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

Book Review-After Suicide

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

The Weight of Marriage

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

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

Insecurities

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

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

Strength

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

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

A Series of Deaths

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

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

Growing in the Same Direction

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

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

Stories

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

Sorrowfully, Suicide in Spring

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

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

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

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

Book Review-Transformed by Trauma: Stories of Posttraumatic Growth

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

Primer on Post Traumatic Stress Disorder (PTSD)

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

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

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

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

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

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

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

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

Finding Posttraumatic Growth (PTG)

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

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

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

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

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

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

Victimhood

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

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

Distress

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

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

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

Proxy Relationships and Marriage

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

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

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

Mental Healthcare

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

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

Ten Step Assessment

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

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

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

Natural Negative Reactions

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

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

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

Incorrect Assessment

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

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

Peer Protection

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

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

More Reliable and Valid

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

Getting the Last Word

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

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

Safety Through Dying

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

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

Never Enough Beds

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

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

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

Documentation of Rationale

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

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

Limits

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

Book Review-Assessment and Prediction of Suicide

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

Ego Vulnerabilities

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

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

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

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

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

Predictive Expertise

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

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

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

Suicide Strikes When Depression Lifts

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

Alcohol and Social Supports

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

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

Hostile Relationships

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

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

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

Triggering Events and Chronic Stressors

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

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

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

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

The Assumption of Efficacy

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

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

Magical Possessions

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

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

Intentions

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

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

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

Suicide is Undesirable

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

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

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

Postvention

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

Inkblots and Pictures

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

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

All or Nothing

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

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

The Werther Effect

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

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

Prohibition and Suicide

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

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

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

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

Wealthy, Even by Wealthy Standards

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

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

Josephine Rantoul

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

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

Christiana Morgan

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

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

Carl Jung

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

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

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

The Underworld

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

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

The Dyad

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

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

The Separations

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

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

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

Sex

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

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

The TAT

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

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

Around Suicide’s Bend

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

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

The Suicides in Murray’s Life

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

It’s Hard Work

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

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

Book Review-Theory of Suicide

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

The Environment

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

Hope

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

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

Stress

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

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

Wounds that Won’t Heal

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

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

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

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

Just After the Depths of Despair

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

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

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

The Parent Trap

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

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

Indirect Causes of Suicide

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

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

Depravation and Abandonment

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

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

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