Book Review-Pathways to Suicide

What if the act of suicide isn’t a moment of desperation but is instead the result of a lifetime of wounds and hurts that just don’t seem to heal quite right?  What if we could see these hurts, and, in doing so, approach a sense of intervening before it’s too late?  This is the heart of Pathways to Suicide.  For some situations, there is a definite path that leads to someone feeling so much pain that they believe the only answer is to stop living.  However, this isn’t a complete story, as there are many others for which the path isn’t clear – if it’s there at all.

Alternatives and Coping

The first stop on the journey towards understanding suicidal pathways is to look at the conditions that seem to be present when we find suicide attempts and completions.  There are some expected answers, such as a life that has been harsh or when suicide is glorified.  Other factors, such as the lack of love and support, are present as well.  However, in the list are two related factors that bear highlighting.

If suicide is the “only” option (as Edwin Shneidman says in The Suicidal Mind), then it is the option to choose.  We find if the perception is that the “only” solution is suicide, many people take it – before finding other options.  The reality of the situation and the other alternatives that may be available disappear in the collapsed view of the cognitively constricted.  Therefore, it’s important to present the suicidal person with a set of options.  If there are options, then there’s no “only.”

Similarly, suicide represents a lack of alternative coping skills that would be more desirable.  In short, the person who attempts suicide is faced with a situation for which they have insufficient or no coping skills.  They decided that they couldn’t cope with their situation and therefore death seemed like the only option.  The key here in helping people avoid suicide is increasing their coping skills and ensuring they have support when their coping skills may fall short.

Why Can’t We All Just Get Along

It’s the cry of Rodney King, a man who was beaten by the cops, whose video caused their trial and whose acquittal caused the LA riots.  “Why can’t we all just get along?”  Much has been made of connections and social support.  What is often overlooked is that negative interpersonal interactions may create more suicidal drive than simply not having deep relationships.  In other words, it’s not the number of relationships but their quality and their valence.  (See High Orbit – Respecting Grieving for more on numbers of relationships.)

Negative relationships don’t necessarily mean conflict.  Conflict itself isn’t bad.  However, relationships that put another person down are at risk for reducing someone’s self-esteem to the point where suicide seems like a worthy option.

Drowning in Theories

Pathways to Suicide admits that we’re drowning in theories with too little hard data.  The book was published in 1981, so one should expect that we’d have more research, and we’d know what better to do about suicide.  Unfortunately, while we’ve made progress, it’s not nearly enough.

I’m particularly disturbed by the lack of research that teases out whether things are correlational or causational.  (The topic comes up all the time in my research.  See The Nurture Assumption for some coverage.)  We’ve got data sets and statistics about all sorts of things, including the impact of age and gender on suicide risk but precious little about detection, assessment, prevention, and training.

It’s like we’re in a time before Mendeleev’s Periodic Table of Elements organized chemistry in a meaningful way.  Until then, things seemed random and chaotic; only after organization did things start to make sense.  We need that for suicide research – but we don’t have it.

Hope and Alcohol

Pathways to Suicide confirms that hopelessness has an even higher correlation to suicide than depression but adds that hopelessness is negatively correlated with alcohol.  That makes the relationship between alcohol and suicide very complex.  On the one hand, alcoholism and the related implications are correlated with suicide.  However, alcoholism normally implies trouble with relationships and work leading to unstable home situations.  It can be that the correlation we see with alcoholism isn’t the alcoholism itself but is instead the impacts to home life.

Alcohol, however, is a short-term tool for coping with difficult situations and one that seems to have a positive effect towards reducing suicide.  Obviously, the question becomes when does the use of alcohol become alcoholism – and the impacts associated with it.

Role Transitions

There are transition points in our lives that separate one part from another – when we become a parent and when our children (finally) leave home for instance.  During our adolescent development, we’re trying to figure out who we want to be and to learn how to separate from our parents.  It’s at these sorts of times, it seems, when we’re at a heightened risk for suicide.

Maris refers to Erik Ericson’s work on developmental stages and how transitioning between stages is an unsettling time.  (See Childhood and Society for more.)  Maris also refers to Piaget’s work, which precedes Ericson’s and is derivative of Emile Durkheim’s.  Durkheim wrote the first substantial work on suicide.  How Good People Make Tough Choices is a slightly different look at the moral development of an individual, which creates a similar set of disruption as the old decisions are no longer necessarily the right, new decisions.

Even more challenging than the role transitions is what happens if you’re not able to make the cognitive changes that each stage calls for.

Stuck Stages

The more that we learn about our development as humans, the more that we realize that our early development has very serious, long-term effects.  The Adverse Childhood Experience (ACE) study showed how our health as adults was driven by the stressors that we faced as a child (see How Children Succeed).  More than that, we discovered some of the problems we face as adult may come from in utero development.  Fetal Onset of Adult Disease (FOAD) is a real thing, and it gives rise to the spooky world of impacts that happen well before our consciousness (see Why Zebras Don’t Get Ulcers).  Even in rats, licking and grooming produces more well-adjusted rats – if there is such a thing.  (This is also discussed in How Children Succeed.)

When we’re unable to complete some part of our development in a stage we leave a part of ourselves behind and we end up dragging it through the rest of our lives.  It takes energy and creates dysfunctions that are hard to shake.  Those undeveloped parts of ourselves can become progressively burdensome to the point where suicide seems like the only option.

Compensating Support

Just like how rats who received proper licking and grooming as pups go on to be more “well-adjusted,” we, too, can recover from, repair, heal, and move past our broken aspects of development with sufficient, consistent love, support, and encouragement for self-image.  Maris asserts that most suicides have lives that are in shambles – presumably where they’re not getting the kind of support they need.

I’m careful to acknowledge that some suicides’ lives are in shambles, but the important piece isn’t the objective reality of their situation.  What matters is how they feel about their situation – and in the moment where they encounter a suicidal thought.  People who are objectively in quite good condition commit suicide over the most trivial or fleeting of things.

Similarly, it’s not the actual tangible support that people are receiving that matters, it’s how they respond to and accept or reject that support.  Joiner believes that burdensomeness is a factor in suicide – and that comes from a feeling that you’re weighing down others.  (See Why People Die by Suicide.)  It’s possible to receive and accept support while not perceiving yourself as a burden – and conversely someone who receives almost no support can believe that they’re a burden.  It’s truly all about how the person perceives the support that is happening.

Separation and Grief

Separation is different than loss – real, permanent loss.  With separation, we can try to regain what we’ve lost.  But the grief that is left for survivors of suicide is permanent and unchangeable and is therefore categorically different than something that seems lost only for a time, like a relative going on a vacation far away.  (See The Grief Recovery Handbook and On Death and Dying for more about the grief process.)

Perhaps the most difficult thing for survivors to accept is the reality that their loved one is gone.  They can know it to be true, and still at some level not want it to be true, and thus are caught in a powerful conflict between their knowledge and the feeling that “it just can’t be.”

Punishment

Maris quotes other researchers that draw a connection between punishment – both physical and verbal – and subsequent suicide, while also noting that punishment and closeness often come from the same parent.  I’d propose that perhaps it’s not the punishment itself that is the problem but rather the child’s inability to predict which they’ll get from a parent that may be the root cause.

I’m strongly in favor of holding children accountable – as my post, The Psychology of Not Holding Children Accountable, explains.  In fact, I believe that a failure to hold children accountable based on Benjamin Spock’s book, The Common Sense Book of Baby and Child Care, has created a world of confusion for children who don’t understand why the “real world” is so much different than the coddling that they received at home.  (See The Coddling of the American Mind for more.)

Put together with other research, I’m skeptical that punishment is the issue.

Societal Influence on Suicide

In trying to determine what leads some people to suicide and others away from it, it becomes obvious that some cultures have higher suicide rates and others lower – sometimes dramatically lower.  It seems that more individualistic cultures seem to have higher rates, and more socially integrated cultures have lower rates.  This is what one might expect when they look at the kinds of powerful bonds that Francis Fukuyama describes in Trust: Human Nature and the Reconstitution of Social Order.  When a society has tight bonds, the individual is less able to dispose of their lives so easily.

Important Occasions

Viktor Frankl in Man’s Search for Meaning explains that planning on dates for rescue can be challenging as a prisoner.  If the date comes and goes and you’re not rescued, your hope will be dashed.  The opposite seems to be the case for suicide.  Suicidal people seem to wait until after special days like birthdays and holidays before attempting suicide.  It’s like they want to be around for one last special moment before finally giving up hope.

This seems to hold true even if the special event isn’t necessarily a special event for them personally.  They need not expect gifts or a big party, just the fact that there’s something special seems to be enough to pull at least some people along life’s journey a bit further.

Power to the People

Another interesting but not totally unexpected finding is that when people live with others, their likelihood of suicide is suppressed.  There may be two factors at play here.  First, it can be that they don’t have the time and space that they need to make the attempt.  This, however, stands against many examples where people killed themselves while others were close by.

Second, it can be that the higher density of people necessarily creates the probability of warm relationships that nurture people.  Much has been said about the need for positive relationships and closeness; perhaps physical closeness encourages the emotional closeness that protects people from thoughts of suicide.  It can, of course, lead to uncomfortable relationships as well, but that seems to be a less powerful factor.

Other People Don’t Matter, Then I Don’t Matter

People who attempt suicide seem to decide that other people don’t matter more than those who die by natural causes.  For some reason, they decide that it’s no longer worth maintaining or continuing to develop relationships with others, because some part of them is already on a journey towards suicide.

Who knows what part of the person makes this decision – consciously or not – that other people don’t matter, because they don’t intend to be around long enough to get value from the relationship.  Or perhaps it’s that they feel disconnected and alone, so their behavior starts to match how they feel.

Don’t Get Dead, Get Even

For some, it may be that there isn’t a way to get even with someone who has wronged them except through suicide.  There’s often little that a child can do to harm a parent, but certainly taking their own life is a way to accomplish that.  Some 47 percent of suicide completers conceived suicide as a way to get even with someone else.

This is an odd paradox.  You get the final word, because it’s your final deed.  Somehow the hatred and malice boils to a level where it’s even worth your own life.  It’s the final power that you can wield even if you feel like you have no power in a situation.

Performance-Based Love

Sometimes the end of suicide comes from a lack of love or perceived abandonment.  Other times, what a person learns about love is a performance-based love that is only present when you’re doing something for the other person.  (See The Four Loves for more.)

The real problem is that this isn’t love.  It’s not love – the commitment – when it’s performance-based.  (See Love, Acceptance, and Forgiveness for more about love as a commitment.)  It’s hard to live in a world where your support is from those who love you but that love stops when you can’t do something for them.  Learning that people take care of other people and that love isn’t dependent upon what you can do for the other person makes the world a lot better place to be in.

Socio-Economic Suicide

Another rock that is overturned in search of the causes of suicide is socio-economic status (SES) and employment status.  In short, it’s how stable a person’s finances are.  The mechanisms for testing this statistically aren’t very good, and it’s no surprise that there are no consistent results between SES and suicide rates.  Nor does there appear to be any employment relationship to suicide rate.

The problem with identifying SES’ relationship to suicide is that the amount of assets one has and even their current income has little to do with how stable, respected, or valuable they feel.  In Thinking, Fast and Slow, Daniel Kahneman shares the research he did with Tversky how people adapt to their current conditions and how they are impacted more by losses.  Between these facts and the idea that people can live at the edge of their means, we’re led to understand that a loss is still a loss no matter how much money you make.

Change Isn’t Good for Your Health

High levels of change in your world may lead to the kind of conditions that encourage suicide.  It’s been noted other places that immigrant populations have higher suicide rates, and those rates appear to be directly related to the degree of change that they’ve encountered – not their community.  However, Pathways to Suicide goes further and explains that high levels of change in someone’s life leads to both emotional and physical health problems.  These problems can, in turn, create challenges for suicidal ideation and attempts.

It’s not necessarily the change itself though.  It’s how the person responds to that change that seems to have a great deal of impact.  In the research for the Confident Change Management course, we discovered great discrepancies between those people and organizations that prepared well for change and those that felt as if they were being tossed like waves in an ocean.

Responsive, Not Responsible

For women who attempt or complete suicide, there seems to be an underlying current related to problems with their children.  Rarely are marriages mentioned; more frequently, there are concerns about children.  This may be a result of the belief that parents – and particularly mothers – are responsible for their children.

We use the word “responsible” for our children in the legal sense and fail to separate the word when we’re referring to their behaviors, which invariably will deviate from what the parents believe they taught and what they desire for their children.  Instead, in our Extinguish Burnout work, we encourage parents to be responsive to their children’s behaviors, because they can’t be responsible for something they can’t control, and children haven’t been controllable since they could be contained by a playpen.

Dulling the Pain

There are many ways that people dull the emotional pain that they feel.  Alcohol is a perennial favorite, but others are used as well.  Some use food to temporarily blot out their feelings, while others rely on the dopamine hit from a new purchase.  Whatever the mechanism, the goal is the same – to reduce the psychological pain to a tolerable level.

What is tragic, however, is that we become habituated to these coping mechanisms and require more and more of them to be able to sustain the same wall against our pains.  The key realization that too many people miss is that alcohol isn’t the problem – alcohol is the solution.  It just so happens that after sustained use and addiction, it becomes its own problem.

If and Only If

Suicidal individuals want to live more than they want to die if – and only if – something in their life will change.  Their marriage, their job, their relationship with a sibling, or dozens of other things.  If it could only be fixed, then life would be worth living.  They could finally put away the thoughts of suicide, because all of their problems would be solved.

Of course, this is fantasy.  When one problem is resolved, others pop up to take its level of importance.  However, suicidal individuals believe that they can hold on, they can cope, but only if their circumstances change.  What they fail to realize is that they don’t have control of those external factors.  They only have control of how they respond.  (See Choice Theory and Emotion and Adaptation for more.)

Unable to Articulate

Sylvia Plath was a poet who knew her way around words.  She could articulate her points clearly, succinctly, and passionately.  Her command of the language and her willingness to plumb the depths of her emotion made her uniquely qualified to write about suicide – having attempted it several times.  However, not all those who struggle are so gifted.  (See The Savage God for more about Sylvia Plath.)

Too many people who end up dying by suicide are never able to fully articulate how they feel, their depression, isolation, and hopelessness.  Part of helping is creating better understanding of others – even when they can’t help.

Reasoned not Rational

It’s important to point out that all suicides are reasoned at some level.  There’s some reason for pulling the trigger or jumping.  If there were not, it would be accidental.  However, just because something is reasoned doesn’t mean that others will find the response rational.  Too often, outsiders see the problems that the suicidal individual is facing and recognize that it’s not that bad.  However, that’s not the view from inside their head.

From the inside, everything appears to make perfect sense, and the negative consequences don’t matter because they won’t be around for them anyway.

Worn Down

In the end, Pathways to Suicide is about the long road that everyone travels and how some of those roads lead to suicide.  While it’s impossible to predict who will take their own life and who will conquer the world, it is possible to sometimes see how the roads sometime lead towards suicide.  The worn down, oppressed, depressed, and hopeless feelings are the Pathways to Suicide.

Book Review-Suicide and Its Aftermath

They don’t know what to say.  My friends, colleagues, and acquaintances are at a loss for words when I tell them of our son’s death by suicide.  While suicide ends the suffering of the person completing the act, it transfers that pain to those who survive.  Suicide and Its Aftermath isn’t focused on assessment and prevention of suicide.  Instead, it focuses on the impact to those left behind and their experience.

Blame

With any tragic situation, there are natural tendencies.  The first, and one we experienced, was a curiosity about what happened.  Even as open as we’ve been with our loss and how it happened, we paused before sharing some of the details.  Some of that was for us to make sense of it, and some was to try to find a way to honor the situation.  The second tendency is to try to find people to blame.  We fought back our own thoughts of blaming people.  Often in the case of a suicide, the family themselves is blamed for the loss of a friend, a colleague, or acquaintance.

While we’ve not heard directly from anyone that they blame us for our son’s death, we’ve heard from others for whom the story is different.  They meet with extended family or friends and find themselves attacked as people lash out, because they’re hurting in their own grief experience.

This is tragic.  The people who are hurting the most are being attacked, because others are in pain and don’t know what to do with it.  There are two things that my suicide research has made crystal clear.  First, there’s no one path to suicide.  Rarely is there something that is done that causes someone to decide suicide is the answer.  In The Savage God, A. Alverez blames himself for Sylvia Plath’s final successful attempt.  He felt he failed her in some final way – but this is after she had a long career of attempts.  Because there’s no known ways to cause it, it’s impossible to know how to prevent it.  In fact, it’s generally accepted that if someone wants to die by suicide, we’re powerless to stop it.  In Suicide Inside and Out, we hear the opportunities that were presented to someone who was in an inpatient program, and they’re ample.

Second, blame is pointless.  What are we going to do?  How could we possibly punish the survivors any more than losing their loved one?  While as a society we attempted to discourage suicide by desecrating the body and denying families inheritance, we’ve largely realized that this is cruel and unnecessary.  It only causes more suffering, and we’ve all had enough of that.

The truth is that the only person to blame for a suicide is the person themselves.  It was their decision.

Postvention

Shneidman in his work with the Los Angeles Suicide Prevention Center discovered something important when working with survivors (to perform psychological autopsies).  That is, survivors had a need to discuss their grief.  They needed a way to connect about their experience so they could process it.  (For more on psychological autopsy, see Review of Suicidology, 2000.)

“Postvention” was thus devised as a word to speak about the care for the survivors, which critically reduced suffering – and was supposed to prevent additional suicides triggered by the first.  Once suicide is experienced, it becomes somehow more real and acceptable.  This makes it more likely that someone close to another who has suicided will consider or attempt it.

It Can’t Be

Perhaps the most challenging aspect of surviving a suicide is to survive the cognitive restructuring that happens.  When we lose someone close to us – particularly in an unexpected or tragic way – we have to change our perspective on the world.  Something that could never happen has just happened, and it means that we must reconsider our perspective on the world.

The recurring thought is that “it just can’t be.”  Our experience of the world keeps fighting back the reality of the situation.  The thought is so incompatible that as we try to reorganize our perspectives on reality, we continue to question the fact that we know all too well.  We know it to be truth and simultaneously can’t bring ourselves to fully accept it.  We’ll get there.  We know it’s true.  But accepting it emotionally is more than can be borne initially.  It will take time.

The Silence

Those around the family are at a loss for words – appropriately so.  However, for some, their own discomfort disconnects them from the people they most want to support.  Most survivors experience material support – often in the form of meals.  However, one of the curious things that happens is how some people can’t bring themselves to reach out and communicate their care and concern.

Countless folks have responded to my messages by saying that they didn’t know what to say – so they didn’t reach out.  The disconnection from friends and colleagues may not take the form of a complete lack of communication – it may be much more focused.  They’ll connect, but only in a superficial way that avoids the elephant in the room.  They’ll not bring up the suicide for fear of triggering more pain.  For many, this results in an awkward conversation as everyone seems to be craning their neck around the obvious barrier to real connection.

My simple advice for those who have friends or acquaintances suffering from loss is don’t be afraid to bring up the topic.  Creating space for the conversation is sufficient.  You don’t need to be eloquent or witty.  You don’t have to find the “right” words – because they don’t exist.  Something as simple as “I don’t want to bring up ‘the situation’ if you don’t want to talk about it, but we can if you want to.”  This creates space for the survivor to engage at the level that is appropriate for them.  Of course, this presumes that you’re willing to walk through uncomfortable conversations if that’s what they need.

Acceptable Anger

Somewhere, we got this idea that we shouldn’t “speak ill of the dead.”  Our ability to be angry with the person who deserted and abandoned us is harmed if we can’t express it.  Desertion and abandonment are the feelings that many people have as they face the cold reality of the suicide.  They didn’t “have to” do it.  No one “has to” die by suicide; it’s a choice.

As The Grief Recovery Handbook explains, grief isn’t a linear process – but anger is often a part of it.  Elizabeth Kübler-Ross in On Death and Dying predicts that anger is a part of the process as well.  We shouldn’t be surprised that we’re angry with the person who chose suicide.  The feelings of desertion and abandonment are predictable.

Suppressing the feelings of anger because others can’t accept that you’re angry with someone has died causes more suffering.

But, why?

Another natural question that follows a suicide is “Why?”  There is very rarely any one reason.  While suicide can be reasoned, it’s not likely to be rational to others.  Like many things in life, suicide rarely follows a cause-effect pattern.  Instead, there are countless factors that pull people away from suicide and some that push them precariously close to the cliff of suicide.

We want to understand the why, because, for most survivors, the suicide answer was never an expectation.  The person who died violated our expectations, so we want to correct our mental models.  (See Resilient.)  The problem is that some things have no “why.”  In the case of suicide, even when a psychological autopsy has been performed, we may not know the real reason.  We may never know the final straw that broke the camel’s back and caused the person to decide death was the best option.

While it’s absolutely expected and natural that you’ll try to find the “why” for the situation, it’s important to accept that there may be no reason that you can understand or that you’ll find a mixture of psychological forces that moved the person to both life and death.  (See Principles of Topological Psychology for more on psychological forces.)

What Next?

Loss of a loved one is such a disruptive process it often lifts people up from their social moorings and makes them question their worlds.  Like any death, one is forced to confront their own mortality.  (See The Worm at the Core for more about confronting our mortality.)  This alone encourages people to reevaluate their world.  If they watch a friend fall victim to a heart attack before they retire, they’ll wonder if they’re putting off their retirement too long.  After all, what good is a savings when you’re dead?

However, the challenges with suicide are more complex.  One must also invite the question about what it is they really want out of life.  Not only must we consider whether it’s time to take it easy, but we also must question what we’d do if we were taking it easy.  The grief of the loss may be short in comparison with the existential crisis it triggers.

Out of Order

Because of the bimodal distribution of suicide – having a peak in the twenties and then much later in life – there’s the very real possibility that the person who dies by suicide will be much younger than those who survive.  This creates a more intense feeling of reorientation, as it violates the natural order of things.  We accept that old people die.  We think that they’ve lived their life, and it’s their time – even if they die by their own hand.  However, when someone younger than you – particularly a child – dies, it shakes your belief in the way that things should be.

Tragedy strikes everyone in different ways, and while most of the time it’s older people dying before younger people, we can’t eliminate the occasional situation where someone significantly younger does die.  We do, however, need to cope with the reality that they did, and it “isn’t right.”

Tell the Truth

In the case of an adult who is close to a child dying by suicide, there’s a natural inclination to protect the child from the truth.  The idea that it’s too painful for a child to process the fact that their loved one abandoned them is pervasive.  However, the research shows that those children who are told the truth – in a caring way – have fewer problems in adulthood.  It seems that the lying about the situation sets them up to have a general distrust of everyone when they discover the truth.  That isn’t healthy for them as an adult.

Additionally, the lie which must be kept creates further distance between the child and the remaining loved ones due to the need to suppress the thoughts of sharing the truth.  (See White Bears and Other Unwanted Thoughts for more.)

Magical Thinking

Magical thinking has a role to play in survivors just like it does in suicide itself.  (See Comprehensive Textbook of Suicidology for more on magical thinking in suicide.)  Some children (and adults) believe that somehow their thoughts and feelings may have caused the death.  While this occurs in any kind of death, it’s particularly frightening when combined with the sense of rejection that can be felt when someone close commits suicide.

Despite evidence or any indication, children (and adults) feel guilty for their feelings and thoughts, somehow believing that they are responsible.  While we can rationally argue that this could not be the case, the feelings are often persistent as people feel that they “had” to have some role in what happened.

While this may seem narcissistic – even for a child – our general tendency is to ascribe more belief about the circumstances we find ourselves in are a result of something we did or did not do rather than recognizing them as the randomness that happens.

Sibling Survivors

Siblings are often considered the forgotten survivors.  The attention and resources are focused on the parents coping with the loss, but too often, siblings are left feeling left out and perceived to be unimportant in the recovery process.  This process doesn’t require that others are unkind or tease them.  There’s no additional pain needed than the pain of losing a sibling.

In addition to the loss of future associated with a suicide, siblings can feel as if they’ve been deprived of a part of their childhood.  They can feel as if their memories of the happy times with their now departed sibling were untrue, or not enough, or unimportant.  These feelings don’t quiet quickly.

The Decision

Survivors get no choice in having their lives changed.  They do, however, get to choose how they respond.  (See Choice Theory for more on the importance of decisions.)  The choice can be to remain stuck and a victim or to decide that victimhood is a poor place to build a house.  (See Hostage at the Table for more.)

If the decision is made to move forward, it will require that emotions and the grief process is allowed to fully express itself rather than being suppressed, hidden, or accelerated.  The process takes its own time and attempts to suppress it or accelerate it can backfire and make the process messier, longer, and more severe.  However, actively looking for ways to heal, grow, and change are healthy.  (See Antifragile for more on growth.)

Helping Others

In Being Mortal, Atul Gawande explains that mortality of people in senior care drops when they are responsible for something as simple as a plant.  Helping others is wired into our DNA, and as we seek to help others in their struggles with surviving suicide, we help ourselves.  This creates a positive cycle that helps all those who are suffering – not just those being helped.  Gawande’s not alone.  Flourish and The Dalai Lama’s Big Book of Happiness also express that we’ll find the most joy when we’re helping others.

We won’t have to hide, drown, or attempt to compartmentalize our feelings of sorrow if we’re completely immersed in our desire to help others.  However, this presumes that you’re giving to others and that they’re not trying to take solace through you.  (See Give and Take for more on giving and taking.)

Others Using You

Others struggle with their feelings and may attempt to become closer to you to assuage their own feelings – and it ends up making you feel used.  It doesn’t help you and is of limited use to them.  Unfortunately, there is little to be done in these situations except to establish appropriate boundaries.  (See Boundaries for more.)

First Responders

Suicides don’t just impact just those who make the choice and their loved ones.  There’s another group that is impacted by suicides.  First responders – police, fire, and paramedics – are often the first to find the bodies and must face their own struggles.  Invariably, the suicide will resemble a friend, child, parent, or sibling from time to time.  First responders are remarkably adept at encountering the situations that others wouldn’t be able to tolerate.  They are, however, often restricted in their ability to communicate about their feelings; thus, while they have a higher tolerance for such events, the events build over time and lead to their psychological distress.

We have to find ways to make it safer for first responders to talk through their feelings and release the psychic pain that others’ suicides inflict upon them.

Prescription Pads

While first responders are also often the first people who must speak with the survivors, physicians often must support their patients who are survivors.  The natural impacts of stress, anxiety, trouble sleeping, and other health problems – including broken heart syndrome – lead patients to physicians for help.

Physicians have the power to prescribe and thereby relieve their patients’ pain.  While tempting – and invariably what the patients ask for – it’s likely not the right answer.  Survivors need to cope with their pain – and that’s not always possible when medicated.  (See Warning: Psychiatry Can Be Hazardous to Your Mental Health.)

Physicians should remain in contact with their patients and opt for more frequent interactions and evaluation before defaulting to a medical answer to a psychological problem.

Warning Signs

One of the nagging thoughts that suicide survivors must face is whether there were warning signs and what they should or could have done to prevent the suicide.  In some cases, there were warning signs, but in others, there are none to be found.  Even if there were warning signs, it’s not possible to stop someone who is intent on the act.  While we all want to do as much as possible – as we should do – sometimes there is nothing to be done.  Sometimes all we can do is live in Suicide and Its Aftermath.

Book Review-Review of Suicidology, 2000

State of the art doesn’t move as quickly in some places as we’d like to believe.  Much of the technology in aviation is half a century old.  Much of what we know and believe about suicide has a similarly lengthy history.  It’s in that context that I picked up Review of Suicidology, 2000 – a summary of what was known about suicide in 2000.  Twenty-one years later, we should know more; but some of the things that we knew then are still valid today – and, in fact, much of what was the state of the art then is state of the art today.  The question is what do we know – today?

Suicide on a Schedule

If you’re concerned about whether someone will commit suicide, the calendar has an odd role to play.  The day of the month (first or fifth) and the day of the week (Monday) has a marked difference on the probability of suicide.  These relationships are social constructs, not some biological imperative, and they demonstrate how much of suicide is about our relationships with others.

The world was supposed to end on December 21, 2012 – or rather at 11:59 PM the day before.  However, the world didn’t end.  The interpretation of the Mayan calendar was wrong.  A calendar based on patterns inside of patterns was simply resetting an outer cycle, but it did drive many people to odd behaviors, including borrowing money they knew they couldn’t pay back.  If the world really did end, they wouldn’t have to worry about that.  Oops.

If you want to guess what age most of the runners in a marathon will be, you need only know that the final digit is highly likely to be a nine.  (See When for more.)  The reason seems to be that we use symbolic beginnings as our prompting to take action – including the action to commit suicide.

April Fool’s Day probably draws its roots from the Julian calendar, which aligns the new year to April 1st in the Gregorian calendar we use today.  It’s a day that jokes are played on others, and those jokes are expected.  It’s all a part of the gentle teasing of those who thought April 1st was the start of the year.

However, there may be something to this start of the year, as in the spring – whatever hemisphere you’re in – suicides rise.  This spring peak is presumed to be related to the start of new life.  Since 87% of the world’s population live in the Northern Hemisphere, it’s natural that people would assume that April 1st is the start of spring – and thus the new year of life.  It would be easy to miss that April 1st in the Southern Hemisphere is roughly the start of fall as the seasons are reversed.

Here, we find a natural cycle of birth and rebirth having some impact on the calendar instead of the other way around.

Performance Aids

It’s really about making it easier for people to access the emergency services they need.  We know that even tiny barriers – like not knowing where the student center is or a few minutes of extra walking – can have a disproportionate effect on behaviors.  (See Demand for more.)  As a result, efforts to remove barriers from access can be a huge benefit to preventing suicide.  One tested way was to produce a green card.  The card listed emergency numbers – and it made it easier to reach out in times of need.

In other words, the card became a sort of productivity aid.  (See Job Aids and Performance Support for more.)  Designed to be used at a time of need, they seem to have become invaluable in reducing the loss of life due to suicide.

Refusing Follow Up

There are conflicting answers about whether simple letters or other gentle follow ups are successful at reducing suicide attempts.  In cases where people received relatively automated letters after their discharge, the impact was positive.  On the other hand, if someone initially refused treatment, the letters and follow ups seem to have had no effect.  The difference seems to be in the relationship that was built – or not built – and thus how the follow ups were perceived.

In the context of a relationship, the follow ups were perceived as care and concern, where those who refused care may have believed they were a nuisance.

Compliance and Results

Getting to answers about what really works with suicide prevention isn’t as easy as it might first seem.  You want to demonstrate results of the proposed intervention, but often that relies on compliance with the intervention.  As Change or Die explains, compliance with a treatment program is often challenging.  Immunity to Change explains how there are often hidden reasons why people want to continue to do things as they have been doing, so any behavior change can be hard.

However, if you want to demonstrate results, you’ve got a much greater probability of doing that if you can get compliance with the protocol.  That means doing whatever it takes to get compliance with the protocol – even if that means home visits.  They’ve been shown to improve compliance, even if the program they were used in turned out to not be effective.

Intent

One of the vexing issues is defining what is and what is not suicide.  It hinges on intent.  The question becomes did the person intend to end their life?  If they’re successful in a suicide attempt, there’s no one to ask the question of, and as a result sometimes psychological autopsies are performed.  In truth, these are interviews of those around the person and a review of their activities to try to reveal their mental state when their life ended.  The problem with this is that there is no way to know for sure what was going through their mind – so there’s no way to check the conclusions.

For those who attempt but do not die, we have two problems.  First, did they intend for someone to find them and save them so they could get attention – or not?  Many cases of suicides that ended up being completed seemed as if they might have been intentionally timed so someone would find them before they died.

Second, for those who survive, how many will claim that it was an accident to avoid the negative attention and forced care that they’ll get if it’s determined that it was a suicide attempt?  How many will have initially decided they wanted to end their lives but changed their mind?

The problem gets even deeper when you consider those people who are careless or reckless in the risks they take but who do not overtly or intentionally attempt to end their life.  Is the person who drives recklessly fast a thrill seeker, or are they unconsciously trying to kill themselves?  How about the rock climber who fails to use a rope?

Intent – both conscious and unconscious – is difficult to assess, and it may be the wrong question.

Where Did I Go Wrong?

If it was a suicide, we know that the person made a decision to end their life, and it’s likely a decision that we won’t agree with.  The question is how did their thinking differ from ours?  Is it they couldn’t see other options, they got stuck in the “only” (see The Suicidal Mind)?  Was it they were cognitively constricted such that they didn’t know there were other options?  Or were they unable to recenter their thinking around reality and instead got caught up in their own thoughts and got off the rails?

Implementation Science

Most of the work on suicide has been primary research.  It’s things like the use of fMRI machines and correlations between parasites and suicide.  (See The Neuroscience of Suicidal Behavior for one parasite, Toxoplasma gondii, for example.)  It’s great that we can establish that there is a relationship between something in the environment and suicide rates.  However, it doesn’t solve either of our key problems: assessment and treatment.

To be able to get to a valid assessment, the approach should reasonably identify those at risk – and fail to identify those who aren’t at risk.  The problem is we don’t have this.  We don’t have any tool or technique to accurately identify 90% of the people who are at risk and flag more than 10% of the people who aren’t at risk.  To find these, we need to take the primary research and determine if the correlational relationship is really causal – and that requires testing our interventions.

Interventions are our ability to change outcomes and therefore our ultimate goal.  However, because of the low rate and poor assessment, we find that it’s difficult to get studies together to test suicide prevention.  Even when we know that there’s a correlation, sorting that into an intervention and a control group proves difficult, because it takes large numbers of participants and a large number of years to determine efficacy.

If we’re very lucky, we’ll have the opposite problem.  The initial data shows that our intervention is clearly effective, and ethics requires that we stop the study and implement the intervention for the control group as well.  It’s a nice problem to have, but frustrating from a study design standpoint.

No matter how you cut it, implementation science – figuring out how to use what we know to change outcomes – is difficult, and that’s likely why so little of it is done.

Hopelessness

While depression often gets blamed for a large number of suicides, it may or may not be the root cause – it’s quite possible that depression is only one of two actors in the play of suicide, and depression isn’t the primary one.  It’s certainly true that depressed people are at a greater likelihood to commit suicide.  However, the line isn’t quite straight.  The greatest period of concern should be when the person is coming out of depression, when the psychomotor suppression fades but before they fully recover.  (“Psychomotor suppression” basically means they don’t want to do anything.)  As they emerge from the depths of depression, they often decide that they want to act upon those suicidal thoughts they had.

However, it seems like there’s an even greater correlation between suicide and feelings of hopelessness.  Hopelessness is the human equivalent of what Martin Seligman and his colleagues found and labeled as learned helplessness in dogs.  As Seligman recounts in The Hope Circuit, one of his original colleagues, Steven Maier, discovered through fMRI scanning that it might be more accurately described as a failure to develop learned control or influence.  In the case of people who lose their hope, it may be more accurate to say that they’ve lost their belief in their control or influence of their situation.  That can lead them to want to take back control in the only way left: to die by suicide.

How does one decide that suicide is the only option?  How is it that you decide the world is better off without you?  One pathway is to believe you’re a truly awful person who doesn’t deserve to live.  A second is that your life is filled only with pain and misery, and the only way to end that is to commit suicide.  A third way is to feel as if you’re confronted with a problem for which there is no solution – or no acceptable solution – so suicide is the only option that remains.  The reality of these statements isn’t particularly important; what’s important is your perception of the situation – something that can be accurate or very far from it.

Chronic and Acute

From the above, it’s probably clear that hopelessness may be a chronic condition that persists with someone over the ages, or it may be a fleeting thought that they linger on too long or just can’t shake.  As a result, hopelessness can be viewed from either the lens of a chronic condition for a person where suicide risk is relatively persistent or as an acute situation that requires a bit of reframing to regain a balanced perspective.

We can tend to see our negative circumstances as personal rather than external to us, permanent or temporary, and global or related only to a specific circumstance.  When we see things as the former in each of these categories, we tend to see our circumstances as hopeless – and that’s bad.  The more we can push towards the second categories, the better off we’ll be.

All Or Nothing

Another dangerous trap is to believe that things must be one thing or another.  Thinking that the world is good or bad, helpful or harmful, sets us up for a problem when things don’t go as we’d like.  Instead of recognizing the good in bad people – and the bad in good people – we write people off or distort our perceptions to the point where we can only be disappointed later.  Dichotomous thinking – “either-or” – makes it hard to recognize the nuances in everyday life.

I explained in Fractal Along the Edges that with greater clarity comes the possibility of seeing things not as “either-or” but instead “and.”

Avoidance

It should be simple.  If you want to prevent suicide, then just push back those suicidal thoughts from your mind.  The problem is that the research says this doesn’t work.  What we learned from the research behind White Bears and Other Unwanted Thoughts is that the more that you attempt to directly suppress a thought, the more energy that you give the thought, and it may use that energy to come back with a vengeance.  So, it’s not that simple.  It’s not just a matter of trying to suppress the thoughts.  However, proper distraction and work on changing the way that you view things – like is advocated in Redirect – are ways that you can keep suicidal thoughts out of mind without giving them more power.

Don’t avoid Review of Suicidology, 2000 by suppression or distraction if you want to understand more about how to detect and prevent suicide.

Book Review-White Bears and Other Unwanted Thoughts

We’ve all had that song we couldn’t get out of our head or that situation we kept playing over and over in our minds.  We’ve had the mental Groundhog Day that some thoughts seem to generate.  White Bears and Other Unwanted Thoughts is a thoughtful walk through the research about what happens when we try to suppress thoughts we don’t want – particularly those that stop, block, or freeze our thinking.

The White Bear

The book, Daniel Wegner explains, isn’t about white bears but is instead about a story of how Tolstoy’s older brother convinced him to stand in a corner until he wasn’t thinking about a white bear.  This, of course, proved difficult.  The more he reminded himself not to think of a white bear, the more he thought of it.  The change is the meta- or abstract idea of not thinking about an object (white bear) requires that you call up the image to understand it, and that, of course, makes you think about it.

It’s a trap.  The more that you actively try to push something out of your mind, the more you must recall what you’re pushing out of your mind, and you find yourself caught in a loop – and one of increasing reinforcement.

Squirrels and other Distractions

For those of us who have seen the Disney/Pixar movie Up, we know Doug the Dog’s obsession with squirrels.  Doug could be distracted by the simple mention of the word – and it would disrupt whatever was happening.  This is disruptive when others use distraction on you, but as an internal tool, it’s a powerful way to shift your thinking from something that you don’t want to think about to something you do.

Where attempts to directly suppress a thought fail, distractions can be a powerful way to shift thinking away from the unwanted thought – if they’re powerful enough.

Marshmallow Stories

Walter Mischel tested children with treats (which was simplified by a reporter to marshmallows).  He lays out the entire process in The Marshmallow Test as he explains the accidental implications.  The test was a delayed gratification test, where if the child could leave the sweet for a few minutes while the researcher was out of the room, they would get two treats.  Some kids did, and some did not.

Some of the children most successful in delaying gratification – and reaping the rewards – were those who used distraction.  The least successful children were those who tried to use their willpower to power through.  (See Willpower for more about how it functions.)  The more they tried to directly ignore the treat that was sitting right there, the more they squirmed – and often succumbed to the temptation.

When Mischel returned later to the results of his momentary torture of children, a powerful story emerged.  The story was those children who had effectively delayed their gratification were more successful in life.  It wasn’t that the limits of the cognitive skills they had learned were confined to their preschool; their ability to delay gratification seemed to serve them throughout their life.

Learning how to delay gratification had lifelong implications, and the best way to do that was to master distractions.

Depressing Distractions

When trying to distract yourself from a disastrous date  or a deliverable debacle, people who aren’t depressed are able to call to mind positive distractors.  They think of a date that did go well (even if the other person isn’t in the picture any longer), or a work deliverable that got rave reviews.  A few moments of basking in the glory of a success made the failure seem more mentally and emotionally distant.

However, the research shows that if you’re depressed, you somehow decide that thinking about a different disaster is the right way to distract yourself from the current thought to be avoided.  Instead of recalling something positive, you’ll recall something neutral or negative.  With prompting, you can get a depressed person to see other positive situations, but it’s not the normal response that the rest of us have.

To be fair, those with depression tend to see the world a bit more accurately than those who are not.  They more accurately predict their chances at asking someone out, getting a promotion and so-on.  (See Superforecasting for more.)  However, they’re not as happy about it.  Our happiness, it seems, is built at least partially on delusion – but that’s not necessarily a bad thing.

Post-Traumatic Stress Disorder

The Body Keeps the Score created the awareness for me that post-traumatic stress disorder (PTSD) was the result of a situation that the person wasn’t able to fully process.  The situation was so horrendous that people would have to block it out of their mind before the processing could be completed.  The act of suppression seems to not just prevent the situation from processing, it may actually be creating the obsession.

Research seems to support the idea that the more you suppress a thought, the easier it is to recall later.  In other words, every time we suppress a thought, we make it easier for the thought to occur.  The solution is to leverage the reality that we habituate to stimuli, and they become less prominent.  Daniel Kahneman discusses bias, including our desensitization and habituation, in Thinking, Fast and Slow.  Albert Bandura successfully demonstrated this in removing snake phobias, which he discusses briefly in Moral Disengagement.  The trick it seems is to progressively walk through only pieces of the situation to the point where you can still feel safe to help the body understand that there’s no need to be fearful.

Exercise of Will

Our thinking is like a focused laser that operates on a relatively narrow band of input and processes only a radically small amount of the data available to us.  We’re bombarded by sensory data and, increasingly, information.  We must select a narrow band of that to focus on.  (See Chris Argyris’ Ladder of Inference, which I discuss in my review of Choice Theory.)  Our ability to control our thoughts is primarily about our ability to control the process of focusing our attention on one thing instead of another.

The more that we’re able to direct our thinking towards those things that are important and useful and avoid thinking about those things which are self-defeating or get us stuck into a loop of thinking, the happier and healthier we are.  Of course, Willpower is more often thought of from the perspective of productivity, but it has a role in our sanity as well.

Mental Repair

The idea that such a fantastically complex machine like our human brain could run without errors is wishful thinking.  What we know is that we’re constantly discovering and recovering from mental defects.  Most people don’t consider laughter much, but it’s one of those mental repair routines.

Inside Jokes explains that, while there are two types of laughter, one of them is associated with an error checking routine in our heads discovering an error and giving us a bit of dopamine because of it.  The typical joke has the format of step, step, change.  It relies on us making assumptions about what the comedian is talking about and the quick change in the meaning of what we were thinking about.  The result is we’re rewarded for realizing that the meanings were changed.

White Bears and Other Unwanted Thoughts proposes that the ability to distract ourselves is also a mental repair routine which is designed to keep us from becoming locked up on a single concept to the exclusion of everything else.  It also believes that we use humor to escape a situation that seems to have become stuck.

Suppressing Emotions

One of my favorite metaphors for the way our brains work is Jonathan Haidt’s Elephant-Rider-Path model that he covers in The Happiness Hypothesis and Dan and Chip Heath picked up in Switch.  It postulates that our reason is the rider on top of a large, emotional elephant.  The rider has the illusion of control, but only until the elephant decides differently.

I’ve been close to people who grew up in environments where emotions were scary and not okay.  The result, in at least one case, was a complete cognitive break when emotions refused to be held back any longer.  That and other situations where suppression of emotions leaked out into other spaces have led me to realize that suppressing emotions is dangerous stuff.

It takes a massive amount of effort on the part of our rational rider to keep such a powerful emotional elephant under control.  When you’re consuming all that mental energy trying to suppress the elephant, there is little left for the rest of life.

Directing the Lightning

Lightning rods are used to direct a lightning strike in a way that prevents damage.  On top of houses, they’re designed to route the lightning down a sizable electrical cable to the ground rather than striking and burning through a house.  One of the effective techniques for distraction is to use lightning rod type thoughts to draw all the attention to something else.

Powerful thoughts – whether due to their importance or the degree to which they’re immersive experiences – can become mental focal point which draw everything in and thus avoid the unwanted thought.

Unhearing and Unseeing

You can’t unhear something, nor can you unsee something.  Whether it’s the critical comment about you made by a friend or colleague or a scene that you shouldn’t see, you can’t get it out of your head.  Once it’s in there, it’s there – no matter what Freud believed.  Though difficult to study directly, there’s every indication that suppressing a thought in any form doesn’t make it disappear.  In fact, there’s evidence to support that even when we believe – rationally – we’re suppressing a thought, we’re not.  We see micro biases start to show up even when the person claims they’re not actually aware of the information consciously any longer.

These subconscious biases drive us more than any of us would care to believe.

Breaking Stereotypes

Al Campanis defended Jackie Robinson when it would have been easy not to.  Jackie Robinson was the first black baseball player to play in the Major Leagues.  Al Campanis was aware of Jackie’s talents and was (reportedly) a friend.  Al was able to see past the stereotypes of the time with Jackie.  Jackie was different; he was someone Al knew personally and knew that the stereotypes didn’t apply to him.  Except that, while Al knew Jackie was a good ball player, he didn’t believe that blacks could manage a baseball team.  His personal relationship with Jackie wasn’t enough to shake this belief.  (See Mistakes Were Made (But Not By Me) for more on this story.)

For the most part, the way that we break stereotypes is to individualize people and situations from the stereotype.  This addresses the immediate situation and allows us to operate – more or less – without the stereotype for that situation.  Over time and enough situations, it’s possible to cause the stereotype to be invalidated.

Buster Benson explains in Why Are We Yelling? that we need stereotypes because they simplify our processing.  The problem comes when these stereotypes are wrong or are too broadly applied.

Malleability of Memory

One important reminder as we leave is that memory is malleable.  It changes every time we think about something.  We forget that the very act of recalling a memory changes it.  Our perceptions are limited, as The Invisible Gorilla points out.  If we spend too much energy suppressing a thought, we may find that the energy becomes attached to the thought.

We need to be careful when we attempt to suppress White Bears and Other Unwanted Thoughts for fear they may come back with a vengeance.

Book Review-A Handbook for the Study of Suicide

One of the most interesting challenges with suicide is figuring out how to study it in a way that leads to better assessments and better interventions.  That’s the heart of A Handbook for the Study of Suicide: learning more about suicide to address assessment, intervention, and useful models.

A Quick History

Views of suicide have changed over time – and they vary by culture.  At various times, suicide to maintain one’s honor was approved by both Greeks and Romans.  But the stories aren’t that simple.  Suicide by slaves was discouraged, because it was essentially stealing property from the master.  In at least one culture with polygamy, wives would compete to be slain and buried with their husband.  The wife who was determined to be the one the husband most loved “won the honor.”

In Italy, suicide was only punishable for three classes of people: criminals, soldiers, and slaves (criminals primarily because it was seen as an attempt to escape punishment).  The criminalization of suicides was one attempt to discourage suicide.  Other attempts were various desecrations of the body, including being dragged naked through town.  They might also be prevented from a burial with standard religious ceremonies.

Other desecrations, such as being pinned down at a crossroads, were an approach to preventing the spirits of those who committed suicide from haunting the living.

Suicide as Sin

If you look at various religions, you can find evidence of some poor choices – for instance the Shakers.  If you’re not interested in procreation, you may find your movement is short-lived.  Similarly, if suicide is too appealing, then you’ll have no one left.  Christianity promises an afterlife that vastly exceeds anything that someone could expect in this life, thereby making death a doorway to something better.  Suicide was simply walking through that doorway.

This became a problem for the early Church, and therefore suicide became progressively associated as a sin until about the last half century.  The arguments that were made associating suicide as a sin varied from the fact that our bodies are temples to associating #6 on God’s Top Ten list, “Thou Shall Not Kill,” to suicide.  Over time, scholars have unwound the foundations for suicide being a sin, and instead suicide was transformed into a weakness or mental illness.

Suicide as Mental Illness

The logic is circular.  Only a person with a mental illness would consider and complete suicide, so everyone who does die by suicide must therefore have a mental illness.  Certainly, the model isn’t literal.  More comprehensive thinking about what’s happening in the mind of the suicidal person can be found in Why People Die by Suicide (Joiner), Man Against Himself (Menninger), and The Suicidal Mind (Schneidman).

Old conceptions that suicide was mental illness give way to the idea that people choose suicide because of the pain they’re experiencing (psychache) or because the forces of desiring life and desiring death tip towards desiring death – without extinguishing the desire for life.

When Suicide is Right

As painful as suicide is to those left behind, what if it’s the right thing?  Consider a person who is terminally ill, fighting pain, and worried about the financial burden that a prolonged illness will create.  In this case, isn’t suicide the right answer?  If this is a reason why suicide is the right answer, at what point does it become the unacceptable answer?  While it’s comforting to think that suicide is never the right answer, there are times when it may be.

In my own life, my grandfather took his own life when he decided that his health was failing and he could no longer have the quality of life that he wanted.  While I miss him, and it was sad that he is gone, I accept that he had reasons for deciding that he was done.

The philosophical problem is what happens when the person is wrong?  What happens when the illness isn’t terminal, it won’t ruin the family, or you can preserve quality of life?

Decision Making

Suicide is a choice – whatever we may think about it, it’s a choice or a decision.  It’s a decision that, of all the options, suicide is the one that seems the most appealing.  However, in all but in a few situations, the right answer isn’t suicide.  So how is it that people believe it’s the right answer?  Part of that comes with the awareness that suicidal people are victims of constrained thinking.  (See The Suicidal Mind.)  Part of the answer may come from a failure to make rational decisions.

Irving Janis and Leon Mann wrote Decision Making back in 1977, and it’s where Janis’ term “groupthink” was popularized.  In this work, we discover the processes that people can use to identify the best alternatives and make rational decisions.  However, Gary Klein’s work, as documented in Sources of Power, helps us to realize that few people use rational decision making.  Instead, he explains, they use recognition-primed decisions that are based on their previous experiences.  Thus they lean on their experiences as much as or more than they try to logically work out what the real options are.

Suicidal persons often become fixated on the one option of suicide to the exclusion of other viable – and even better – options.  Schneidman explains that “only” is the four-letter word of suicide.  (See The Suicidal Mind.)  If we want to reduce suicide, we need to find ways to reduce this fixation, increase skills for finding alternatives, and help people see that there is always hope while you’re alive.

Social Constraints

We don’t steal or loot others’ businesses.  (Or at least most of us don’t.)  The rules of society govern our actions, and even if they’re not fully able to constrain them, they certainly influence them.  How Good People Make Tough Choices is quick to point out that there’s a categorical difference between truly moral temptations and ethical dilemmas.  In the first case, we know what is right – as defined by what society expects – and in the other, we’re balancing multiple foundations of morality that are in conflict.  (See The Righteous Mind for more on the foundations of morality.)

Suicide rates are influenced by the social context and constraints that surround it as is evidenced by the fact that they vary so widely between different countries.  There’s something to the way society is formed that can either encourage suicide or provide insular protection against it.

Internal Perceptions of External Events

Why does a breakup drive one person to suicide but barely phases another?  Why is job loss so traumatic for some and uneventful for others?  If the external event is the same, why aren’t the results the same?  The answer comes in the way that we view the situation.  Our reactions are based primarily on the internal meaning that we assign to the event – not the event itself.  Richard Lazarus in Emotion and Adaptation makes it clear that stressors are not stress.  Our belief about the probability and impact both play a role in our assessment but, critically, so does our belief in our capacity to cope.

Even highly likely and largely impactful events barely register when there are high degrees of self-esteem and internal locus of control.  (See Deci’s work in Why We Do What We Do for more.)  The difference in reactions is therefore about the assessments and capacities – which we can train and instill in people.

The Road of the Gypsy

One of the other interesting findings is that immigrants have a higher rate of suicide than those who are native born to a country.  The cause isn’t known, but it does seem as if those who travel the road of the gypsy are more prone to believe that there’s a magical place where their frustrations with life will be removed.  As Viktor Frankl explains in Man’s Search for Meaning, sometimes these false hopes can be deadly.  It isn’t, however, false hope to believe that you can learn something from A Handbook for the Study of Suicide.

Book Review-Suicide: Inside and Out

Years ago, I was doing a conference in the Union Square area of San Francisco, and I received a warning about the homeless in the area.  During the day, things were fine; but I shouldn’t go walking alone at night, because many of the homeless in the area had untreated mental illness.  As I inquired more about it, I was told that since the state shut down the mental institutions and “dumped” those with mental illnesses on the streets, it was impossible to control the homeless population – and it was riskier to ignore them.

This is what I kept seeing as I was reading Suicide: Inside and Out.  It’s a story of the mental hospitals that are all but gone.  State run facilities are, for the most part, a thing of the past.  They were dismantled both figuratively and literally because of their dysfunction, some of which is explained in the book.

The Ruse

The core of the book is the account of David Kent Renolds who went inside the mental hospital as a patient.  The backstory was devised to make him appear as a suicide risk, and he, at one point, faked a suicide attempt.  Those who criticize the work (and the book) attack it on ethical grounds or on the inconsistencies generated by placing a presumably sane and non-suicidal person in the midst of a system designed for those who needed care.

My own conflict was less about the ruse and more about the factors that moved people further towards – and not away from – suicide.  Thomas Joiner in Why People Die by Suicide focuses on three factors for suicide risk: self-harm tolerance, burdensomeness, and connectedness.  While self-harm tolerance isn’t impacted, burdensomeness and connectedness are both negatively impacted by an inpatient program.  Several aspects of the report indicated the sense that Reynolds was a burden and there was minimal contact with the outside world.  In fact, there was only one pre-arranged contact from the outside world and one meeting with the administrator who knew Reynolds’ true identity.

Suicide Status

Suicide status, or “S-status,” meant certain things, not the least of which was isolation.  Instead of being relatively free to roam in an open ward, suicide watched patients had less mobility and freedom – and certainly less privacy.  While Reynolds explains that aides did their best to provide a modicum of privacy, it was still difficult to balance the need to protect a patient from themselves and simultaneously give them freedom.

The privileges that come with being off suicide status are many, and so it behooves the S-status patient to try to convince the staff that they’re not really considering suicide any longer – whether they are or not.  It’s a careful balance between being seen as sane enough to know you’re sick and seeming that you can’t possibly be as well as you’re letting on.

I’ll Die, If I Want To

One of Reynolds’ observations was that the person dedicated to their self-destruction wouldn’t have much of a problem attempting suicide again, since it’s practically impossible to protect someone from themselves every moment of every day.  It’s too easy to grab a razor or a rope.  It’s even quicker to step in front of a speeding car – all these opportunities and more presented themselves during Reynolds’ experiment.

This leads to the particularly thorny problem with caring for severely and persistently suicidal people.  You can’t take your eyes off of them for a moment for fear that that moment may be their last.

I Am Here

The Fifth Discipline Fieldbook shares that the word “ubuntu” stems from the Zulu phrase “Umuntu ngumuntu ngabantu,” which means “A person is a person because of other people.”  Reynolds made it clear that people failing to acknowledge him – either in general or by speaking about him but not to or with him – was one of the most difficult parts.  He craved acknowledgement as a human being.

This is the most basic form of connectedness – connected to others at a level of at least acknowledgement of existence.  Deeper connections are, of course, necessary.  However, they’re all built on the foundations that people are visible.

Temporal Distortion Field

Today and tomorrow are the same.  There’s little reason to look forward to one day versus the next, because everything is the same.  It’s a monotonous march across the pages of time, which seems to have no beginning, no middle, and no end.  People speak of beach time, where the grid-like confines of a quarter-hour calendar are lost to the waves gently lapping at the shore.  Unlike the pleasant images of the beach, time wasn’t under the patient’s influence or control.

It was 45 minutes of waiting punctuated by 30 minutes of something only to return to 45 minutes of waiting to be interrupted for the next thing that had to happen.

Lack of Control

“Learned helplessness” was Marty Seligman’s phrase for the feeling that you didn’t have any control of your circumstances, so there was no point in trying to make it better.  (See Seligman’s work in The Hope Circuit for more.)  Others have framed the lack of control in terms of a lack of hope.  C.R. Snyder explains in The Psychology of Hope that hope is built on willpower and waypower, where waypower is knowing the path forward.

Inside of the ward, there was no knowing or planning for what was next, because information flowed so poorly that few people really knew what they were supposed to do – and fewer still knew when they were supposed to do it.  In my own work, I’ve discovered that a lack of hope is a very, very dangerous thing and something to be actively avoided.

Suicidal Risk

Then and now, the best indicator of whether someone is a risk for suicide is their own assessment of the risk.  There are no widely accepted screening criteria with high confidence that can be used, and as a result, we still struggle to identify the real suicidal risk of anyone.  We have the statistics to show men vs. women and age-bracket vs. age-bracket, but these are generalities covered by statistical math that doesn’t reveal who needs the most attention – and who will be just fine.

If we’re going to get good at managing suicide, we’ll have to find a way to do better than asking the patient how they feel.  Suicide is too impulsive to believe that people will be able to self-diagnose.

Behavior Isn’t Stable

Kurt Lewin described behavior as a function of both person and environment.  (See A Dynamic Theory of Personality for more.)  He knew that our behavior would change as the conditions changed, and he saw this as an opportunity to create environments for the best results.  However, the psychologists of Reynolds’ day held a different view.  They saw a patient’s behavior as a stable force driven by their makeup that couldn’t be shaped by the situation they were in.

Aides and nurses saw a different and more realistic view as they discovered that the conditions a patient found themselves in could substantially alter the kind of behavior the patient would exhibit.  In the most basic sense, patients would be nicer to those aides and nurses that they felt were kind to them.  This is one of the many factors that impacts patients who exit inpatient treatment.  They go back to the same situation that brought them to seek care in the first place.

Emotional Upheaval

There’s a flurry of activity when a tragedy – of any kind – strikes a person.  There’s initially a wealth of support from every angle.  However, as the days turn to weeks and weeks to months, the degree of support wanes, and the business is replaced with an icy calm.  It’s a time when one can pause, reflect, and wonder what’s next.  It’s a time when suicide may seem like an option.  In the moment of a great tragedy and loss, it can be that the mechanical and tactical aspects of the change are so consuming that they can help you avoid the extended thinking about the meaning of the event and how it will impact the rest of your life.

We see that often it’s when people appear to be getting out of depression or have been released from a hospital that they commit suicide.  Whether it’s that the psychomotor retardation associated with depression is waning or that people finally settle into the long-term implications, it’s not clear.  What is clear is that the danger associated with a loss doesn’t dissipate quickly.

Decoupling from Reality

One of the other concerning aspects of the account is the tendency towards decoupling from reality.  Increasingly, people would become involved in their own thoughts – whether or not they were connected to reality.  One begins a paranoid perception that everyone is out to get them or, at the very least, is always talking about them.  It’s hard to see that the world really doesn’t revolve around you when you’re inside your head, because your own internal world does.

The more that we can help people be grounded in realistic, positive futures, the less likely they are to invent their own distorted view that may tangle living and death in ways that mean they no longer want to live.

In the echo chamber of our minds, minor setbacks become catastrophic events, and minor victories invite celebration.  Unfortunately, we’re more focused on the losses and the negative than the positive, so we’re weighed down by the amplification of the negative more than the amplification of the positive.  (See Thinking, Fast and Slow for more on negative bias.)

Degree Not Kind

The difference between a normal person and an abnormal person is a matter of degree – not of kind.  It’s not that abnormal people are something that normal people are not, it’s just that they’re more or less of it than the normal range of people.  Instead of being in the middle, they’re on the edges.

It’s important to realize that this may be one of the reasons why the staff can’t identify the “normal” person in the abnormal situation.  While other patients can see something different, the staff rarely can.  This is important as we look at suicidal ideation as a continuum on which people fall and not a destination or specific point.

The List of Clues

Near the end of Suicide: Inside and Out is a list of suicidal clues.  They’re supposed to be indicators to look for when you are assessing the potential for suicidal attempts in a person.  I’ve elected not to reproduce them here in part because some are myths and in majority because their predictive value is low.  We get so wrapped up in the idea that we can ask a few questions and sort people into the high risk category (whatever that means) that we fail to realize that suicidal intent comes moment by moment and has very little relationship to the state the person is in when the questions are being asked.

We no longer have the opportunities that existed with David Kent Reynolds did his study – but even if we did, I’m not sure it would reveal any answers to why people commit suicide.  It feels like it doesn’t necessarily help to know Suicide: Inside and Out.

Book Review-After the Ball: How America Will Conquer Its Fear and Hatred of Gays in the 90’s

I was just graduating high school as the book After the Ball: How America Will Conquer Its Fear and Hatred of Gays in the 90’s was published.  There was, obviously, a lot going on in my world, so I can’t say that the perspectives in America about homosexuals was top of mind for me.  I was aware of the fear and hatred but largely as a part of the awareness about AIDS and HIV.  For me, it was never a thing one way or another.  Within a year or two of graduating I met some openly gay and transsexual friends, and we didn’t talk much about how other people treated them.  To me, they were – and are – simply friends.

Reading After the Ball wasn’t about trying to understand homosexuality for me.  I realized that the book stirred a lot of controversy when just putting my hands on a copy was so expensive.  I learned that many of the books had been destroyed by hate groups and that drove the price of the few remaining copies up.  The reason I wanted to read After the Ball was because it was effective.  It changed the perception of gays in the 90s.  A friend of mine with a non-binary child pushed back as I was speaking with him saying that it hadn’t gone far enough.  I suppose that’s true – but it’s equally true that the ball was moved very far down the field towards acceptance of alternative approaches to sexuality.  (See The Anatomy of Love for other approaches to sexuality.)

I was hoping to find a way to bridge the gaps that were created over the past few years as the world faced COVID-19 and the divisiveness that had been created.  I wanted to find a way to help families heal from the divisions that formed Fault Lines.  I can’t say that I found those answers, but I did find some other answers that might be more valuable.

Hate Groups

Calling the religious right a hate group is likely to win me more enemies than friends but that’s what they are – or at least were.  Jesus’ directives are clear: love your neighbor; these things remain faith, hope, and love – and the greatest of these is love.  However, somehow some people get wrapped up in righteousness and pursue fear, hatred, and alienation instead.  Unable to reconcile homosexuality with their view of “right,” they lashed out and attacked – and they encouraged and legitimized psychological and physical harm towards gays.  The enlightened writing of Jonathan Haidt in The Righteous Mind wasn’t available – and probably would have been rejected if it was.  Understanding and acceptance of others wasn’t on the agenda.

I first encountered the title After the Ball in the book The Marketing of Evil.  It called out the book as evil.  I was so shaken by The Marketing of Evil that I broke my process of reviewing books for it.  I didn’t want to draw attention to a book that was so inflammatory.  I still feel that way today as I realize that the worst thing that After the Ball proposes is a propaganda campaign – something that even major corporations do all the time now.

In Defense of Sacred Ideas

It’s not that the perception that the Bible finds homosexuality wrong is completely unfounded.  The hate groups can point to passages that support their assertion.  The story of Sodom and Gomorrah is where we get the word “sodomy” from.  And yet, it seems as if the context is twisted and bent to fit the desires of those who tell the story.

For me, one of the most mis-told stories in the Bible is “turn the other cheek.”  While growing up, I probably heard the sermon a dozen times or more that this meant you should not lash out to protect yourself.  However, when you raise the historical context, you’re confronted with the awareness that what was likely being said is that you should give others a chance to show who they really are.  In historical times, one hand was used for wiping your feces and the other for interacting with others.  If someone was willing to smack your cheek with their left hand it was clear the kind of person they are.

The story of Sodom and Gomorrah is a story that is as much about a failing to respect others’ wishes as it is about sodomy directly.  However, it’s easy to miss this subtlety when the passages condemn the whole of cities instead of focusing on the fundamental lack of respect for one another.

Homophobia and Homo-hatred

The manifest problem isn’t a fear of homosexuality but rather is a hatred of it.  It’s not that people are afraid of homosexuality directly, it’s their lashing out against it and the decision that gay and lesbians must be somehow bad or evil.  It’s the response that causes us to separate the world into us vs. them, and homosexuals are decidedly “them.”  (See Mistakes Were Made (But Not by Me) for more on us vs. them.)

Hatred is the unfortunate and natural outcome of a fear.  Too few people are taught how to address their fears head-on and conquer them in a positive way with tools like desensitization.  (See The Body Keeps Score for more on desensitization.)  Instead of the fears getting smaller, the reactions get larger, and the result is the need to lash out to reduce the fear.  It’s been said, and it’s psychologically accurate, that those who lash out the most about homosexual behavior are the most drawn to it.  Their attacks on homosexuality are primarily to protect themselves from it.

The Big Lie

After the Ball calls it “the big lie.”  The lie is that homosexuality doesn’t exist.  The data puts it at about 10% of the population – and yet too many people don’t believe they know a single homosexual person.  At least, that is what the data said decades ago.  Somehow, one in ten people were homosexual, but people didn’t know anyone who was gay.  Given Robin Dunbar’s work on stable social relationships, this is statistically improbable.  (For more on Dunbar’s work, see High Orbit – Respecting Grieving.)

However, if no one knew anyone who was gay, then maybe, just maybe, it didn’t really exist after all.  We’re willing to accept that there are Yeti with shadowy, impossible to see photos that depict a dark blob, but when it comes to gays, we just can’t believe.

Come Out, Come Out Wherever You Are

“Olly Olly Oxen Free” was the call we’d make when hide and seek was over, that we had given up.  We’re still not quite there with homosexuals.  While much progress has been made with the acceptability of homosexuality, there are still prejudices and biases.  There are still stigmas and shunning, and it makes it hard for those who have homosexual feelings to come out into the open.  It’s hard coming out of the closet.

Courage is not the absence of fear, it’s moving forward despite the fear.  (See Find Your Courage for more.)  If you want to increase courage, you reduce fear.  More people put themselves at professional and personal risk by “coming out of the closet” and openly sharing their homosexual orientation.  This courage is one part of the plan for overcoming fear and hatred.  The more that gays and lesbians are seen as normal and acceptable, the harder it will be for individuals to be attacked, dismissed, and shunned.

Call It What You Will

An exasperated Abraham Lincoln was said to have asked his Cabinet, “How many legs does a lamb have if you call the tail a leg?”  The answer five came up and was quickly rejected by Lincoln. “Wrong!  It’s still four.  Calling it a leg doesn’t make it one.”  The easiest – but not the best — way to deal with a problem is to deny it exists.  The premise here is the problem that straight America just wants gays to cease to exist, and denying that they do in some distorted way makes it true.

Like Lincoln’s quote, it doesn’t make it so – but more importantly, I’m slightly disturbed that it’s framed as a problem.  Instead of looking at homosexuality as a different perspective or set of beliefs, many attempt to elevate it to a difference in values at the level of morality and immorality.  It turns out that what you call it – and how you communicate about it – really matters.

Real Immorality

Part of my frustration with it being converted into a moral issue is that I believe that immorality should be reserved for those things which violate the foundations of morality.  (See The Righteous Mind for the foundations of morality.)  Albert Bandura spoke of the conditions that lead to immoral behavior in Moral Disengagement, and Philip Zimbardo spoke of it in The Lucifer Effect.  Vicktor Frankl spoke about what he saw of the Nazi concentration camps in Man’s Search for Meaning.  The differences are striking.  The first moral foundation is care/harm, and these other examples violate care/harm in ways that all but a few deviants who happen to be homosexual haven’t done.  It should be quickly noted that there are plenty of heterosexual deviants, too.  The point is that homosexuality in and of itself doesn’t mean – or imply – that other people are harmed.

Certainly, we face issues then and today which could be called moral issues – but they’re not the issues about how we interpret the nuances of the Bible – or of other religious texts.  Because people don’t subscribe to your views and are not motivated by the same things that you’re motivated by doesn’t make them evil or bad.  It makes them different.  (See Who Am I? for more on Reiss’ 16 basic motivators and how we’re all motivated by different things.)

The Propaganda Machine

Propaganda gets a bad reputation.  It’s been used in very evil ways.  Perhaps the greatest example is the propaganda war that Adolf Hitler waged against Jews and Russians.  (The Russians get less attention because they had an army and put up a more violent fight.)  The propaganda specifically made both groups seem sub-human.  That process created the conditions which enabled the concentration camps and the attempted genocide.

Propaganda at its most fundamental is a one-sided approach to a topic designed to persuade others that the purveyor of the propaganda’s point of view is right.  The proposed Waging Peace Campaign rests on three pillars.

#1 – Desensitization

If you want to get over fear, the technique developed by Albert Bandura may just be the thing.  Afraid of snakes?  Find safe ways to look at pictures of snakes, then be in the same room, then near them, then touch them, then hold them.  It takes time, but desensitization works.  It’s not the fear of snakes that After the Ball is trying to cure.  It’s fear of homosexuals – and the process works en mass as well as it works one-on-one.  The more that homosexuals are portrayed in mildly uncomfortable but not threatening ways, the more normal it becomes, and the less fear there is.

We know that anything that becomes common elicits less of a reaction.  If encountering openly homosexual people is common, then it shouldn’t be such an issue.

#2 – Jamming

Another, more disruptive, approach to changing perceptions is to introduce two incompatible emotional responses at the same time.  For instance, introducing the idea of a wholesome family and then revealing that the parents are homosexual necessarily creates the need for the two conflicting emotions to be reconciled.  While the process is not easy for the individual, it can be effective at causing the lesser emotion to recede.

Other approaches to jamming place a negative emotion with the positive emotion that drives bigotry.  Bigotry continues because we receive a reward for acting on our bigotry, thus reinforcing it.  (See The Power of Habit for more on reinforcement.)  However, if you spoil the reward by adding in guilt, shame, or regret, you steal the power that the engine needs to reinforce the behavior and thereby lessen it.

#3 – Conversion

While the first two techniques are aimed at reducing fear and bigotry, the third is about increasing likability.  That is, while ambivalence is a good start when you’re coming from bigotry and hatred, it doesn’t go far enough to protect against backsliding.

The real trick is to create friendships with straight people – and to allow those friendships to spread.  This is easier said than done as Mistakes Were Made (But Not By Me) relates how Al Campanis could like Jackie Robinson and know that he was a fine baseball player but simultaneously not believe that he’d make a good manager.

Certainly, making friends and creating affinity with others is the right strategy, the degree to which it may be generalizable is questionable.

Out Come the Freaks

One of the most direct criticisms of the homosexual movement for equality comes in the form of the visibility of the “freaks.”  That is, those people who represent the furthest extreme.  Those who would seek to shock straight America into accepting the movement do more damage than good.  It’s for this reason that Kirk and Madsen recommend that the more socially acceptable come forward (where they’re able) to be spokespersons for the movement rather than allowing parades of debauchery to be the single message that heterosexual America sees.

After the Ball divides homosexuals into two broad categories.  The “Rs” look like and can be seen like straights – and they like it that way.  The “Qs” can’t look like straights – and they don’t want to.  They want to be queer (different).  Despite the natural aversion to standing out and being recognized as gays, if desensitization is to be effective, it needs the “Rs” to take up the banner.  Without the normalcy, gays could be rejected out of hand.

Free Software

Richard Stallman was the programmer-activist who led the charge for free software.  It’s spawned a whole market of open-source and openly licensed software that has made the world better.  Yet many in the world of open-source software cringe when they hear that he’s spoken at another event or to the press.  His beliefs are so extreme that they seriously jeopardized the legitimacy of open source software.

Quietly, other voices started emerging with more moderate views and a less militant approach to finding ways to drive commerce without perceived exploitation.  This is the same approach that After the Ball proposed for improving the relationship between heterosexual and homosexual people.

The Principles

After the Ball proposes a set of principles that gays should use to improve the situation realizing that gays would have to be better than straights to gain acceptance.  They are:

  1. Don’t Just Express Yourself: Communicate –Focus not just on expression but what the message is that you’re sending.
  2. Seek Ye Not the Saved nor the Dammed: Appeal to the Skeptics – The greatest opportunity for any movement is to appeal to those who are interested in learning more and who have not yet developed any prejudices.
  3. Keep Talking – The goal is simply to work on desensitization, and that requires a lot of low-grade discomfort. It’s the kind of discomfort that is acceptably generated through talking.
  4. Keep the Message Focused: You’re a Homosexual, not a Whale – Don’t pickup every other cause like lost puppies and bring them into the fold. Stay focused on what is important.
  5. Portray Gays as Victims of Circumstance and Oppression, not Aggressive Challengers – Look for support and sympathy rather than invite conflict, resistance, and battles.
  6. Give Potential Protectors a Just Cause – Make it easy for others to join the cause by focusing on the fact that gays are being discriminated against rather than trying to convert others’ sexual practices.
  7. Make Gays Look Good – Appearing as model citizens and pillars of society makes it easier for others to support you.
  8. Make Victimizers Look Bad – Where possible and appropriate, allow victimizers’ actions to become well known, so that others are repulsed by their actions.

Civil Disobedience

After the Ball has advice for civil disobedience, from ensuring non-violence (on the part of those practicing it) to communicating the willingness and acceptance of being arrested for the disobedience and the need to connect the act of disobedience with the cause.  Unfair taxation of tea preceded the Boston Tea Party, and so civil disobedience must make the connection between the act and the cause clear.

Stand and Be Counted

Today, we’re three decades after the publication of After the Ball.  Much has changed and gotten better.  Thankfully, gay bashing has receded to rarity.  However, there are still legitimate concerns about the degree to which someone can be open about their sexuality for fear of reprisal.  In some sense, this feels like a continuing journey.  It may be that there is no after in After the Ball; you’ll have to decide for yourself.

Book Review-Man Against Himself

One of the things about researching suicide is you get the very real sense that it’s somehow an internal conflict that boils over into an act of self-aggression.  It’s this very real consideration that leads to Karl Menninger’s 1938 classic book, Man Against Himself.  In it, he seeks to expose his experiences with people who choose to harm themselves – through suicide and other ways.  His belief is that our best defense against self-destructiveness is to bravely expose the inner thoughts of those troubled souls who choose self-harm so we may design interventions against them.

The High Cost of Living

For those who are in constant psychological pain, each day of life is purchased at great cost.  Every day weighs on them more heavily.  It’s these costs that we seek to reduce or eliminate and replace with sources of strength and resources that make them feel as if things are continuing to get better.  However, sometimes our efforts come too late, and people feel the weight of the deficit they’ve been running for so long.

Most of us can’t understand these burdens directly.  Nor can we seem to engage the broader public into the appropriate consideration of the factors that lead to suicide.  We find that suicide then – and now – doesn’t get the kind of attention it deserves.  Instead, we continue to ignore that living can extract a high price for those who are suffering.

External and Internal

If the pain is visible and external, it could be said that suicide remains a heroic death.  It’s the conquering of the forces of life and death that conspired to imprison the suicidal person.  If the torture is internal and invisible, then the suicidal person must have been crazy.  This view is prejudiced and dismissive of the power that our thinking has.  It invalidates psychic pain.  (See The Suicidal Mind for more on psychache – psychological pain.)

The truth is that all suicide is composed of both parts – the visible and the invisible.  We know of invisible things that are no less real because they’re invisible.  We can’t see magnetic fields, but we know they exist.  Most of us have never personally seen a pathogen – whether it be bacteria, virus, or spore.  That doesn’t stop us from becoming infected by them.  Despite our desire to be able to see and understand, we must accept that sometimes we’ll not know what the factors were and whether they were truly internal or if there were unseen external forces at play.

The Long Slide

Menninger proposes that the actual suicide attempt has a long prelude.  The decisions and thoughts that preceded the attempt led to the conclusion.  I struggle here, since the data about whether suicide is preplanned or not is inconsistent at best, with some people seeming to plan out an elaborate event and others seemingly impulsively deciding that the time is now.

That being said, I can acknowledge that many of the seeds of suicidal thought are sown years before.  Just as Dr. Spock learned decades later that his advice to parents may not have been as good as he initially thought, it’s possible that seemingly innocent comments and perspectives led to unhealthy and risky attitudes.  (See Finding Flow for more on Dr. Spock.)

Menninger relates several stories where thoughts that occurred in childhood came to be revisited as a specter in the future.

Self-Punishment

Crime doesn’t pay.  It’s a cliché that was broadcast to all of us in an attempt to reduce the desirability of a life of crime, but the fact that we need the cliché is an indication that this isn’t obviously true.  We’ve internalized somehow that all crimes must be punished – whether or not anyone else sees it.  In some ways, people pursue self-punishment as an atoning sacrifice before others could possibly implement sanctions against them.

Generally, the pull towards self-punishment is in a normal band and it keeps good people on the right track.  (See How Good People Make Tough Choices for more about this mechanism.)  For some, there seems to be no atoning for their perceived sins.  They’re angry at their mother; when she dies in an automobile accident, they blame themselves for her death.  There are no amounts of self-punishment that can compensate for this supposed injustice.  Never mind the fact that no amount of thinking about harm towards another person actually harms them until and unless it is acted upon.

For the suicidal person, it seems as if there’s always another infraction or injustice that must be atoned for, and some of those are so large that there is no way to pay the debt without sacrificing their own lives.  Our conscience “is a strong deterrent and a harsh judge.”

Enmeshment

Enmeshment describes identities of multiple people that are mixed, confused, and fused.  At the extreme, it’s pathological and creates a number of problems.  In its normative state, we all believe that we carry a part of someone else inside us.  We hear the words of our parents, our coaches, our former bosses, etc.  This can be comforting for survivors, because they can believe they continue to carry a part of the suicide victim with them.

However, for those who have pockets of extreme hate, it may create the opening thoughts need to provide a path towards suicide.  If I’m angry at my father, and I kill myself, I somehow kill that part of him that I carry inside of myself.  This isn’t the most direct or bulletproof logic, but it’s often all that a suicidal person needs to push them across the chasm.

Inconsistency with Self-Image

One of the quirky parts of suicide is that it is seen in people who are the recipient of sudden fortune as well as those who are subject to the expected misfortune.  This discontinuity can be explained by a sense of impostor syndrome and the belief that you don’t serve the recognition or positive results that you’re getting.  (See The Years That Matter Most for more on impostor syndrome.)  It denies your reality, and you believe that you can’t find a way to be seen as you see yourself.

The disconnect can lead to a sense of invalidation not just of self-perceptions but of the entire self, and this intensely conflicted state may drive the apathy that’s necessary to create the conditions for suicide.

Get Down or I’ll Shoot

A man is standing at the edge of a bridge considering jumping off as a form of suicide.  The police officer shouts, “Get down or I’ll shoot,” and the potential suicide attempter calmly steps down.  What kind of sense does that make?  Well, the kind of sense to be effective in a world of potential suicide.  Somehow, jumping off the bridge to your death could be okay, but being shot by a police officer is not.  Conversely, there are some people who choose “officer-assisted suicide,” deliberately provoking the police so they will be shot and killed.

There’s weird logic that works inside suicide, including the unescapable fact that many who attempt suicide and are critically injured (but are not dead) plead for assistance and reassure those helping them that they want to live.  Some will eventually die of their injuries, and some will not.  This only confirms the perspective that suicidal people are not singularly focused on death but are instead caught between the desire for life and the desire for death.

Predestined

Sometimes, parents or other authority figures label people.  Little girls are told about their “lot in life,” which must be submissive.  Black Americans are told that they’re inferior – even by their own parents.  The result is that sometimes they sow the seeds of later internal angst either because the person achieves more than what their self-image allows them to accept – or they aren’t successful, and as a result, they believe that they’ll never accomplish anything with their lives.

Tell a girl that she’ll be dominated by men, and she may just seek out precisely the kind of men that will make that label truth.  This is, of course, not what you want.

The Tragedy of Alcohol

At one point, the concern for alcohol was the DTs – delirium tremens.  However, as Menninger explains, he maybe saw one case a year.  The damage that alcohol does is not so much physical as it is psychological.  Sure, there are liver and physical issues – but those are not the most important ones.

The important observation he makes is that he’s been unable to identify the line between casual, social, and acceptable drinking and the point which it becomes an addiction.   That may be because that it is indeed gradual.  Addiction is a coping mechanism that gradually gains control over you instead of you over it.

Alcohol starts as an escape from the problems – but ultimately becomes a much bigger problem.  While it may, for a time, provide a justification for unjustifiable behaviors, ultimately people lose patience and see alcohol as the problem – instead of the solution.

It’s Okay, If They Let You

The big story of my time was the “chase” of O.J. Simpson’s white Ford Bronco on the California freeway and the trial that followed. “If it doesn’t fit, you must acquit.”  For most, the belief is that he got away with murder.  Though he never did admit it, the perception is still the same.

At some level, we continue to be shocked that people who have money, prestige, and power commit crimes – and are never charged.  Ultimately, the same behaviors that would result in prison time for the rest of us is somehow okay, because they’re special and different.  The problem, as Jerry Falwell, Jr. found out, is that you can’t betray the central images that allows you to maintain that power and prestige, or it will come crashing down.

Small Defects of Exaggerated Importance

One of the observations from the safety of outside of the suicidal person is that the problems the suicidal person sees as so large and so horrendous are rarely so bad to the rest of us.  The suicidal person seems to focus on their faults, limitations, and foibles no matter how small and catastrophizes them into unchangeable limitations that can never be overcome.

Instead of a balanced view of both positives and negatives, there’s the irrational magnification of the often-insignificant limitations.  It’s these insignificant things that often pits Man Against Himself.

Book Review-The Savage God

Reading about suicide through the lens of an author about the death of another author isn’t where I’d normally start.  However, The Savage God was referred to by both The Suicidal Mind and Myths about Suicide, so it was clearly a work that held some value for others, so I wanted to read it.  It’s a story – on the surface – about a relationship between Al Alverez and the couple, Ted Hughes and Sylvia Plath.  The key was that Sylvia Plath successfully completed a suicide attempt six months after being estranged from Ted.

No Solutions

Alverez is quick to point out that he has no grand solutions to suicide.  In fact, he doesn’t believe in them because, “Suicide means different things for different people at different times.”  While it may seem that this disclaimer implies that there is no insight into the suicidal mind, nothing is further from the truth.  While he offers no solutions, he does offer a better understanding of how life and death sometimes get tangled on the way to good art.

I must confess that I hadn’t remembered hearing Sylvia Plath’s name before this.  I’m certainly no great fan of poetry so while Virginia Wolff’s name was familiar to me, Slyvia’s was not.  (Virginia Wolff also died by suicide.)

Once a Decade

The attempt that took Sylvia’s life wasn’t her first – far from it.  She seemed to have a “deal’ with death.  She’d tempt fate with some sort of a suicide attempt once a decade, and if she survived, she’d get a new lease on life and a new energy that she could pour into writing.  This magical deal is apparently not unique to her situation, as is explained in Comprehensive Textbook of Suicidology.

Being an artist – a good artist – necessarily requires that someone opens themselves up to their emotions.  That process can sometimes overwhelm a person and make them feel as if they’re pouring out their emotions on the page – and they therefore need some way to replenish them.

Unmentionable Death

The idea that death is unmentionable is a new invention.  Throughout history, we’ve had a more intimate relationship with death.  However, somehow, we decided that if we would speak about death, we’d invite it into our worlds, and so it became the unmentionable.  It was always with us yet simultaneously unspoken.

Death, it seems, is now more taboo and less discussed than sex was for the Victorian era.  Now, we can discuss every form of sex, and the result has been a significant reduction in teen pregnancy.  (See Dialogue – Defensive Routines for more.)  Perhaps if we can regain a healthy respect for and willingness to discuss death and suicide, we can remove the mystery and reduce the magic allure of suicide.

Until the Next Do We Meet

What the Spaniards did to the native Indians was cruel.  The work and the torture were so unbearable for many that they committed suicide to avoid it.  The Spaniards became worried about the loss of their labor force and developed an equally cruel story to prevent the Indians from committing suicide.  They threatened to commit suicide themselves to go to the next world where they would be even harsher to the Indians than in this world.  Apparently, the tactics, no matter how cruel, worked, and the labor force was preserved.

Where most people believe that suicide is an escape, the Spaniards removed this idea.  If you believed that suicide would lead you to an even more torturous existence, then perhaps people wouldn’t try it.  This may be some of the hidden motivation for Christianity’s eventual condemnation of suicidal attempts.

Follow the Money

The Roman perspective on death was slightly pragmatic from a state point of view.  If one committed suicide, it was considered a crime in so much as it was avoiding other charges – and it primarily concerned the inheritance of property.  Property inheritance can be a big deal when it comes to wealthy families.  Capital in the Twenty-First Century explains the importance of inheritance and how our perspectives about it have changed.

For the Romans, there wasn’t a moral aspect to suicide, only a financial one.  Suicide meant that the state could seize a person’s property.  As a result, while suicide was relatively common, no one wanted the label for fear that it would mean their families would be deprived.

Coroner’s Records

Coroners often avoid recording a death as a suicide.  Some refuse to accept that it was a suicide without a note – even if the physical scene is clear.  As The Suicidal Mind shares, the percentage of people who leave suicide notes is low – maybe 20%.  Thus, it’s expected that official statistics that record suicide may still be underreported after many of the legal sanctions have been repealed – and very few are enforced.

This partiality may be seen as compassion on the part of the coroner – and in some cases, it may be comforting to the loved ones left behind.  More broadly, it creates challenges as we try to get an accurate picture of suicide, since we can’t trust the records to tell us the true rate of circumstances.

Ambition Beyond Ambition

Alverez makes a statement that rings true with the statistics: “Here’s the difficulty about suicide: it is an act of ambition that can be committed only when one has passed beyond ambition.”  What rings true about it is that it has been frequently observed that suicide attempts increase at the end of depression treatment.  If depression is a causal factor for suicide, why should people be more susceptible at the end of a successful course of treatment?  There are two plausible answers.

First, depression has a noted psychomotor retardation.  That is, people who have depression don’t want to do anything.  So, if the desire to do nothing recedes before the desire to continue life, you get the willingness to do something – even attempt suicide – which previously seemed like too much work.

The second plausible cause is that people, recognizing the improvement, start to return to the focus of their own lives and other cases.  As a result, the person feels abandoned in some small or large way.  The result is a perception that their life going forward would be one of emptiness and loneliness.  (See Loneliness for more on loneliness.)  One must remember that depression robs a person of the joy that they would normally feel.  Without full restoration of joy, they may see little positive in their lives if people withdraw from them.

The “Logic” of Suicides

Suicide, Alverez notes, is a closed world with its own irresistible logic.  That is, the world of superstitions and omens – what Comprehensive Textbook of Suicidology described as magic.  Our self-talk, our internal voices, are personified, and those that are reassuring and supportive can be pushed away so that they’re no longer heard or hearing them requires great strain.

Of course, for most suicide victims, there is no logic, only twists and turns that appear as logic when the mind is troubled.  (For more on how things can look logical but are not, see Mastering Logical Fallacies.)  As these fallacies become exposed to the person themselves, they may seek suicide as a way to escape the pain of the confusion and conflict in their heads.

The Final Reveal

After sharing insight into Slyvia Plath’s eventual suicide and the events that led there, Alverez finally admits his own attempt at suicide and his reticence to admit that fact.  It seems that even in those who’ve ultimately resisted the allure of suicide, there exists a sense of The Savage God that those who succumb are painfully aware of.  Maybe in reading The Savage God you’ll find a way to live with the image or to understand those who have succumbed to suicide.

Book Review-Bruised and Wounded

While most of the books that I’ve been reading and reviewing over the past several weeks (and months) are focused on the clinical diagnosis of suicide and its prevention, Bruised and Wounded is focused on those who are left in the wake of suicide. The loved ones who must find ways to bravely soldier on when they know that their compass has been lost, and the only map they have no longer applies to the situation.

Maps and Compasses

Our beliefs about the world and the way that it works allows us to predict the future and thereby live in it. Humans are prediction machines (see Mindreading), and to do our marvelous task, we must take many things for granted. Gary Klein, in Sources of Power, is clear that our ability to simulate situations is quite limited, and therefore simplification is necessary. That means we must accept some truths as invariant.

The loss of a loved one, whether a sibling or a child, is a tragic reorganization of the way that things should work. No parent should have to bear the death of their child. It goes against the natural order of things. When something goes against the natural order of things, we know that it’s reorganizing the way that we see the world.

Kinds of Diseases

There are effectively three different kinds of diseases we can encounter:

  • Curable – The kind of disease that we have a treatment for.
  • Treatable – The kind of disease that the person will always have but we can keep at bay through treatment.
  • Terminal – The kind of disease for which we can do little to prevent the person from succumbing to.

While these are the medical versions of these categories, there are similar mental health answers. Some things we’re equipped to address completely, some we can mitigate, and some we have no chance of controlling or conquering.

Those who have encountered a loved one who committed suicide are familiar with the final two types as their loved one fell into one of them. Either their condition seemed unalterable despite the best efforts, or it was under control until something broke, and it couldn’t be (or wasn’t) kept in check any longer.

Desperate Attempt

As was addressed in The Suicidal Mind, suicide is an escape from psychic pain. Bruised and Wounded takes it one step farther to describe it as a desperate attempt. It’s the “only” remaining option. (This is also in The Suicidal Mind.) There are no options left that are good to escape the pain, so this is the only option left.

The fact that it’s a desperate attempt furthers the need to protect and encourage hope in everyone. (See The Psychology of Hope for how to do this and The Hope Circuit for more on why.)

The Rhythm of Recovery

Recovery from loss has its own rhythm, as explained in The Grief Recovery Handbook and On Death and Dying. Recovering from the loss of a loved one is difficult and unpredictable. However, there is a way to recover from being Bruised and Wounded – it might just be found in the book.