Book Review-Cognitive Behavioral Treatment of Borderline Personality Disorder

If there was ever a manual that wasn’t called a manual, it’s Cognitive Behavioral Treatment of Borderline Personality Disorder.  It’s the manual for dialectical behavioral therapy (DBT), but it doesn’t have the word “manual” – nor any of the components of DBT – in the title.  I’d previously reviewed DBT Explained, which sorted some of the essential mysteries about the therapy practice, but at roughly one-quarter the size of this book, it summarized some of the details.

Suicide Connection

I need to pause and explain that the reason for the interest in DBT is because it’s an effective treatment for people who have suicidal ideation or a history of previous attempts.  The connection isn’t obvious until you realize that patients with borderline personality disorder (BPD) are prone to “self-injurious acts.”  Linehan quotes the rate at 70-75% of BPD patients based on other studies.  It’s not surprising that she and her colleagues encountered suicidal ideation, attempts, and death by suicide during their careers.

Manipulation

One of the commonly lobbed labels for suicidal patients is that they’re being manipulative.  Too often, we hear, “They’re not really serious.”  The belief that patients who attempt suicide are not serious is pervasive.  Farberow and Shneidman wrote (edited) The Cry for Help, which demonstrates how little the perspective has changed since 1965.  In my review of The Suicidal Person, I shared the stark difference between the healthcare provider perspective of manipulation compared to attempter.  Healthcare providers perceive manipulation where there is none.

However, for the moment, let’s accept the assertion that it is manipulative, and pause before we accept the pejorative judgement about it.  We’re manipulated every day.  We wear seatbelts because of laws and peer pressure.  We buy one brand over the other because of the manipulation of price discounts and sales.  Why is manipulation even a problem?

The problem, as expressed in Compelled to Control, is that everyone wants to be in control, and no one wants to be controlled.  The sense that we’re manipulated means that someone else is controlling us.  That sense is unacceptable to most of us.  (Work Redesign makes it clear there are some people exist who do want to be controlled – probably through conditioning.)

Healthcare professionals resent the sense that others are manipulating them – but at some level, we have to accept that the behaviors are because their lives are unacceptable.  There’s too much uncertainty, pain, or suffering, and they want to find a way out.  Who among us wouldn’t try to find ways to escape unimaginable pain?

Abuse

Another staggering statistic is that up to 76% of women meeting criteria for BPD are victims of sexual abuse during childhood.  It’s the tragedy pointed to in The Assault on Truth.  The human race is reticent to admit that there are such horrors being perpetrated on our children.  We’d rather turn a blind eye to the problems than confront our failure to protect them.

Synthesis

It’s convenient, but incorrect, to view the world as static and unchanging.  We see things as fixed rather than flux, because it’s easier for us to process.  The truth, however, is that things are constantly in a state of flux.  They’re constantly changing in both predictable and unpredictable ways.  It’s easier to see things as independent parts, but it’s harder to see them as parts of a broader whole.

From the universe with galaxies pulling on one another, to the orbit of planets around a star, down to even the atoms that make up our bodies, what we perceive as safe, solid, and stable are actually arrays of predictable forces and motions.  Most of the space that atoms fill up are actually space, as the electrons form shells around their nuclei.

When we view people as fundamentally stable and fail to accept the times when they’re not how or what we expect them to be, we fundamentally misunderstand reality.

Validation and Change

The fundamental tension in DBT is the tension between the absolute necessity to validate the person so that they know they are seen and understood and the need to support and encourage their change.  In the context of either counseling or considering suicide, something isn’t right, and it needs to change.  Since we only ever have control of ourselves, we need to find ways for us to change.  (See Compelled to Control for more about our inability to control and therefore change others.)

It’s too easy to invalidate.  It’s too easy to say that the world really isn’t that way.  It didn’t happen that way.  It’s hard to start from the perspective of “I can understand and accept that you experienced it that way.”  This invites the challenge of whose perception is “right” but opens the possibility that there are multiple ways to experience something.  It’s difficult to navigate from here to a place of mutual understanding where every experience is acceptable.  It is, in fact, the way the event was processed.  However, there is the need to be open to alternative views.

The real gift is in understanding how to give feedback – and how to help people receive it.  Thanks for the Feedback councils people on how to receive feedback better, including how to identify the triggers that might prevent them from reacting well.  Books like Crucial Conversations and Difficult Conversations offer additional advice about ensuring the transition from acceptance to change is managed well.

Distress Tolerance

Though much of what Mischel found in The Marshmallow Test hasn’t been replicated, there’s an interesting core to the work.  What is the impact of learning to tolerate short-term discomfort for long-term rewards?  Mischel’s answer was a better life.  Einstein’s perspective was, “Compound interest is the 8^th wonder of the world.”  Invest, rather than spend today and harness, its power for your good.  Spend more than you earn, and you’ll suffer needlessly.

Teaching distress tolerance is a key piece of DBT.  Effectively, the tools that are taught in DBT aren’t that different than the tools used by the children in Stanford’s child care center.  Distraction and removing focus from the pain are the key starting points.  Admittedly, DBT does add mindfulness and practices that a child looking for a marshmallow wouldn’t have.  They also attempt to engage in a better appraisal of long-term implications.  If there is value to the pain, they try to find it.  Nietzsche said, “He who has a why to live for can bear almost any how.”

Emotional States

For too many, emotions are scary, uncharted territory.  It’s a place where they dare not go.  When they find themselves feeling or expressing emotion, they’re embarrassed.  Too many were raised in homes where emotional expression wasn’t acceptable.  To be a good child, an acceptable child, there could be no expression of emotion.  When emotions were expressed, they were sent away or, worse, told “If you keep crying, I’ll give you a reason.”  The result of this constraint of emotions is that when they flow, people are confused and overwhelmed.

Imagine a child who is taught that all anger is bad.  They’re taught if they get angry, they’re bad.  The result is that when they get angry, they also feel guilt and shame.  Instead of processing one emotion, they’re overwhelmed by two or three.  Anger is an important and necessary emotion.  Aristotle said, “Anybody can become angry – that is easy.  But to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right way – that is not within everybody’s power and is not easy.”  Here, Aristotle is implying the universal nature of anger – and both the power and difficulty of harnessing it. Because anger isn’t acceptable, people never learn to interact with it in a way that allows them to find ways to harness it.

Another emotion that is stifled is the sense of sadness, including loss and grief.  Borderline personality disorder patients think, “If I do cry, I’ll never stop.”  They’re afraid that once they let the “monster” out of its cage, they’ll never be able to put it back.  The research on emotion doesn’t matter.  To them what is real is the threat that emotions are things that can overwhelm and overpower reason.  At some level, this is truth.  After all, as Jonathan Haidt explains in his elephant-rider-path model, it’s the emotional elephant, not the rational rider, that is in control.  (See The Happiness Hypothesis and Switch.)  However, at another level, we know that emotions cannot maintain control of us over the long term.

We know that emotions, once expressed appropriately, tend to fade.  (See How Emotions Are Made, Emotion and Adaptation, and Emotional Awareness for more on expressing emotion and the relationship to moods.)  The safest thing to do with emotions is to let them out and let them pass.  Dan Richo in How to Be an Adult in Relationships encourages acceptance and allowing.  Buddhist philosophy suggests detachment and mindfulness, where emotions are acknowledged and then set free.

Inaccessible Territories

We like to believe that our minds are reliable processors of information, but we know through research that this isn’t truth.  We know from Kurt Lewin’s work that there are psychological states, and that the transition between states requires energy.  The path between states may be mediated by other states, and it can be that we perceive that there is no path from where we are to the place we want to be.  For instance, in moments of intense grief, it’s impossible to see how to be happy again.

We also know that our frame of mind dramatically shapes our responses.  Judges grant more pardons after lunch than before.  It makes no sense, but blood sugar and hunger shape our decisions in ways that cannot be seen.  (See Willpower.)  We know that priming people with safety words makes them more likely to take risks.  (See Thinking, Fast and Slow.)  Capture explains how we can get into self-reinforcing states – that end badly.

After the Mistake

Mistakes are, in life, a fact.  It’s not if you’re going to make a mistake but when.  As a result, it’s not that informative when a mistake happens.  What’s really informative is how we respond to mistakes.  Do we apologize?  (See Anatomy of an Apology for how to apologize well.)  Do we make it right?  Or do we hope that the mistake isn’t noticed?  John Gottman in The Science of Trust explains that repair attempts are a vital part of our relationship health.

Don’t Feel

When someone is ashamed of their emotions, they’ll sometimes tell themselves not to feel.  They try to will their way away from their current emotion by overpowering it.  However, this strategy is doomed to fail.  As mentioned above, it’s the emotional elephant that is really in charge.  More than that, we know that cognitively this doesn’t work.

In White Bears and Other Unwanted Thoughts, Daniel Wegner explains how we cannot not think about something without first thinking about it.  This paradoxical situation means that the more we try to actively avoid thoughts, the more consuming they become.

The only working strategy is to allow feelings to run their normal course.

Fear of Getting Better

One of the challenges of therapy is that people may decide they enjoy the process so much that they’d rather stay in the process than recover.  It sounds odd, but one of the barriers to successful completion of therapy is that sometimes the person wants to stay in therapy.  As explained in Immunity to Change, there are sometimes these hidden barriers that stop people from making the change you want them to make.

In the context of therapy, the greatest loss is the relational loss with the therapist.  If they get better, then they will no longer have a reason to stay in the relationship.  Of course, this is a barrier to them getting better – whether they’re conscious of it or not.

Responsible for What You Become

The tragic reality is that most people will encounter a trauma in their life.  It’s a part of the human condition, which very few will escape.  While trauma is inevitable, continued suffering is not.  We’re often not responsible for the trauma that happened to us, but we are responsible for how we respond to it.  (See also Hurtful, Hurt, Hurting for a similar concept.)

What You Cannot Do

There is a misalignment of image that can occur between the person themselves and the therapist – or other caring person.  Internally, a person may be consumed by self-hate.  (See Compassion and Self-Hate for more on self-hate.)  One’s self-image may be such that even if there is no self-hate, there is also no opportunity for pride or positive feelings.  There may be no opportunity for self-esteem or self-agency.  This can come in stark contrast to the perception of others.

When the therapist (or other person) suggests that there is capability and possibility, it may be met with the retort, “If you knew me, you wouldn’t ask me to do what I cannot do.”  For that person, they literally cannot accept the possibility that they can do what is being asked – even if they’ve done it before or demonstrated the behavior.

This can become a problem for the therapist as well.  Once someone has demonstrated a behavior, they expect it can be replicated, while the person may steadfastly insist that it’s not possible.

The opportunity here is to help the person see that they are capable – but this can take time.

Threat Response

One of the dysfunctional power dynamics that sometimes happens is that the patient exerts control over the therapist, often by threatening suicide.  There are numerous techniques that are described that refocus the power of the relationship such that the patient isn’t manipulating the therapist.  One of the ways that this is done is by “extending.”   This is, in essence, taking the patient more seriously than they take themselves.  If they say something like, “If I can’t get an appointment next week, I’ll kill myself.”  An artful response might be, “How can we talk about a mundane topic like scheduling when your life is in danger?”

Arbitrary Change

One of the challenges in change is connecting the change with reasons and theories of operation, so that the change made isn’t arbitrary but, instead, is relevant and powerful.  Of course, the real challenge when working with people is identifying which changes are relevant.  Without a clear understanding of the factors driving people – either in the specific or in general – it becomes hard to identify what influences what – and therefore what small thing may be capable of making a large change in the back end.

As the therapist improves their understanding of the person, including their history, perspectives, and values, they’re better positioned to develop or adapt working theories to accommodate the person and the change that’s being proposed.

When Praise is Invalidation

It seems like praise should be a good thing.  The person being praised should experience it as a positive – but that’s not always the case.  Sometimes, when you’re receiving praise, you recognize that the other person’s sense of you and the situation are very far from your sense.  It can feel as if they don’t understand.  This lack of understanding can be invalidating.  As a result, praise often needs to be strong enough to move the person’s self-esteem and sense of personal agency forward, but not so far ahead of them that they feel as if you don’t understand.

One approach is to start by recognizing that there were possibilities for improvement – which the person is likely focused on – but that the overall experience or activity was good.  By allowing for imperfection, you make it easier for someone to accept the praise.

Another fear associated with praise is that the person who is doing the praising will withdraw support.  The historic experience is that, after the praise, support is withdrawn, and therefore praise is associated with a new sense of vulnerability – one that is quite often unwelcome.  In these cases, it’s useful to reinforce continued support with the praise.  “You’ve done a good job of managing the relationship with your mom.  I’ll continue to be here if you need me.”

Forming the Chains

Too often, we can’t connect the things that we do and the outcomes that we get.  We take actions, and the results are so erratic, inconsistent, and delayed that we can’t make the connection.  Instead of seeing how things connect to one another, we perceive them as completely random or beyond our control.  In some cases, the sense of randomness is real – but in other cases, our behaviors have a real and measurable impact on the outcome.

It’s possible to discover previously unseen relationships between behaviors and outcomes with careful analysis – but this isn’t natural, and patients can resist the process of determining the connections between behaviors and outcomes.  DBT calls this “chain analysis.”  When worked backwards, this is often called “root cause analysis.”

The idea is that, given an outcome, we can identify the one root cause of that outcome.  I prefer a slightly broader definition, where it’s not a single root cause but rather are a cluster of conditions that led to the outcome.  Some of those conditions are the behaviors of the actors in the system.

Consider a situation where a family doesn’t have much savings, and they suddenly need to fix the car – but they don’t have money to pay for it and to feed the family.  What is the root cause of the problem?  Is it the failure of the car – or the failure to put aside an emergency fund?  What additional conditions must be present?  For instance, not having family members willing to help lend money.  What happened that family members aren’t willing or able to lend money?

Threats to Way of Being

Sometimes the criticisms we receive aren’t perceived as being about some situation or behavior but rather as a threat to our very way of being.  Rather than being an isolated case, it’s seen as a fundamental condemnation of the way that we think and act.  This perception can incite anger or despair depending on whether the response is directed outwardly or inwardly.

Unfortunately, we view our identities from an unconscious and multifaceted lens.  It’s not always possible to identify what another person would consider a threat to their way of being.  That makes it important to be prepared to recover if you accidentally trip over something that someone feels is core to their identity.

You Don’t Know What I’m Going Through

A familiar trap that people, whether clinicians or not, fall into is saying to the other person, “I know what you’re going through.”  The problem is this statement is false.  We don’t know exactly what they’re going through.  We didn’t grow up with their family of origin.  We don’t know all the pressures on them at the current moment.  A better response is, “I can understand some of that,” or perhaps indicating what aspects you believe you can understand.  We can’t assume that we know what someone is feeling completely.  Our experiences may be similar, but they are not the same.

Irreverent Communications

Sometimes a conversation is headed down a bad path.  Irreverent communications can be sufficiently disruptive that he helps the other person “jump a track.”  In other words, if the path the conversation is going down seems stuck, irreverent comments can break the pattern to allow a new pattern to emerge.  It’s a strong driver for change, sometimes with hidden costs.

Too much irreverent communications, and the other person will believe you’re not taking them seriously.  Not enough, and you may be stuck in patterns of communications that don’t lead to results.

Who Is on the Case?

It’s typical now for healthcare to include a case manager.  This is a person whose job it is to help ensure that the patient is getting what they need.  While this has been shown to be clinically effective in many cases, it may not be the best choice for BPD patients.  DBT emphasizes patient agency.  There’s extra value in having the patient take ownership of their care that case management or overly paternal approaches from the therapist can rob them of.

In general, the goal is for patients to speak up for themselves and only have healthcare workers (case managers or therapists) step in when the patient isn’t capable of supporting their own care – and only until this can be resolved.  Every patient should be capable of advocating for themselves, they just need to be shown how to do it.

Friends and Family

Virginia Satir in The New Peoplemaking and The Satir Model explains the family systems that can keep someone stuck in a dysfunctional pattern.  Rather than focusing on one person’s behavior, the model encourages us to look to how the system reinforces certain behaviors and discourages others.  (See also Thinking in Systems for a primer on systems.)  This highlights the powerful allies – or saboteurs – that friends and family can be when someone is making changes.

Change or Die points out that many successful substance use change programs intentionally change the environment that surrounds the addict to encourage positive behaviors.  Kurt Lewin said that behavior is a function of both person and environment.  While you’re working to change the person, you can change the environment.  (For more of Lewin’s work, see A Dynamic Theory of Personality and Principles of Topological Psychology.)

Hospitalization

The sad reality of hospitalization is that it isn’t for the patient.  It’s for the provider.  They get to pass the buck and make someone else responsible should a patient die.  The problem is that no one has ever shown that inpatient hospitalization is effective.  On the contrary, we know that the period of greatest suicide risk is immediately after being discharged from an inpatient program.  So why do many providers still subject patients to hospitalization?

The risk of suicide becomes too great, and they panic.  They decide that they’re not throwing away their career because they can’t be certain a patient won’t attempt suicide.  As a result, they give up.  They decide that they’re not capable of helping the patient through Cognitive Behavioral Treatment of Borderline Personality Disorder.

Book Review-The Suicidal Person: A New Look at a Human Phenomenon

Understanding the suicidal person is at the heart of prevention.  If you don’t understand them, how can you help them?  The Suicidal Person: A New Look at a Human Phenomenon examines the suicidal person while retaining their humanity.  Instead of simplifying them to a mental disorder or relying on a formulaic, linear set of cause and effect for suicide, it examines what in our humanity makes us susceptible to suicide.

Beyond the Medicine

Konrad Michel was trained as a medical doctor.  He was indoctrinated in the medical model, yet he also recognizes its limitations.  Certainly, biological systems can – and do – interfere with the proper functioning of the mind, but there’s more to it than that.  There’s more than a simple machine on a mobile frame to our consciousness and humanity.

Experiencing the suicide of a patient early in his career, he was left in silence to process the experience without the support of those around him.  No conversations.  No discussions.  No review.  Just silence.  He was left with a sense of guilt at the failure to protect his patient.

The implication was somehow that he should have known and prevented it.  This is despite the general acceptance that there are two kinds of people working in mental health: those who have experienced a suicide and those who will.  The probability is certainly strong that an active professional will experience this kind of loss.

His Own Son

Michel acknowledges the loss of his own son.  An expert in the field of suicidology couldn’t protect his son from the thing that he was seeking to prevent.  Some would be quick to judge Michel.  I, on the other hand, am quick to laud his bravery in sharing this very personal tragedy.  It takes courage to admit that you don’t have control and to share your hurt.  (See Find Your Courage for more on courage, and Compelled to Control for the limits on control.)

I know firsthand that you can’t control the trajectories of your children.  (See No Two Alike and The Nurture Assumption for more.)  One of our children triggered our journey into understanding burnout by demonstrating just how little control we had in preventing his questionable decisions.  (See https://ExtinguishBurnout.com for the resources we compiled on burnout.)

Reasons to Be Depressed

Just because you have a reason to be depressed doesn’t mean that you should be.  Read that again.  There are two pieces to it.  First, everyone has reasons to be depressed if they really focus on it.  Perhaps you’re not tall enough, handsome enough, rich enough, smart enough, or athletic enough.  Maybe you’ve been betrayed.  Maybe you’re worried about a layoff – or, if it’s already happened, how you’re going to find a job again.  We’ve all got plenty of reasons to be depressed – but not all of us are.  (See Hardwiring Happiness for tools to escape this negative framing.)

Second, depression isn’t a state you want to be in if you can avoid it.  The results of depression are worse health or death.  Suicide is correlated with depression – though not everyone who has depression dies by suicide, nor does everyone who dies by suicide has depression.

There are some people who have every reason to be depressed.  They’re struggling to make ends meet, and they’re happy.  They’re working 60 hours a week to pay for their kid to get through college.  They’re caring for an aging parent.  All these burdens, yet they don’t descend into depression.

It’s not as easy as simply deciding not to be depressed.  There are real reasons both physiological and psychological why people are depressed – and there are things that can be done to reduce the chances for depression – and to move away from it if you’re there.

Reasons for Suicide Attempts

John Bancroft created a simple survey to assess reasons for an overdose.  He gave the survey to health care providers to predict what happened and to people who had overdosed (and had obviously survived).  The differences between the two groups were striking and reflect the pejorative way that these health care providers see patients who’ve overdosed.

56% of the patients selected “The situation was so unbearable” – and none of the providers did.  They missed out on the fundamental reason for the overdose.  Similarly, patients endorsed “Lost control and don’t know why” 27% of the time while none of the providers did.  The health care providers saw the overdose as a manipulation based on the 71% of providers who endorsed “To make people understand how desperate you felt” when patients endorsed it only 20% of the time.  Similarly, providers endorsed “To influence someone to change their mind” 54% of the time while their patients only selected the item 7% of the time.

Part of this discrepancy may be driven by the sense that provider assessments are “objective” where patient assessments are “subjective.”  As a result, most physicians don’t ask for reasons and seek to understand the outside factors.  Techniques like Motivational Interviewing have made it clear that this isn’t the right strategy – but the message hasn’t reached mainstream medicine.

State of Mind

There are many who believe that it takes a great deal of strength to override the natural aversion to self-termination.  However, this isn’t a single thing that must be overcome.  There is the first barrier of self-harm.  For some, they’re quite willing to harm themselves as evidenced by the number of people who use cutting as a way of coping with their emotions.  The dynamics of this are complicated.  In some, if not many, cases the person has learned that emotions are unsafe and, as a result, have suppressed them.  The result is that they feel numb and recognize that they should be feeling something.  Cutting generates a pain sensation that signifies that they can still feel and generates some sense of safety and control.

The second layer is a willingness to extinguish the flame of their life.  This does take a different conviction.  It requires a degree of certainty that suicide is the right answer, one that is often generated by an altered state of mind called “cognitive constriction” by Shneidman and others.  (See The Suicidal Mind.)  David Kessler in Capture takes a larger and more nuanced view, where the state is more than just constriction but also reinforcement of the ideas.  Caught in a loop, individuals become more convinced of their beliefs.  Cass Sunstein, speaking of extreme positions, expresses the same sense of reinforcement in his book, Going to Extremes.

This state of mind change may explain why, when asked who could have helped before a suicide attempt, 52% of people said “nobody.”  Suicide is often described as an “unbearable” state of mind.  The person believes that there is no hope.  (See The Psychology of Hope for more on hope.)

Triggering Suicidal Modes

Michel believes in the creation of a suicidal mode that can be triggered.  It’s the activation of this suicidal mode that puts patients at risk.  Suicidal mode is that state of mind where suicide seems like the right answer – and where access to means may result in tragedy.  The triggers to enter that state of mind are varied.

Looking at this from the perspective of M. David Rudd’s fluid vulnerability model of suicide, as described in Brief Cognitive-Behavioral Therapy for Suicide Prevention, we see that there’s a baseline risk and an acute risk following an event.  What’s not defined well is what that trigger is.  Certain things can reliably identified as potential triggers – job loss, death of a loved one, divorce, etc.  However, even in the presence of these events, many people don’t enter a suicidal mode.

The key to the distinction (in my view) is trauma.  Trauma, as explained in Trauma and Recovery, is a temporarily overwhelming event.  What is overwhelming is different from one person to another for two reasons.  First is the coping capacity of the person.  Peak, Antifragile, and The Rise of Superman speak of what humans are capable of – and the conditions necessary for them to develop skills of any kind.  The skills to compensate for a wide variety of potentially overwhelming events are no different.  For instance, someone who has developed anti-loneliness skills (generally speaking, connections) will be more resilient after a death than those who have not.  (See Loneliness for more.)

Second (and equally, if not more, important) is that the way that each person is impacted by an event – the degree to which they connect with it and feel it – is shaped by who they are separate from their coping capacity.  Consider an adult who has an avoidant insecure attachment style.  Generally speaking, they’ll be impacted less by a divorce because they expected it.  (See Attached for more on the avoidant attachment style.)

Also consider how seeing a dead animal along a roadside might trigger someone if the animal looks like their beloved childhood pet; though long gone, they remain in the person’s memory.  For most, a dead animal along the roadside is an unfortunate occurrence.  When connected with the death of a beloved childhood pet, it may itself be triggering.

From a prevention point of view, this is problematic.  Certainly, it’s difficult on the outside to know what might connect with a person and traumatize (or retraumatize) them.  It’s even more troubling to know that often people don’t know themselves what may trigger them.  It could be a passing smell of their grandma’s perfume or the smell of cedar as they remember walking into her closet.

Unhelpful Healthcare

One of the persistent challenges with suicide prevention is that individuals don’t feel safe expressing their suicidal thoughts.  They don’t feel comfortable sharing it with friends because of the belief that they won’t understand or the perceived burden it would place on them.  They don’t share their thoughts with healthcare providers for similar and different reasons.

They may consider that healthcare providers have “real” problems to deal with.  They don’t need to be bothered by some troubling thoughts.  On the other side, they may have an unfortunately real fear that the professional they’re talking to might “lock them up.”  Involuntary commitment solves the anxiety of the healthcare provider while denying the person with suicidal thoughts of their personal liberties.

Either way, the trust that would be necessary to disclose suicidal thinking isn’t high enough in many cases for friends – and especially for healthcare considering the threat of loss of liberty.

Rethinking Risk Factors

Michel makes the point that too many people believe that risk factors are prescient instead of recognizing them as statistical reductions from a sea of former data.  Mutual fund advertising often includes the disclaimer “past performance is no guarantee of future results.”  Similarly, just because someone does or does not have risk factors for suicide doesn’t indicate whether they’re personally going to die by suicide.  Craig Bryan makes this point clear in Rethinking Suicide where he uses a car accident analogy.  Teenagers are more apt to have an accident – but we don’t know which ones.

Certainly, to be responsible we need to consider the risk factors and mitigate those where possible, but some demographics are unchangeable.  It’s a good thing to address food and shelter insecurity.  It helps to provide proven treatments for depression.  There are things we can do – but whether we do or not is no guarantee of a specific outcome.

If we want to save people, we need to look for the person in The Suicidal Person.

Book Review-The Perversion of Virtue: Understanding Murder-Suicide

The numbers are vanishingly small.  Murder-suicide accounts for just 2% of suicides, themselves numbering around 14 per 100,000.  Still, every death is a tragedy, and because it’s a tragedy it deserves study and understanding.  In The Perversion of Virtue: Understanding Murder-Suicide, Thomas Joiner puts forth the idea that the order is wrong.  Not the order of the actions but the order of the thoughts.  He posits that a person first decides on suicide then decides – based on a perverted sense of virtue – that another or others should die.

The virtues that Joiner proposes as the drivers are mercy, justice, duty, and glory.  People, he proposes, pervert these virtues to match their frame of the world in a way that ends in murder.  Simply, if I should die (by suicide), they should die as well (by murder).

Columbine

The tragedy at Columbine High School unfortunately opens the chapter of school shootings, even though it was always intended to be a tragedy of bombs, which malfunctioned.  (See No Easy Answers for a different perspective on the tragedy.)  The stories coming out of Columbine were varied.  Some argued that the boys, Eric Harris and Dylan Klebold, were bullied.  Joiner argues that they were not particularly singled out, and that their motive was glory.

They had decided on suicide but thought it would be great to go out in a “blaze of glory,” like Timothy McVeigh.  McVeigh bombed the federal building in Oklahoma City, killing 168 – including some from the on-site preschool.  (See The Oklahoma City bombing.)  There were more people than that in their school.  Perhaps they could “break his record” and go down in history.

Luckily, due to the bomb failures they didn’t kill more than McVeigh.  They did, however, become synonymous with school shootings and will remain in the history books for a very long time.  This is much to the chagrin of their parents, who continue to try to understand how their precious babies could become killers.

It is at the very least plausible that they had first decided to die and then decided to turn it into a moment of glory, absolutely.  It lends the first bit of credence to the idea that perhaps murder-suicides happen when one believes they have nothing left to live for – and then they realize that societal norms no longer need to apply to them.  After all, what is someone going to do, kill them?

Demographics and Statistics

Interestingly, demographics of perpetrators of murder-suicide more closely resemble suicide victims than murderers.  (I use suicide victims, because while they are a perpetrator, they’re also a victim of suicide.)  Also, murder-suicide tends to follow the weekly cyclic pattern of suicide – peaking on Monday/Tuesday rather than of murder, which peaks around Saturday/Sunday.

Timetables

Joiner criticizes the coupling of murder-suicide based on the timeframe.  In essence, the argument breaks down to the reality that any chosen timeframe would be arbitrary.  He is, of course, correct.  It would be arbitrary.  The line between a day, two, or ten is based on what seems to be reasonable.  It’s no different than the suggestion to see a primary care doctor every 12 months.  There’s no research to say whether 11 months or 13 months would be a better answer.  A reasonable starting point was proposed, and we’ve stuck with it.

The arguments extend into intent at the time of the murder.  Did the person intend suicide at the point of the murder, or did suicide become the answer on the basis of foiled plans?  It’s an important – but difficult to identify – distinction.  To get to suicide, we must infer intent – but here we have to infer the timing of that intent, and that feels doubly hard.

Killing

Joiner also emphasizes the difficulty with which someone kills another of their own species.  Hitler and the Nazis accomplished this by changing the perception of Jews to being sub-human.  If they’re not human, then the built-in prohibition to killing your own species didn’t apply.  (See Moral Disengagement and The Lucifer Effect for more.)

In wars, it’s well-known that opposite sides frequently engaged at close range without losses, because neither side would direct sufficient effort to killing an opponent.  Unfortunately, this often breaks down when one person kills someone on the opposite side, and the powers of protection and vengeance take hold and cause them to return fire.

It explains how a man could climb out above the trenches, holding up his trousers with one hand and carrying a message in the other, and make it without being shot – perhaps without even being shot at.  If someone comes to protect their way of life from “others” like fascists, having a very human problem like keeping their trousers up breaks the illusion that they’re something different from us.

Shoots and Kills the Officer

It’s like the news story, “Man Bites Dog.”  It’s the opposite of what you expect.  There are few situations where it’s clearer that an officer is authorized to use lethal force than when the person they’re speaking to is pointing a firearm at them.  There is a clear, intentional threat.  They’re within their rights to pull the trigger of their gun and injure or kill the person threatening them.  However, Joiner points out that there are several law enforcement officer deaths each year that are the result of such a standoff.  The officer issues the order to put down the gun, the person doesn’t, and ultimately shoots and often kills the officer.  What is difficult about these situations is why didn’t the officer shoot?

Joiner’s argument seems to be that they’re unable to take another’s life – even when their own is in mortal danger.  It’s a plausible explanation.

The more interesting societal question, for me, is that we’re dealing with excessive police violence against citizens – and, with these as examples, it appears the opposite is true as well.

Desire and Ability

It’s quite possible to desire something and to be unable to get it.  It’s easy to imagine a desire for a sports car or a large house and not be able to afford it.  Joiner uses the same approach to explain why people who want to die by suicide might not be able to accomplish it at a given moment.  In these cases, their desire becomes latent until a situation where the desire remains and means become available.

Here, it’s important to recognize that, overwhelmingly, the research suggests that few people will switch suicidal means once they’ve decided.  If they decide to jump from the Golden Gate Bridge, not only will they not switch to hanging as a method, they’ll likely not find another bridge.  (That’s why it’s so great that we finally have anti-suicide barriers on the Golden Gate Bridge.)

This gap may hold back many who’ve decided on a means that is not readily available.

The Disagreements

I started reading The Perversion of Virtue to gain further insight after disagreeing with Joiner’s book, The Varieties of Suicidal Experience.  I find I still disagree with him about 100% of suicide victims having mental illness.  I still disagree that every suicide leaves detectable signs.  “Impulsive” from the perspective of having never thought about suicide before an attempt isn’t a reasonable standard when up to one-third of people have had suicidal thoughts in their lives.

Still, there’s something to the state of mind that people can get into.  (See Autopsy of a Suicidal Mind and Capture.)  It could very well be that murder-suicide is suicide followed by The Perversion of Virtue.

Book Review-The Varieties of Suicidal Experience

Perhaps the hardest thing that I must do in my professional career is disagree with those whom I deeply respect.  In The Varieties of Suicidal Experience, I find that Thomas Joiner sometimes takes positions that I don’t believe fit the evidence – and I believe that there are important insights to be learned.  This is not the first of Joiner’s books that I’ve reviewed.  Why People Die by Suicide and Myths about Suicide are both his.  As I started my reading on suicide, they formed critical foundations for what I believed.  Let me start with the disagreements and move on to the insights.

Suicide and Mental Illness

Here, Joiner states, “I insist that any and all suicidal behavior is a manifestation of at least one mental disorder of some kind and of some above-zero level of acuity, an important and debatable point.”  (Acuity is the severity or complexity.)  The issue I take with the statement is that it is stated with an absolute nature.  It’s not most but rather all.

Some of Joiner’s research reviewed an old study done by Eli Robins at Washington University in Saint Louis.  The study was done in 1956 and 1957 and used 134 deaths.  The original research fell well short of the 100% mental illness that Joiner proposes, but his reevaluation of the data moved people from no discernable mental illness to having a mental illness.  This makes me feel uneasy.  The original researcher, one who did the first retrospective study approach that Shneidman would later call “psychological autopsy,” would seem the best positioned to evaluate his data.  As a sidebar, Robins’ work was roughly simultaneous with Shneidman’s work, so while Shneidman is credited with the approach, it’s perhaps best stated that it was simultaneously discovered or invented by Robins.  (See also Autopsy of a Suicidal Mind.)

There are two nits with the whole discussion.  The first is, what does Joiner mean by a mental disorder above zero-acuity mean? Second, why does this all matter?  To the first point, most psychological diagnoses require some set of conditions and/or duration.  What Joiner is saying is that there are signals – but they don’t rise to the level of an official diagnosis.  That requires understanding the difference between actionable signals and noise.

Signal processing (and the artificial intelligence that, in part, builds on that work) recognizes that everything has some part of what you want – the signal – and some part of what you don’t – the noise.  The goal in signal processing is to isolate the signal from the noise.  We’ve developed numerous techniques to do this – and I routinely use tools that implement them when producing videos.  However, this relies on the ability to distinguish the signal from the noise, and that’s not so easy.

Let’s assume the threshold of sensitivity for suicidal ideation is someone who no longer finds joy in things they once enjoyed (anhedonia).  It’s a key marker for depression.  As markers go, it’s a pretty good one.  However, the problem is that nearly everyone has experienced it – at least for a short time – at some point in their lives.  They’ve gotten bored with a hobby and either put it on pause or have given it up.  If we use even this very important signal as our minimum bar, we essentially flag everyone as having the kind of mental illness that Joiner is proposing.

So why does it matter?  Well, there are a few answers to this, but they revolve around the impact it has on people – both those left behind from a suicide loss and those considering it.  For those considering it, it establishes a shame cycle.  For those considering suicide, the thinking may be, “If I’m considering suicide, then I must have a mental illness – and I should be ashamed of that.”  I don’t believe that considering suicide means you have a mental illness – research points to one in three of us will at some point in our lives.  Nor do I believe being ashamed of a mental illness is fair or right.  Whether this is rational or not isn’t the point.  As Capture points out, it doesn’t have to be rational in a broader sense to make sense to the person in the moment.

For those left behind, they’re left with the belief that they missed something.  If the person had a mental illness, then it should have been detectable, and they should have seen it.  They missed it, so they’re responsible for their loved one’s death.  Let me be clear: this isn’t the case.  However, it’s the thoughts that many loss survivors have repeated to me.

Suicide Predictability

Joiner, perhaps rightly, takes issue with those that say predictability of suicide screenings is little better than a flip of a coin.  (I’ll admit I once had a room of suicide prevention-interested people flip a coin to make this exact point.)  The problem is that, while Joiner’s literal point is true that predictability is over a 50/50 split, it’s not by much.  He quotes George Murphy from 1972 as saying, “From the numerical standpoint, the prediction of no suicide in every case would be highly accurate. … It would also be entirely unacceptable clinically.”  This is the problem as Craig Bryan aptly points out in Rethinking Suicide. That is, it depends on what your goal is. If your goal is accuracy, then identify no one.  If your goal is prevention, you’ll need to identify (hundreds of) multiples of the people who would die by suicide.

He explains that we can’t predict the number of people who are going to be in an accident individually – though the statistics allow us to estimate the total number.  That’s what we have with our research, tools, and predictive models.  We can predict a rate within a population, but what we really want, what we desire more than anything else, is to be able to know who might die so we can intervene.

The tools we have now are excessively sensitive.  That is, they say that people are at risk when they are not.  The result is that we flood the mental health system with people who aren’t suicidal.  Lisa Horowitz at the National Institutes of Mental Health (NIMH) has argued that these people need help, too – even if they’re not suicidal.  I’m happy to accept this on face value.  They do.  However, the unresolved problem is whether they need it more critically or acutely than others.  The answer is no – and we’re back to the problem of prioritizing our available mental health resources to those with the greatest needs.  So, the harm in relying on screening tools for individual prediction is that they don’t work, and they flood the mental health system with patients who, though deserving of services, aren’t the most critical.

Joiner continues the discussion with, “In ‘reasoning backward,’ we have saved millions of lives by learning from specific events like car and plane crashes, though it remains difficult to prospectively predict individual accidents.”  This is quite right.  However, it’s also very different.  In the case of automobile accidents, the greatest gains came from a set of design decisions and approaches, as Ralph Nader points out in Unsafe at Any Speed.

We’ve poured untold millions into programs to encourage seatbelt usage over 50 years.  We’ve made amazing progress.  However, we’re still only seeing the low 90s percent utilization of seatbelts (based on miles traveled, information from the US Department of Transportation).  My point is that when it comes to changing human behavior – or understanding it – it’s not as easy as it seems.  I’m not convinced that the screening activity actually points to anything useful – and I’d rather see us invest our energy on potentially more useful strategies.

Suicide and Impulsivity

Joiner also puts forth the idea that no suicide is truly impulsive.  Specifically, he states, “A key refrain of this book is that suicidal people know what they are doing even if they do not reveal it to others, and that this applies with equal force to phenomena like murder-suicide, suicide-by-cop, and so on.”  Later, he says, “Some believe the main mechanism involves impulsivity—more specifically, that an impulsive resort to a lethal method may be prevented by distance from that method, allowing the impulse to pass. Perhaps occasionally this is so, but the role of spur-of-the-moment processes in lethal suicidality is dubious.”  What does this mean?  There is at least some allowance for impulsivity, but Joiner’s perception of the frequency of the phenomenon is radically different than the research.

Though there are many different studies with different rules, timings, and results, there’s more than a few interviews of suicide attempters (who didn’t die) where the large proportion hadn’t considered suicide prior to a few hours before their attempt – on the order of 70%.  Joiner properly criticizes the structure of some of these, because their questions were leading towards the answer that they hadn’t considered suicide.  However, other studies record rapid and dramatic fluctuation in suicidal thought intensity.  I’ve seen no evidence that this shouldn’t apply to people with no suicidal thoughts rapidly developing them.  In fact, Craig Bryan in Rethinking Suicide recites a personal story of a Marine whose suicidal thoughts came on quickly and intensely.

The other argument is that the attempter studies necessarily don’t precisely represent those who died by suicide.  I concur.  There will be some gap between those who have died and those who lived.  That being said, I don’t know that I can move the needle from majority (~70%) to a rare event.  Of course, we can’t know – but that’s a lot of movement when the impact of living versus dying is so close.

What I suspect may be happening is WYSIATI – What You See Is All There Is.  (See Thinking, Fast and Slow and Incognito.)  The clinical experience of suicidologists will necessarily exclude all impulsive types.  The only people that suicidologists will see are those people who are concerned about their suicidality – or those for whom others are concerned about their suicidality.  Therefore, the “feeling” that suicidologists and clinicians will have is that it is a rare (or never) event.  As Taleb notes in The Black Swan, failing to see something doesn’t mean that it doesn’t exist.

Let All Flowers Bloom

Joiner explains that he’s concerned about places where researchers provide alternative theories and approaches.  He suggests a philosophy of “Let all flowers bloom.”  In short, let people do what they want and let the evidence decide.  Conceptually, I concur.  Let’s try things and hope to find answers.  However, structurally, I disagree.  Sometimes, flowers are weeds, and they’re choking off other approaches.

Perhaps the greatest example of this is the preoccupation with screening for suicide.  So many hospital systems, forced by The Joint Commission, are implementing suicide screening programs.  The Joint Commission accredits hospitals, and not being accredited isn’t a real option.  The Centers for Medicare and Medicaid Services (CMS) represent a substantial portion of the healthcare system volume.  CMS doesn’t require The Joint Commission accreditation – but they have said that it meets all the CMS requirements.  So, if you’re accredited, you pass CMS requirements.

The Joint Commission requires suicide screening, so it effectively becomes required for most hospitals – and almost all that want CMS patients.

The problem, as indicated above, is that the approach breaks the mental health system.  It makes it impossible for the system to take care of patients who need care, because it’s flooded with patients who aren’t in crisis or even acute need.  (If you don’t believe this, call a random mental health and ask them how long until you can get in to see them.)

Deaths of Despair

Joiner makes the point that his arguments overlap those made in Deaths of Despair and the Future of Capitalism and Bowling Alone.  I’d add to these Loneliness and Social Forces in Urban Suicide.  At the root of this is the sense that people die by suicide because they’re alone and suffering.  However, despair isn’t evenly distributed.  He explains that the suicide rate in the world has generally been trending down, while that in the United States has climbed.  He did acknowledge that the US rate fell in 2019 and 2020.

I think it’s important to note that the relationship suicide rates have with turmoil is complicated.  It would surprise no one that suicide rates during the Great Depression were multiples of our current rates.  It might be odd, however, to consider that, during the World Wars, the rates seem to have been lower.  It seems that the focus on unity and helping others has a stabilizing effect.  This won’t surprise people who’ve been through a twelve-step program, as they’ve seen how those who serve others are more likely to succeed in the program.

Alcohol

Joiner explains the similarly complex relationship that suicide has with alcohol.  Many people believe that alcohol is implicated in most deaths by suicide, but that’s not the case.  In multiple studies, more than 60% of people don’t have any alcohol in their system at the time of their death.  That doesn’t mean that the remaining were intoxicated, but rather they only had some alcohol in their blood.

Contrast this with the longer term, and we can understand the perception that alcohol plays a larger role in suicide.  The problem with looking at the longer term is that there are interferences caused by socioeconomic factors.  A non-functioning alcoholic loses relationships, employment, and shelter.  Thus, when analyzing the impacts of long-term alcohol use, it has an effect – but at least in part because of the other outcomes of alcoholism.

Alcohol isn’t unique in this regard and in fact may be a slower, more muted driver.  As The Globalization of Addiction and Chasing the Scream both explain, other substances have similar downstream impacts.  Observationally, I’d say that they often occur much more rapidly.

Barriers Loom Large

While dismissing impulsivity, Joiner argues that suicide is difficult, and therefore even small barriers loom large in suicide prevention.  (See also Nudge for small barriers.)  Studies have shown that delaying access to or blocking suicide means reduces deaths.  Specifically, barriers on one bridge reduce the deaths at that bridge and don’t transfer those deaths to other bridges.

The public often believes there’s no point in blocking an attempt or access to a means.  After all, they’ll just find another way, they argue.  However, the data doesn’t support that.  First, evidence from changing gas formulation in the UK and fertilizer formulation in Sri Lanka to make them less lethal point to little means substitution.  In the case of those who were aborted from their attempt on the Golden Gate Bridge, a substantial majority never die by suicide.  Even with the elevated rate of suicide by those with previous attempts, roughly 90% of those who have attempted suicide never die by suicide.

It’s no secret that we fear death.  Whether we want to call it an evolutionary imperative to live or simply accept that most people fear death, the data supports our desire to live.  (See The Denial of Death and The Worm at the Core for more.)  Joiner rightly asserts that overcoming this bias towards life isn’t easy.  It’s important to counter a myth that no other species have individuals dying by suicide.  That’s simply not true, as there are numerous species with various forms of self-termination that occur at rates well better than chance.  (See Why Zebras Don’t Get Ulcers for some examples.)

Murder-Suicide

Joiner asserts that murder-suicides should be thought of as suicides that decide to include murder rather than murderers who decide to die by suicide.  The framework of the argument is that people are suicidal, and then decide that it would not be fair to leave others around – either because they harmed the person or because it’s unfair to leave them in such a cruel world.  He cites the review of mass murders in Columbine, Aurora, and Parkland as examples.  (For more on Columbine, see No Easy Answers.)

This is an interesting argument – however, the number of murder-suicides that we face as a society is vanishingly small.  They’re tragic – but they aren’t frequent.  Generally speaking, it’s 2% of suicides.  When we’re already dealing with a number that’s 14 per 100,000, that is a very hard number to get good data on.

Staring Down Death

One interesting, sub-clinical, indication of suicidal intent is a lowered blink rate.  It seems that people who have suicidal ideation blink at a rate slower than the general population.  While this is an interesting correlation, there are many other causes for a lowered blink rate, and therefore it may not be particularly useful as a screening for suicidal ideation.  Joiner states that it is as if “they were in a sense staring down death.”

Suicide by Cop

The first time I heard the phrase “suicide by cop” was decades ago.  I was watching a news report with my brother-in-law, and he said it casually but also as a matter of fact.  He was a lifelong law enforcement officer.  I can’t remember the details of the event, but it wouldn’t surprise me if it were a man who brandished an unloaded firearm at an officer – forcing the officer to shoot.  Joiner explains that 14% of the weapons brandished to an officer were unloaded.

Final Exit

Joiner takes issue with an “exit guide” who helps guide people to suicide.  The guide in question seemed to be a part of the Final Exit Network – likely built on Derek Humphrey’s Final Exit work.  Certainly, we should not treat suicide as casually as we’d treat walking across the room.  However, simultaneously, we have to be careful about overarching statements that assisting someone in suicide is wrong.  Undoing Suicidism makes the point that we’ve gotten too paternal in our approach, and even in places where physician assisted suicide is an option, the constraints are prohibitive.

There are no clean answers here.  On the one hand, we have a responsibility to our brothers and sisters to ensure that their decisions that would remove them from our community of the living are properly considered.  On the other hand, we need to accept their right to make a choice.  I don’t know the answer here, but I do know that I don’t know the answer, just as I don’t understand all The Varieties of Suicidal Experience.

Book Review-Suicide Across the Life Span: Premature Exits

Suicide has changed across the millennia of human existence, and it is changing across generations.  Suicide Across the Life Span: Premature Exits walks us through what we know about both the history of suicide and how generations experience and interact with their unique suicide risks.

History

Before looking at modern generations and their suicide experiences, it’s important to recognize that suicide isn’t a new phenomenon.  As Stay, A Sadly Troubled History, and other books have done, Suicide Across the Life Span reviews known suicides throughout history – and the list is long.  When we’re reviewing suicide in the present, we need to acknowledge that it does have a long history that includes various kinds of exaltation and condemnation.

Generations

The other primary theme that works throughout the book is the concept of generations.  Most people are aware of generations, how they behave in similar ways at various ages, and how there are differences.  There are some relatively minor differences in the categorization of generations between this book and those used by Chuck Underwood in America’s Generations.  But the fundamentals are sufficiently similar that I won’t revisit generations separately here.

I will say that it’s the experiences generations have that creates their uniqueness, and therefore generations are only slightly generalizable across national boundaries.  The public events that move us and unite us are largely viewed from the perspective of nation.

Vampires

There were two behaviors to death by suicide that we’ve long sense abandoned.  One was dragging bodies behind carts, and the other was driving a stake through the heart and burying the person at a crossroads.  It strikes me that the community might have been aware of the suffering of the person and have been concerned that the person might come back to terrorize them.

Consider the fact that the way vampires were killed was to drive a stake through their heart.  It’s an interesting coincidence that those who died by suicide were treated with the same approach.

Suicidal Crisis Strength

It’s widely believed that most people who die by suicide go through moments of suicidal crisis.  Though there is some disagreement about the percentage of people who plan their suicide and those who are “impulsive,” research indicates that 71% of people who attempt suicide and don’t die hadn’t considered it more than 1 hour prior to their attempt.

As was explained in Capture, sometimes we get into states where there’s reinforcement of negative beliefs that are difficult to get out of.  However, when we do learn to get out of them the first time, we build our capacity to get out of them in the future.  Antifragile likens our gradually increasing capacity to how we grow muscles by first tearing them down and then, with sufficient recovery time, allowing them to be rebuilt stronger.

Rejecting the Positive

Someone tells you that you did a really good job.  They’re impressed.  You respond with “it was nothing.”  Perhaps you believe you’re being humble.  However, being humble isn’t about thinking less of yourself.  It’s about thinking about yourself less.  (See Think Again.)  Humilitas provides a definition of humility as “power held in service of others.”  In either case, the positive comment is like a rock skipping on a lake.  It doesn’t sink in that someone is sharing a presumably honest assessment that not everyone could have done what you did – whether or not you believe it.

Sometimes, our self-esteem can get so low that we’ll reject a positive remark as incompatible.  Instead of letting the positive comments sink in, we reject them.  We think, “they don’t really know me,” or “they don’t realize how easy it is.”  Sometimes, it might even seem like you’re an imposter.  (See Imposter Syndrome.)

Anxiety

It could have been ripped out of yesterday’s headlines.  “Anxiety seems to be the dominant fact — and is threatening to become the dominant cliche — of modern life.”  The problem is that it’s not from yesterday.  The quote appeared in Time magazine on March 31, 1961.  It predated the 500% increase in violent crimes that my generation, Generation X, experienced during their late adolescence and young adulthood.  It also predated the internet and social media.

We’ve seen a rise of suicide rates that are often attributed to our urban, industrial lifestyle with further changes that are elevating the rate of teen suicide.  Anxiety and lower self-esteem have been associated with social media use.  It seems as if the forces that are moving us to suicidal risk are getting larger than they’ve ever been.

Protective Power Limits of Love

We’d like to believe that we can protect those we love.  It seems like our love should be enough to prevent bad things from happening to them.  However, parents cannot protect their children.

Alcoholic Suicides

It seems like figuring out the relationship between alcohol and suicide should be straight forward.  However, it’s not as simple as it seems.  While alcohol use is a factor, there are many suicide deaths that don’t involve alcohol – and many more where alcohol is a part of the poison cocktail designed to bring about the death.  Disambiguating between alcohol being the cause or being implicated also has other issues.

Alcohol addiction, or alcohol use disorder, isn’t without its life complications.  That is, alcoholics tend to lose jobs, shelter, and relationships as a result of the alcohol.  If they subsequently die by suicide, is alcohol the direct trigger, or is it the loss of one of these other aspects of life?  The rise in mid-life alcohol-related suicides may be related to the consequences of alcohol use disorder becoming more prevalent in their lives.

Who Has Considered Suicide

The book asserts that 55% of the people in their survey acknowledged having considered suicide.  The data around this number is difficult to get, because people don’t want to admit it.  Studies range in their prevalence, with some putting the number somewhere between 1:3 and 1:6 people.

Jumping Out of the Basement Window

When trying to understand ethnic and racial disparities in the suicide rates, one realizes Caucasian people are most likely to die by suicide.  As Dick Gregory once said about the plight of minorities, “You can’t kill yourself by jumping out of the basement.”  Viewed from a different lens, one might look at the expectancies.  That is, minorities, in most cases, don’t expect that they’ll be wildly successful.  (I’m not saying it’s right, just saying it’s typical.)  As a result, they may have less turmoil when they encounter situations where they’re rejected or face loss.  For better or worse, they expect it.

Breaking Down Stigma

Suicide, while becoming more acceptable, still has a stigma attached.  (See Stigma for more about stigma in general.)  I was speaking with a friend about one of our mutual friends who lost her husband recently.  Our mutual friend wanted to make it clear that he didn’t die by suicide.  Clearly, there are still reasons for people to want to separate themselves from suicide and the stigma associated.

The book asserts that “survivors can be helped by breaking down the stigma attached to suicide. This can only be done by education.”  I certainly agree that education – and understanding – isn’t harmful, but it misses the essential point that stigma is, by its very nature, a lack of normalcy.  If we’re going to truly remove stigma around suicide, we have to stop believing that it’s abnormal and that someone did something wrong for them to want to die by suicide.  As Judith Rich Harris explains in No Two Alike and The Nurture Assumption, the factors that shape lives are too numerous to control.

Balancing the Witch Hunt and the Whitewash

When someone dies – from any cause – there’s a need to establish what happened.  It’s the reason why we do autopsies.  (See Postmortem.)  The problem is always the balance between relentlessly seeking a cause and assigning blame and the decision to stop the investigation before a cause can be found.  It’s another form of what Jim Collins calls the “Stockdale Paradox” in Good to Great.  On the one hand, we need to work towards finding systemic causes and what we can do better.  On the other hand, we sometimes must let go and accept that we’re not going to know the answer.

Without careful consideration of both the loss survivors in the moment and the need to find causal factors so we can eliminate them, we’ll never eliminate Suicide Across the Life Span.