Book Review-Loving Someone with Suicidal Thoughts

The thought of someone you love dying is terrifying.  The thought of them dying by suicide is even more so.  Too many people suffer and consider suicide.  Too many people who love them are tortured by their inability to stop the person they love from considering or attempting suicide.  The heart of Loving Someone with Suicidal Thoughts is learning to live in these terrible circumstances.

The Worry

Friends of ours, whose son died, admitted guilt about their feelings.  There were the unfathomable feelings of loss.  The feelings of disorientation existed, too.  They had the feelings that you expect with any death of someone you love.  It was doubled by the fact that parents aren’t “supposed” to outlive their children.  But what they were troubled by was the sense of relief.  They’d lived for years terrified that there would be a middle of the night phone call or a knock on the door at 3AM.  They were troubled by the sense of relief they felt, because their fears were finally over.  They would pick the worry every day over the actual loss, but they couldn’t help but admit that the relief was a part of what they were feeling.

I won’t pretend to fully understand.  I understand that sometimes the waiting is the hardest part.  While a rejection is infinitesimally small compared to the loss of a child, sometimes the rejection is better than the waiting for someone to decide.  The fear of what may happen is worse than what does happen.  When it comes to suicide, this isn’t true.  The hardest part is the finality of the loss of someone you love.

I do not share this to encourage people to die by suicide.  I share it so that we can recognize that those who love someone with suicidal thoughts are in their own torture.  Healing for the suicidal loved one is healing for everyone.

Am I Not Enough?

Widows of husbands who have died by suicide are prone to ask, “Wasn’t I enough?”  In the frame of the present, loving someone with suicidal thoughts leads to natural self-doubt.  If I were better, then they wouldn’t have suicidal thoughts.  Love is supposed to conquer all, just like in the movies – so if it doesn’t, then I must be doing something wrong.  Brené Brown explains in I Thought It Was Just Me (But It Isn’t) how we all question our value and how we need to accept our inherent value and know that we are enough.

That leads to a painful realization that there may be times when we don’t have enough control or influence to prevent the results that we don’t want.  We love the illusion of control.  (See Compelled to Control.)  However, the truth is that we have much less control than we would like to believe.

The Impostor

“Nobody would like me if they really knew me.”  Impostor syndrome is the sense that you don’t really belong where you are.  You don’t think you know enough.  You don’t think you’re good enough.  You wonder how you’ve managed to fool everyone for so long and, more importantly, when they’ll figure out that you’ve been pulling the wool over their eyes.  (See The Years that Matter Most for more.)

The fundamental premise is that there’s a gap between the way that someone is appearing and the way they really are.  It starts small.  We hide a part of ourselves, because we don’t expect that others will appreciate it.  (See No Bad Parts for more about different parts of our psyche.)  Over time, we’re reinforced that people like the person we’re showing them, and we begin to progressively believe that they only like the image we’re projecting – not the real person.  This leads, ultimately, to people believing that the parts they’ve hidden must stay hidden, and that people wouldn’t love them if they knew the real them.

In most cases, the people who love you already know what it is that you want to hide and are just allowing you to hold it back in respect for your choices.  We hear this all the time as parents have a child come out as homosexual.  Friends sometimes comment that they’ve known for years but respected them enough to wait until they were ready to discuss it.

While this isn’t a universal reaction, it happens often enough that it calls into question the idea that people don’t really know you.  Sometimes, they can know more about you than you do – and they love you still.

Always a Choice

Once suicidal thoughts have come to someone, particularly if they’ve ever made a plan, it’s always on the menu.  When they stub their toe, waiting on it to stop hurting, taking medication, or dying are the options.  It’s not that suicide isn’t a very bad option – it’s that because it’s been recognized, it remains a recognized option.  It takes some conscious effort to remind oneself how bad an option it is – and that it might be good to take that option off the table for now.

One of the problems with suicide screeners is that they can’t distinguish between people who have had a plan and know better than to use it and those who have newly formulated a plan.  It’s hard to discern the difference between someone who has their world well under control and those who are barely hanging on.

Universal Warning Signals

There’s a persistent myth that everyone who dies by suicide has sent detectable warning signs.  (I prefer signals to signs because signs sound clearer than the average suicidal person is.)  The problem with the desire to find this is laid out in Rethinking Suicide and in Myths About Suicide.  Some people, possibly more than 50%, don’t consider suicide more than a few hours before their death.  If they don’t know themselves, what kind of signals are they sending?

Not only must the suicidal person send a signal about their intent it must be detectable.  Most of the warning signs list include a dozen or more things, and those things have a very low predictability for whether the person is or is not suicidal.  In fact, the American Association of Suicidology (AAS) once proposed an acronym, “IS PATH WARM?” as a set of warning signs for suicide – that is, until the research showed that it wasn’t effective.

For me, I focus on clear, loud signals like the following: directly indicating they’re planning to die by suicide, giving away all their possessions, or explaining that it doesn’t matter because they won’t be around.  Those are clear, detectable signals; things like changes in mood or behavior aren’t, because many people change their moods and behaviors without considering or attempting suicide.

Feelings, Beliefs, and Facts

How we feel, our emotions, are undeniably our experience.  We feel the way we feel – and no one outside of us can say we do or don’t feel a certain way.  However, that doesn’t mean that the feeling is congruent with reality.  We can feel unloved and be loved deeply.  We can feel lonely in a crowd.  We can be alone and not feel lonely at all.  (See Loneliness for more.)  Because we feel it, we think it’s truth when it may not be, as Lisa Feldman Barrett illustrates in How Emotions are Made.

Similarly, we trust our beliefs as facts when we shouldn’t.  In fact, research shows that we routinely fail to search for ways to disprove our hypotheses.  In the famous Wason selection task, less than 10% of participants could correctly identify how to properly ensure that the provided conditions and rules matched.  There’s plenty of other research to indicate that we’ll sometimes cling onto beliefs that we should know are wrong, but we’ve invested too much in them.  Going to Extremes walks how this can be used to create radical groups.

The natural bias to accept our feelings and beliefs as facts sometimes leads us to believe we’re unworthy or unloved when the truth is radically different – and we can cling to this even if we’re faced with irrefutable evidence that this isn’t true.

Detachment

One of the most important tenets of Buddhist philosophy is the idea of detachment.  The idea is that the more attached you are to your views and the outcomes, the more suffering you’ll feel.  (Suffering is another major tenet.)  (See Resolving Conflicts at Work for more on detachment.)

When loving someone who has suicidal thoughts, detachment may be more than you can muster – and you wouldn’t be alone.  The one step that you may be able to take is to listen without judgement or resistance.  Maybe you can listen without becoming attached to the words in a way that you feel you’re responsible or have any control of the outcomes.

Courage

Many people don’t understand that courage isn’t the absence of fear, it’s the presence of fear and proceeding anyway.  (See Find Your Courage for more.)  I can’t think of anything more courageous than loving someone with suicidal thoughts.  You are constantly afraid that they’ll decide to take their own life, and the best you can do is love and support them through it.  It’s an impossible situation in which too many are placed.

It’s courageous to say to your loved one that you want them to feel better, so they’ll stay, instead of trying to coerce or manipulate them into compliance.  (See Motivational Interviewing for more on non-coercive, effective strategies.)

911

There’s a temptation – even among therapists – to treat every mention of the word “suicide” as an emergency requiring a call to 911.  However, we know that many 911 calls end in tragedy – particularly with people who have mental illness or are suicidal.  (See People in Crisis for more about suicide by cop.)  While being present with someone who has suicidal thoughts is scary, it doesn’t mean that 911 is the right answer.  Calling 911 may be the right answer if they’re in imminent physical harm or they’ve made an attempt that you’re aborting.  If they’re pre-attempt and you need help, the national mental health hotline at 988 is an option to get tips and support for your loved one.

As the moments move to days, there’s another pull to have someone committed to inpatient treatment.  In the cases where it can be done, it may still not be the best answer.  It necessarily deprives the person of their freedom and sense of autonomy.  It often substantially damages relationships to the point they cannot be repaired.  To make the decision to have someone involuntarily committed to an inpatient program is very risky for the relationship and not particularly protective of the person, as the probability of suicide after exiting an inpatient program is roughly 300x.

Sometimes, the best you can do in the moment and in life is to keep Loving Someone with Suicidal Thoughts.

Book Review-Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living

It’s a worthy question.  What are the alternatives to suicide?  That’s the question that Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living attempts to answer with its subtitle.  How do we transform the pain that people feel and their desire to die?  Though an academic volume with multiple authors and the readability challenges associated with both of these aspects, the answers that you find may surprise you.

Flip a Coin

One of the depressing and discouraging statements about the predictability of suicide is that even the best work on screening, assessing, and predicting who will die by suicide in the short term is only slightly better than the odds of flipping a coin and getting heads.  Estimates vary about the ability of assessment to predict suicide, but they’re in the 50% range.  While the behaviors we’re doing imply that we’re much better at determining who will and won’t die, the realities are different.

Interact with healthcare, and you’re likely to be confronted with a set of questions about your suicidality.  It may start with depression and hopelessness, or it may directly ask about suicide thoughts, but you’re likely going to be asked.  Frequently, we see PHQ-2 (Patient Health Questionnaire-2) asked – and if the person answers in a way that’s concerning, they are automatically asked the PHQ-9 (Patient Health Questionnaire-9) questions.  Sometimes, people use the Columbia Suicide Risk Screener (CSRS) or the Ask Suicidal Questions (ASQ) screens.  The stories of patients being encouraged not to answer in a way that would trigger concern are perpetual.  No healthcare provider wants to do the extra work, nor do they want to see the person held for extended periods of time waiting for one of the few people trained to do a formal assessment.

It’s called universal screening, and it’s a requirement by accreditation bodies.  They require that you have the process if you want to receive their stamp of approval.  And because their accreditation means that you can bill insurance and the Centers for Medicare and Medicaid Services (CMS) – which is almost all of a hospital’s business – hospitals do what the accrediting body requires whether there’s efficacy or not.

That Which Needs to Stop

Shneidman described suicide as a way to stop psychic pain that he called “psychache.”  (See The Suicidal Mind.)  One of the common factors in suicide is a desire to stop something – whether it’s directly called out as psychological pain or not.  With the cognitive constriction that accompanies a suicidal crisis, people may not be able to see other solutions to stopping their pain – except suicide.  (See Cognitive Therapy for Suicidal Patients for cognitive constriction.)  The key to finding alternatives to suicide is to find alternative ways to stop the pain without stopping their heartbeat.

Dysregulation Vulnerability

The research is inconclusive.  Some believe that all suicidal people exhibit signs and create invitations for others to intercede for them.  Others look at research on suicide attempters that leads to the conclusion that many attempts – greater than 50% – were not considered a few hours before the attempt.  Because of these numbers, studies have attempted to connect suicide with impulsivity – with very little success.  The measures we use for impulsivity seem to not effectively capture the possibility that someone will consider suicide.

However, when the focus is changed to skills for emotional regulation, the story changes.  It appears that those who are more capable of emotional regulation are also more capable of riding out the short term storms that seem to lead too many to suicide.  It’s like Mischel’s Marshmallow Test has an impact on preventing suicide as well.  Learning that things will likely get better if we can just wait a bit seems to protective.  Rick Snyder in The Psychology of Hope explains that hope is made of willpower and waypower.  Waypower is understanding the path forward.  Willpower is that capacity to hang with it and keep trying.  (See Willpower and Grit for more on the power and makeup of willpower.)

Meaning in Life

Viktor Frankl famously wrote that “Those who have a ‘why’ to live, can bear with almost any ‘how’.”   (See Man’s Search for Meaning for more.)  Meaning in life – even a little meaning – can be a powerful protective force.  Simon Sinek believes that everyone should Start with Why.  It’s about finding meaning in your life, and that meaning can be small.  As Atul Gawande explains in Being Mortal, giving patients even something as simple as a plant to take care of can help them live longer lives.

We crave the idea of being useful.  Thomas Joiner’s Interpersonal Theory of Suicide (IPS) posits that lack of connectedness, feelings of burdensomeness, and ability to inflict self-harm all drive suicidal behavior.  (See Why People Die by Suicide.)  Being helpful to something or someone else directly combats that feeling of burdensomeness.

Connectedness

Robert Putnam signaled a problem when he wrote Bowling Alone.  Social capital – our connections with others – were eroding, and no one knew what to do about it.  Sherry Turkle takes it further in Alone Together, as she describes how we are becoming technologically connected and interpersonally disconnected.  There’s been an assault on our feelings of connectedness – and it’s not getting better.  In 1990, about 75% of us felt we had a best friend.  By 2021, that number is down to about 59%.  In short, if connectedness to others is a protective factor against suicide, its impact is fading.

Three Step Theory

Klonsky and May built on Joiner’s IPS theory and proposed that it’s a three-step process to get to suicide.  The three-step theory posits that pain and hopelessness move people to the first stage of suicidal ideation.  To get to the second step, they propose that pain must outweigh connectedness.  The final step of attempting suicide requires the capability to attempt – or the capacity for self-harm.  Generally, this is the integration of an ideation-to-action framework with Joiner’s IPS theory such that the process of getting from idea to action has a path.

The caution that I’d have with the three-step theory is that the process of the three steps can potentially happen very, very quickly.  It’s still a framework, since pain and connectedness aren’t quantified into scales that can be measured against one another in an objective way.  It’s about the person’s perception – and that is often colored by cognitive constriction.

Who Failed Who

Bumper stickers of people who have rescued dogs ask the question, “Who rescued who?” implying that the dog may have saved the person’s life.  While, in the case of the bumper sticker, it’s not meant in the literal sense, there’s often a reversal that happens when a treatment fails to move from blaming the practitioner or the process and instead transferring the blame to the patient.

We know that this isn’t right, that it’s frequently not the patient who failed but rather the poor therapeutic alliance, the skills of the professional, or the technique itself.  However, that doesn’t prevent many people from defecting the blame and placing it on the patient.  (See Mistakes Were Made (But Not By Me) for more.)

Once There’s a Plan, There’s Always a Plan

One of the challenges with suicidal ideation is that even the mental health professionals, whom you would typically seek out for help, are often disturbed by the word suicide and reflexively move to defend themselves.  Litigation around suicide encourages providers to suggest emergency rooms and hospitalizations at rates substantially more frequent than would otherwise be prudent.  Instead of focusing on the patient and what they need, the provider moves to protect themselves – whether it’s good for the patient or not.

One of the bigger problems with suicide assessments is that once you’re high risk, you never move back down the risk scale.  Whether you’ve made a previous suicide attempt or you’ve just developed a plan for your suicide, there’s no backing down from the high-risk category.  You see, if you’ve tried once, you may have figured out what you did wrong in your plan.  If you’ve “only” planned a suicide, they know you’ve got an idea how you’ll do it.

This neglects the basic understanding that once you’ve created a plan, it will always stay with you.  It’s not the sort of thing that you forget.  You can’t.  (See White Bears and Other Unwanted Thoughts for more.)  Therefore once you’ve developed a plan once, you’ll always be at an elevated risk – no matter what your risk for suicide is in the moment.

Tactics like suicide contracts for those professionals willing to treat people who dare say the word “suicide” are more for their benefit than the patients.  It absolves them of some responsibility if they believe that the patient committed to telling them despite ample evidence that safety contracts make patients none the safer.

Ultimately, this is the result of professionals who believe that they’re responsible for preventing patients from dying by suicide.  The truth is that if someone really wants to die by suicide, you’re not going to stop them.  (See Suicide: Inside and Out.)  Instead, it’s healthier for the person who is suicidal to accept that it’s their responsibility to keep themselves alive and the professional is just someone on the team to help make that happen.  It’s powerful for the professional to admit to themselves and their patients that they’re unable to save anyone at all – they always have to save themselves with help.

Suicide is the Solution, Not the Problem

Okay, it’s a bad solution.  However, suicide is a solution to problems and pain.  Only the patient themselves truly knows the entirety of their life, their experiences, and their pain.  We can, from the outside, only get glimpses of what’s inside.  It’s not unlike addictions, which are largely seen as the problem when they are, in fact, poor solutions to other problems the person is facing.  Often, these are the same kinds of pains that suicidal people struggle with.  (See The Globalization of Addiction, Dreamland, and Chasing the Scream for more about substance use and addiction.)

When we recognize that people see suicide as the solution and they’re the experts on their lives, we can bring to them things that are outside their perspective and experiences that may give them at least a few Alternatives to Suicide.

Book Review-Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients

What we wouldn’t do to be able to classify suicidal risk over someone’s life.  The ability to see when a person is – and isn’t – suicidal would be a great boon to our work to prevent needless deaths.  This is the grand vision to which Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients aspires.  We’re not there now – and we may never get there – but there’s value in continuing to attempt to understand suicide before it claims even one more life.

Most of Those who Died by Suicide Were Mentally Ill

It’s hard to study whether someone who died by suicide was – at the time – afflicted with a diagnoseable mental illness.  The person is no longer around to discuss the situation, and therefore the psychological autopsy process – with all its limitations – must be used.  (See Review of Suicidology, 2000.)  The primary problem with the psychological autopsy approach is that it is subject to the biases of the investigators – and if they believe there should be mental illnesses, they’ll look for it.

DSM-5, the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychological Association, is frequently referred to as “the book of woe” and is further characterized as leading clinicians to over-pathologize normal responses.  If you’re supposed to find something, and you look in the DSM, you’ll probably find something.

So, the retrospective interviews with family members, friends, and colleagues often led to identified mental illness.  Perhaps the most telling aspect of the results that found mental illness is that the primary finding was alcoholism – what would now be called alcohol use disorder (AUD).  This is telling, because in 2019, 25.8% of people in a general population survey reported having indulged in binge drinking in the preceding month.  This means they’d likely qualify to be diagnosed with at least mild AUD.  In the studies referred to from Suicide Over the Life Cycle, the percentage of patients diagnosed with a primary diagnosis of alcoholism is substantially similar to that number.

Certainly, alcohol use could be considered a mental illness, and it is also correlated with suicide deaths.  However, few would characterize it as a severe mental illness – what people often think of when they believe someone is impacted by a mental illness.  If we lower the bar to any kind of mental impairment, we could perceivably make most people who die by suicide have a mental illness.  It would, however, necessarily include nearly every adult.

The second primary diagnosis in the referenced studies was depression, something that many people in the United States struggle with today.  Again, it’s something that most people would not characterize as a serious mental illness but something that is included when categorizing most people who die by suicide as having a mental illness.

And that’s not all.  The other challenge is in the identification of those who are suicidal.  The approach used was coroner determination, which is known to be quite inaccurate.  It’s entirely possible that a coroner will decide to mark something as a suicide only when they suspect mental illness, thereby biasing the samples.

So, is there research that says most people who died by suicide had a mental illness?  Yes, that’s true.  However, the research is fundamentally flawed in at least two dimensions, and the conclusion that someone had a mental illness might include more of us in the general population than anyone would like.

Alcoholism

Let me return to the problem of alcoholism as a factor for suicide risk.  On average a person who has alcoholism who dies by suicide have been alcoholics for 20 years and die at age 47.  It’s hard to separate the impacts of alcoholism from the disorder itself.  We know that alcoholics often have unstable home, professional, and social lives.  Their disordered drinking leads them to lose their jobs, their homes, and their relationships.  These are all substantial factors that lead towards suicide – with or without the introduction of alcohol.

To be clear, it’s not that there isn’t a relationship between alcohol and suicide – there definitively is.  The challenge is that alcohol can induce alcohol myopia whether or not the person is an alcoholic, and it’s difficult to separate the work, home, and social losses from the alcohol use when determining how correlated they are.

Roles and Responsibilities

Durkheim’s assertion that suicide seemed to increase during periods of economic downturn has been well replicated – for men.  Men’s expectations are shaped by society such that their worth is driven by their ability to work and provide for themselves and their families.  Economic downturns obviously make that harder, and it’s easy to accept that men will choose suicide rather than face and address their inability to find work – presuming there is a solution.

Women, on the other hand, are often shown to be more distraught over relational or family-relational issues.  They’re more likely to be influenced by divorce or estrangement than moderate fluctuations in the business cycle.  This seems to be driven by acculturation.  We expect that women will be more focused on family and relationships and disruptions are more impactful.

These are, obviously, stereotypes.  However, both fall into the key category of missed expectations.  We’ll find that people are more likely to die by – or attempt – suicide when their expectations aren’t matched with the results that they’re getting – and that applies to men or women.

On the Same Team and No Suicide Contracts

It’s subtle.  When you insist on a contract with a person, you’re acknowledging the potentially adversarial direction of the relationship.  Contracts are used as instruments to document an agreement – but more frequently, they’re the basis for determination of right and wrong.  When we pressure someone into a contract, we’re acknowledging the very kind of adversarial relationship that we should be avoiding with a suicidal person.  On the surface, asking for a contract that says the other person won’t attempt suicide is pointless, since they’re not likely to think of the contract during a suicidal crisis.  More importantly, what consequences can the contract extract from a dead person?  (The answer is none.)

Rather than a focus on no-suicide contracts – which don’t work – we can do something that will potentially improve our outcomes.  We can find ways to signal that we’re on their team.  We’re there to support them.  We don’t think that suicide is the right answer, but we want to better understand them and help them solve the problems that may make them believe that death is a better option.

Blame Seeking Messages

Often after a suicide death, there’s a rush to figure out who is to blame.  It’s a bad outcome, so someone must have done something wrong.  The problem with this is a belief that, for something bad to happen, then someone must have done something wrong.  We don’t expect there is someone to blame if a tsunami wipes out a village, so why do we believe that there is always someone to blame when someone dies by suicide?  I’m not saying there are never people to be held accountable for malpractice, but this is much rarer than we seem to give credit for.

Seeking the answer to “why” is an unfortunate artifact of our evolution and our desire to predict the future.  Rare events, whatever their cause, are met with skepticism and confusion, since our prediction engines have failed.  (See The Black Swan, The Signal and the Noise, Superforecasting, and Noise for handling rare events.)  We look for someone to blame, so we can incorporate their malfeasance as a part of our models.

Hopelessness

Suicide Over the Life Cycle oversimplifies the response to the hopeless person and says, “The clinician should not expect to dissuade patients of their hopelessness; rather the clinician must win the patient’s cooperation to undergo, and stick with, treatment.”  Certainly, there’s no point in developing a direct conflict with a patient.  However, there’s a path between directly disagreeing with the hopelessness that someone feels and basically ignoring it.  In fact, both cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT), the most common treatments, encourage patients to challenge their own thinking and to remove cognitive distortions – with the assistance of the therapist.

Rather than dissuading patients from hopelessness, it may be enough to just try to understand it.  As the research around Motivational Interviewing shows, sometimes listening is all that is needed.

Habitual Errors

Sometimes, the cognitive distortions facing a patient can be identified and addressed.  Habitual errors in thinking are termed “cognitive distortions” by Aaron T. Beck. They include the following:

• arbitrary inference, drawing a conclusion based on insufficient or even contradictory evidence;
• selective abstraction, attending to only a portion of relevant information;
• overgeneralization, abstracting a general rule from a single event and applying it to both related and unrelated events;
• magnification and minimization, exaggerating or underestimating the magnitude and importance of events;
• personalization, attributing causality to oneself when several factors contributed to an outcome; and
• dichotomous thinking, categorizing people and events in absolutistic, black-and-white terms (e.g., good versus bad).

What to Do When a Client Dies by Suicide

When a client dies by suicide, the counselor, therapist, social worker, or coach will feel the loss themselves and need to process these feelings – but they’ll also need to consider how they will engage with the family.  Some will try to minimize contact and pretend that nothing happened even to the point of failing to address the next of kin’s questions and requests.  Suicide Over the Life Cycle makes it clear that this is a bad strategy.

In our own situation, Alex’s social worker elected to not be responsive when we reached out.  That failure to respond was very problematic – enough that there was a cross-agency escalation.  Even if you don’t feel comfortable answering questions, it’s a good idea to be responsive as possible to the family, because you want to avoid becoming adversarial with them.

While we cannot foresee suicide as an outcome in most cases, it’s important that we begin to see Suicide Over the Life Cycle as best we can.

Book Review-The Neurobiology of Suicide: From the Bench to the Clinic

By the late 1990s, a great deal was being learned about the neuroscience of the brain.  Magnetic resonance imaging (MRI) became popular in the 1980s, and it was extended to functional magnetic resonance imaging (fMRI) in 1990, which opened up new doors in learning about not just the structure of the brain but also the patterns of neurological firings.  As we began to learn more about the brain, it became important to share that with the broader clinical community to encourage research-informed care.  The Neurobiology of Suicide: From the Bench to the Clinic, published in 1997, was a step towards that goal.

Adverse Childhood Experiences (ACE)

In 1996 and 1997, the people who would participate in the landmark adverse childhood experiences (ACE) study were just being selected.  The long-term follow-up would continue for years.  However, it’s an understanding of the developing awareness that people with trauma– or even instability – in their childhood would have problems in their adult lives.  (See How Children Succeed for more on the ACE study.)

The language of the book is “chaotic” family situations – the kinds of trauma and instability the ACE study was destined to find later.

Suicidal Behavior Family Clusters

One of the places where the answers get fuzzy is when the book claims that suicidal behavior clusters in families – like so much else in psychiatry.  Here, the evidence proposed is a twins study: the twins who are paternal (coming from one egg) are compared with those that are maternal (coming from two eggs).  The concept is straightforward.  If they came from one egg, then they have the same genes, and therefore we can say that there is a genetic cause to something if both members of a twin pair are affected.

However, as Judith Rich Harris carefully explains in No Two Alike and The Nurture Assumption, there are many other confounding variables that tend to make all twins alike.  The environment that the children are raised in matters.  In other tests, even identical twins diverge in their interests sometimes – and sometimes not.

There seems to be some evidence that genetics play a factor in suicide – but no more than the typical 50% genetics, 40% environment, and 10% unknown that we often see for anything else in psychiatry.  So, it may be true that there are clusters of suicides around family trees, but it’s not necessarily clear whether this is due to genetics, cultural cues – both societal and familial – or something else entirely.

Like many things in suicide research, just because there’s a correlation there is not necessarily a causation.

Low Base Rates

In Rethinking Suicide, Craig Bryan explains why prediction may be a fool’s errand, and that reason is a low base rate.  To be an effective screening tool, it would need to be substantially more precise than any of our existing tools for any mental illness.  It’s like trying to shoot a 9” plate on the Moon – technically possible but very technically challenging.  It’s no surprise, then, that in 1997, it was explained that the tools of the day weren’t very predictive.

Behavioral Intent

The challenge with whether something is – or isn’t – a suicide often hangs on the idea of intent.  Did the person intend to strike the tree with their car, or did something else happen?  It’s incredibly hard to know if someone was truly intending the accident or whether it just happened.  Who is to say it wasn’t texting and driving instead of a willful act?  There is no way to know for sure.  While it’s possible to guess – through a psychological autopsy (see Review of Suicidology, 2000) – that doesn’t mean that the psychological autopsies are foolproof.

Given the very low incidence of people writing suicide notes (<25%), it’s no wonder that the question of intent during accidental circumstances can be so challenging.

Research

The real challenge that was facing researchers in the late 1990s was that the degree of risk that researchers’ institutions were willing to take for suicide research was very low.  This often prohibited the researcher from doing the best science they wanted to do, and instead hamstrung them into research approaches that were less clinically demonstrative for the sake of lowering the risk.

Funding was also a challenge, as other conditions like cancer and AIDS were receiving substantially more funding.

In the end, The Neurobiology of Suicide is a good map of the headwaters of what we were starting to learn about neuroscience and suicide.

Book Review-Suicide and Its Prevention: The Role of Attitude and Imitation

The idea that suicide is a global health problem isn’t new.  Many organizations had noticed the ongoing and escalating problem of suicide, and in 1989, the World Health Organization published Suicide and Its Prevention: The Role of Attitude and Imitation.  The collection of chapters from different authors was intended to represent the state of the art in suicide prevention at the time.  Some of the work recorded here continues to be explored today.

Only the Internal Matters

The book explains that one of the limitations of considering suicide a mental illness (a concept itself that has fallen out of favor for good reason) is that it restricts focus on the external factors that are leading people to be suicidal.  I strongly disagree with the assertions of the author of the chapter, Menno Boldt, because what most of the research says is that it’s not our circumstances that matter, it’s what we make of our circumstances that matter.  Whether it’s Kahneman’s work in Thinking, Fast and Slow about the relativeness of our perception of our situation or Rich Tedeschi’s work in Transformed by Trauma, Lisa Barrett Feldman’s work in How Emotions are Made, or Richard Lazarus’ work in Emotion and Adaptation, we know that what we make of the circumstances is more important than the circumstances themselves.  In the introduction to Man’s Search for Meaning, Viktor Frankl quotes Nietzsche with, “He who has a Why to live can bear almost any How.”  A why is necessarily about the internal beliefs of someone, not in their external circumstances.  (See Start with Why for more.)

Unendurable

It should be clear by the preceding that the idea of unendurable pain isn’t some fixed point but rather changes with other factors of a person – most notably, their sense of purpose and hope.  We’re implored to save people from unendurable circumstances, but there’s no way to know what those are.  The methods by which one saves others from the unendurable may be equally traumatizing.  It may be possible that someone’s loss of freedom with commitment to an inpatient facility is worse than whatever conditions they’re being saved from.

Aristos

It’s a Greek word that means the best possible solution given the circumstances, and it’s the way that I’d describe excellence.  Some people assume that excellence approaches perfect – but it’s not that.  It’s the ability to make the best possible outcome with what you have.

Unfortunately, at the point where the book was written, the meta-analysis showed that there was little improvement in the treatment of suicide in the preceding 25 years.  That’s not exactly doing the best possible in the circumstances.

More than Mental Health Professionals

However, one of the small wins that had been made by 1989 is that it was clear that the need for suicide prevention training needed to extend beyond just mental health professionals.  If we were going to identify people at risk for suicide, it would require that we engage everyone in the process.

Resignation

One of the observations is that physicians in private practice were more likely than those in employed positions to die by suicide.  The story of Ralph and his resignation to his position from Work Redesign seems particularly appropriate.  Ralph didn’t want more freedom and power even when it was offered because it would have invalidated his prior decision to give up.  Perhaps it’s that the pressures on an employed physician are different than those in private practice, but it may be equally likely that those who have taken employed positions have resigned themselves to the state of affairs.  Of course, it’s also possible that they’re disproportionately different, and these differences caused them to self-select into either private practice or corporate employment.

Marching Forward

While there’s little to share from a 30 year old book on suicide prevention, it’s important to recognize that we’ve been working for a long time on Suicide and Its Prevention.

Book Review-Treating Suicidal Behavior: An Effective, Time-Limited Approach

What started here would eventually become brief cognitive-behavioral therapy for suicide prevention (BCBT-SP).  In Treating Suicidal Behavior: An Effective, Time-Limited Approach, David Rudd, Thomas Joiner, and Hasan Rajab review what works in therapy of suicidal patients – and the current state of the literature.  Craig Bryan and David Rudd would publish Brief Cognitive-Behavioral Therapy for Suicide Prevention.  Of course, Thomas Joiner would go on to write Why People Die by Suicide and Myths about Suicide – among other works.

Concern

The book opens with a state of the art in suicide prevention for 2001 – and finds that it’s hard to identify the mechanisms of action for several studies, minimal clinical relevance for more, and plenty of mixed and confusing results.  This is true of 2001 – and today.

One of the things that seemed to elevate itself above the noise wasn’t a program specifically, but rather it was a component that seemed to be found in many of the effective programs.  That is the feeling that someone else cared about the suicidal person.  Whether it was Jerome Motto’s work with caring contacts or intensive tracking, it seemed that when people showed concern for the suicidal person – or appeared to show concern – it formed a protective bubble against the kinds of crisis that might cause a person believe that they are better off dead.  Perhaps, when others care for you, there’s always hope.

Caring Contacts

Motto’s work on what would be called “caring contacts” was first published in 1976.  The 2001 research, which confirmed the efficacy of the approach of sending letters randomly to those who declined treatment, wasn’t available as Treating Suicidal Behavior was being published.  As a result, the response in the book to the idea of caring contacts was tentative but hopeful.

Since then, the idea of caring contacts has proven to be a very cost effective intervention – particularly for those that are unwilling to pursue direct treatment of the things that may have brought them to suicidal ideation or a suicide attempt in the first place.

Effect Sizes in Ideation, Attempts, and Deaths

One of the challenges in the space of suicide even today is that the rates of suicide – and even documented attempts – are so low as to make it difficult to assess the efficacy of a program.  As a result, many research studies fall back to assessing impact on suicidal ideation.  The problem with this is that the degree to which this will impact the key metric – deaths by suicide – isn’t easy to predict.  Kirkpatrick’s Four Levels of Training Evaluation provides a reasonable framework to understand how asking for self-reports of how people feel about their ideation can be problematic.

It’s more challenging from the point of view that there’s no way to tell someone to not think about something without first bringing that thing to mind.  White Bears and Other Unwanted Thoughts makes this point quite clearly.  You can’t not think about a white bear if I tell you to not think about it.  So, talking about suicide makes it harder to not think about it – but not necessarily to not act on it, as the correlation between suicidal thoughts and ideation to action is rather low.

No Research for Inpatient Hospitalization

When most people think about others who have suicidal ideation and might attempt, they rather instantly think that the person should be hospitalized into an inpatient program – or even involuntarily committed.  There are numerous problems with this thinking; before that, it’s important to note that there is no study that proves that inpatient hospitalization is an effective treatment method.  In fact, there are studies that show the highest risk of suicide is the six months following discharge from an inpatient program.

There’s some anecdotal evidence that patients will lie to providers to get released so they can live without the rules and supervision – at least some of them for the purpose of making a suicide attempt easier.  Of course, other, less sinister explanations of the lowered psychomotor retardation of depression as it ends is another plausible reason for the problem.  Either way, discharge from a hospital inpatient program can be hazardous – with no proven efficacy for doing it in the first place.

Cognitive Distortions

One can easily forgive Mastering Logical Fallacies because they’re easy to make.  They are themselves a form of cognitive distortion.  They could be considered other variations of the kind of thing that Kahneman described in Thinking, Fast and Slow where we know that our thinking is biased and there’s very little that can be done about it.

The kinds of cognitive distortions seen in patients with suicidal ideation is a bit stronger.  They’ll give up on problem solving sooner – particularly related to interpersonal situations – and they’ll visualize fewer positive options.  It’s like they’re picked up a set of horse blinders and can only see what’s directly in front of them – even if they’re pointed in the wrong direction.  Therefore one of the skills that every potential suicidal person needs is the capacity to detect when their options are being narrowed into a state of cognitive constriction.  (See The Suicidal Mind for more on cognitive constriction.)

The Path to Suicide Leads through Cognition

Richard Lazarus in Emotion & Adaptation and Lisa Feldman Barrett in How Emotions Are Made agree – how we feel is mitigated through the lens of our cognition or thoughts about something.  If we want to address suicide we cannot ignore that even our affective feelings about things are influenced by our cognition – just as our cognition is influenced by our feelings.  If we are able to view things as positive and not a thread, then our feelings will follow.  Conversely, if we’re feeling depressed and hopeless then we’re less likely to see options and more likely to remain stuck “in a funk” because the nature of the affect makes it difficult to access positive thoughts.

Components of Personality

Beck proposed four components of personality: Cognitive, Affective, Behavioral, and Motivational.  This framework is similar to the one used for the fluid vulnerability theory of suicide (see Brief Cognitive-Behavioral Therapy for Suicide Prevention), which is: cognitive, affective, behavioral, and physical.  Beck’s model respects the hidden influences that motivations have on us.  In The Hidden Persuaders, Vance Packard explains how hidden things motivate us.  Steven Reiss delves deeper into what motivates each of us in Who Am I? relying on factor analysis to reduce motivations into 16 key factors.  What most of us fail to realize is that we make decisions and then rationalize them in many – if not all – cases.  (See Noise.)

Legal Foreseeability

Many clinicians are concerned about the idea of being sued for malpractice when treating suicidal patients.  This concern shows up in the text as recommendations for detailed documentation during or following sessions and to document, immediately following notice of death, anything that may not have previously made it into the records.  There’s some practical guidance to respond with compassion to the family’s inquiries about the treatment that the deceased patient received.  All of this is good advice.  However, overall, the legal concept that is false is the idea that we can foresee a risk of death by suicide.

There’s a difference between doing best practices of screening and assessments and whether these best practices are effective or not.  Even the best clinicians can’t get above about 80% prediction in hindsight.  Shneidman was famously put up to this test, and his results, though good, were far from perfect.  The fundamental principle of foreseeability is flawed, because no one can predict with certainty those who will and will not die by suicide.  No tool, technique, or approach meets the standard for predictability required for admission as evidence in federal courts.  Federal court rules require that experts’ testimony must be based on scientifically reliable instruments.  This is conveniently side-stepped, because the issue is the failure to execute a test – a test that is not sufficiently reliable to be admissible in court.

I feel for those who have lost loved ones – whether the professional behaved at the level of professional practice or not.  However, fundamentally, the idea of legal proceedings based on the death fails to meet the basic legal premise of foreseeability.

It Gets Better in Time

So many things in life get better if you just hold on a bit longer.  The idea that things will – or can – get better is one of the challenges of cognitive constriction (see The Noonday Demon).  Depressed and suicidal people literally can’t believe that the situation will get better in time – and that time is likely not far away.  This is true of the emotions that people are feeling even if the underlying circumstances of their life may not change as quickly.  One suggestion for people who consistently find themselves back in this space is to create a mood graph that records how the person feels over time.

The tangible output of this exercise is a graph that shows that things do vary and to get better.  This is irrefutable evidence in the place of a perception that things will never get better.  If you’re unable to get a mood graph, sometimes recalling happier times can be effective – but be prepared: it will likely take multiple examples rather than just a single one.

When the Rules Change

Some people who are suicidal arrive there because their perception of the world has been so radically altered that they don’t know what the rules are any longer.  They had a world view that has been shattered and they quite literally don’t know how to predict the next moment.  This is possible anytime an underlying belief about the world is shattered due to an accident, betrayal, or loss.  If you believe the world is a generally beneficial place, and you suddenly discover a friend was murdered, you’ll have to change your belief system to match the observed outcome, and that’s uncomfortable.  As creatures that thrive on prediction (See Mindreading and The Blank Slate), we literally don’t know what to think when one of the major rules is changed.

It should be shared that this is one of the reasons why postvention is so important.  Often after the death by a loved one due to suicide, the fundamental rules of life are reorganized whether the loved one was a spouse (or romantic interest), a parent, a child, or a friend.  Helping the survivor understand how the world can function in a way that allows for suicide is a great way to care for them.

Testing the Belief System

Recognizing that all of us hold belief systems that drive our predictions of the world can be good when talking with people who are considering suicide.  It allows you to look for, and then ultimately test, the beliefs that the person has about themselves and the world.  Often in a depressed or suicidal space, people will view things more negatively than they should – and, as mentioned earlier, they may have a hard time believing things will get better.  These beliefs lead to automatic thoughts that, though brief, can shape emotions and moods.

Ultimately, what you may find is that, though challenging, it may be important to understand Treating Suicidal Behavior.

Book Review-Suicide and Scandinavia

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

The Hypothesis

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

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

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

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

Dependence

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

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

The Discussion of Death

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

Death as Relief to Deadness

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

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

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

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

Connections

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

High Expectations

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

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

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

High IQ

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

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

Bias Towards Action

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

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

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

Reduce Depression, Reduce Suicide

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

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

Perturbation

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

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

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

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

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

Willpower

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

Hope

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

The Embarrassment of an Attempt

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

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

Unconditional Self-Acceptance (USA)

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

Unconditional Other Acceptance (UOA)

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

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

Unconditional Life Acceptance (ULA)

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

Achievement

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

The Downward Spiral

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

Missing the Positive

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

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

Gaslighting

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

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

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

Mind Control

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

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

Depersonalization

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

Overgeneralization

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

Burdensomeness

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

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

Fluid Vulnerability

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

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

Book Review-The Cry for Help

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

The Presuicidal Phase

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

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

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

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

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

Suicidal or Accidental

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

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

Secondary Benefits of a Psychological Autopsy

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

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

Irredeemable

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

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