Book Review-Suicide Clusters

Sometimes suicides don’t occur randomly across time and space.  Sometimes they seem to act like an epidemic or a contagion.  They start, and they drive more suicides than would be expected.  We call them Suicide Clusters.  In a previous review of Life Under Pressure, the authors took apart a single cluster trying to understand its causes and what could be done to stop the spread.

Suicide Clusters is more of a review of the suicide clusters that have occurred than an attempt to focus on how they form or what can be done to prevent them.

From the Start

It’s easy to believe that suicide clusters are a new phenomenon, but they appear to go back to at least the fourth century BC.  While there’s some question about the degree to which animals have the level of consciousness necessary to die by suicide, if we allowed that they did, there would be reports of mass animal deaths.  Aristotle was reportedly mystified by mass beachings of small whales that occurred routinely.

Death Myths

Some of what may make the contagion spread is a set of beliefs about death that aren’t realistic – and certainly can’t be verified.  There’s a belief that death is painless, but as Marcia Linehan says in Building a Life Worth Living, there’s no data to support that.  More broadly, some beliefs include the ability to observe others mourning the death.  The idea is that somehow someone can be dead and still be conscious, as if somehow death unmoors consciousness from the body.

Finding strategies for helping individuals challenge their beliefs about what death might mean – and particularly how it might be better – is an important deterrent to the development of suicide clusters.

Media Coverage

Much has been made of the impact of the media, including news reports, books, films, and TV series, on suicide rates.  These effects are real, and they are why there are recommendations for the media for how to report on a suicide death.  The short version of these guidelines is to not glamorize the death.

In Community

These are guides for how schools and communities can use to craft their responses as well, but these guides are often filled with contradictions that are difficult to navigate.  Finding a path that acknowledges suicide as a mode of death but doesn’t glamorize it isn’t easy.  Allowing meetings and memorials in ways that are consistent with other deaths seems easy, but it’s not.

However, the effort is necessary to help prevent Suicide Clusters.

Book Review-Therapeutic and Legal Issues for Therapists Who Have Survived a Client Suicide

The line went dead.  It wasn’t a client who had hung up but a colleague, but the news was no less ominous.  A client had died, and they had just finished telling the clinician.  At that moment, they realized they had no idea what to do next.  Therapeutic and Legal Issues for Therapists Who Have Survived a Client Suicide hopes to provide a map for what to do next.

Legal Advice

I’m not an attorney – and this isn’t legal advice.  I can, however, flag a place where an attorney’s immediate reaction of not talking to anyone is not always the best answer for the clinician personally or for the overall legal risk.  In Effective Apology, John Kador shares some of the research that indicates a simple apology can reduce medical malpractice.  The one thing that attorneys would tell you not to do is the thing that can make a big difference.

Some families will want to blame a clinician – and others will want to know that the clinician cares.  Engaging in the right way with the family, including honoring their wishes about participating or not participating in memorial services, can go a long way towards humanizing the experience and reducing the chances that they’ll blame the clinician.

The other piece of advice that attorneys will often share is that you not speak with about the situation with anyone.  The problem is that this cuts you off from your professional support resources at the very time you need them most.  It’s important to consider that your colleagues could be called into court – but what happens to you if you don’t have ways of processing the loss?

Forcibly Alive

There’s a narrative that some people have around suicide prevention that the clinician should be all powerful and somehow compel a patient to remain alive.  This is not truth.  In Suicide: Inside and Out, the ease with which someone could die should they be determined to was made clear.  Suicide contracts fell out of favor, because they weren’t effective at keeping patients alive.

The simple fact is that the individual is ultimately in control of their life and their death.  No third party can or should take that responsibility.

Suicide Doesn’t Mean You Did Something Wrong

In the aftermath of a suicide death, it’s easy to believe that you must have done something wrong.  It’s easy to confuse undesirable outcomes with a mistake being made.  Even in cases where it is possible to think that you could have prevented the suicide the one moment that it occurred, there’s no evidence that the outcome wouldn’t just happen in a week or a month.  We simply can’t know.

Our natural tendency is to want it to be something we did wrong so we can change it.  It’s so much better than thinking that we are sometimes powerless to stop it.

Supervision

Clinicians who are under supervision are particularly vulnerable to questioning their value and whether they’re in the right profession.  Often times, new clinicians are bought into the omnipotence of the profession and haven’t yet learned that there are some things that cannot be helped.

Unfortunately, some supervisors feel discomfort themselves as one of their supervisees loses a patient to suicide.  They question themselves, and they’re uncomfortable to the point where they don’t create the right kind of space to allow supervisees to process their grief, loss, and confusion.

The Search for Why

All people who are left behind a suicide death need to be able to figure out “why.”  We’re sense-making machines, and suicide is so senseless.  Whether family member or clinician, there is a very real need to determine why – and often there are no satisfactory answers.

Sometimes, the best we can do is be aware of the Therapeutic and Legal Issues for Therapists Who Have Survived a Client Suicide.

Book Review-Grief After Suicide: Understanding the Consequences and Caring for the Survivors

Is grief after the loss due to suicide different from grief from an accident or not?  How should we care for all those who are grieving including those who’ve lost due to suicide?  These are the questions that Grief After Suicide: Understanding the Consequences and Caring for the Survivors answers.

Ripples

Every suicide has ripples of impact on others.  Other people are impacted by the loss of another life.  One key question is how many people are impacted by a suicide.  There are two key challenges in answering this question.  The first challenge is understanding what we mean by “impacted.”  Do we mean that they have a kinship relationship – and how close of a kinship relationship?  Obviously, parents, children, and siblings count, but what about aunts, uncles, grandparents and cousins?  This leads to the broader group of those whom we have relationships with.  Perhaps one particular aunt is closer than the other.  Could it be that the nature of the relationship – or friendship – defines the impact of the suicide?  If that’s the case, what degree of friendship counts for impacted?

Taking a further leap, what about parasocial relationships?  This is the sense of connectedness we feel to celebrities and people with whom we have no direct relationship.  The research related to the deaths of Marilyn Monroe, Robin Williams, and many others makes it clear that many people feel impacted by celebrity deaths to the point of deciding to die by suicide.  Clearly, this has a substantial impact.

The challenge of where to draw the line has largely confined research to close kinship relationships, thereby substantially restricting the number of people considered.  Research does indicate that roughly 7% of the US population were acquainted with someone who died by suicide in the preceding year.  Some estimates of the number people were aware the death was a suicide put the number at around 425 people.  It’s still an average, but it’s something.

The second challenge is that the question presumes that every suicide impacts the same number of people.  The death by suicide of a homeless person without family may impact relatively few people – those people in their community and the medical staff that treated them.  Conversely, the celebrity deaths will have impacted substantially more people.  As Clayton Christensen explains in How Will You Measure Your Life?, averaging the data sometimes destroys important details.

Similarities and Differences

The research on the differences between a suicide death and a non-suicide death are mixed.  There are certainly differences, but they tend to fade with time.  Importantly, they also seem to disappear when we compare suicide deaths exclusively to accidental and violent deaths, suggesting that the differences in grieving are triggered by the unexpected or unexplainable nature of the death rather than the mode.

We are, as humans, prediction machines.  (See The Righteous Mind, The Blank Slate, and Mindreading.)  We seek to be able to predict our environment, our world, and our outcomes.  When our ability to predict fails, it often causes us to seek meaning, so we can update our views of the world in hopes of better predicting the future.  It’s not surprising that an event as large as a death would trigger us to reevaluate our belief about the world.

In fact, when we speak of trauma, we describe it as the connectedness between the person and the event – and the degrees to which it personally impacts us and requires reevaluating our fundamental beliefs about the world.  (See Trauma and Recovery and Traumatic Stress.)  Reevaluating our worlds due to trauma is intensively disruptive.

Guilt and Shame

The disturbing question for parents losing a child is how your child couldn’t endure the life you gave them.  Working backwards from the perspective of seeing suicide as the best solution to the pain they’re feeling (whether or not this is true, it was likely their perspective) we must face the fact that they felt that their life – the life that the parents gave them – was too painful.

The suffering cry from those who’ve lost their significant other to suicide is similar yet different.  They may wonder why they weren’t enough.  Why weren’t they enough to stay for – to endure for?

There are, of course, no answers to these questions.  What we can offer the bereaved is that they’re not responsible, and their loved one likely wasn’t considering their full life because their pain was too great.

Judith Rich Harris provides an exhaustive exploration of why parents can’t be truly responsible for their children in No Two Alike and The Nurture Assumption.  Basically, the argument is that we cannot control what they’re exposed to in the world and therefore can’t completely shape their development.  Additionally, there’s no way for us to foresee all the circumstances of their lives prior to conception.  The weathermen can’t predict the weather more than a few days in advance, why should we believe we can predict the way the world will be – for them – decades into the future?  The outcome remains a tragedy – but there is no way we could have known what the circumstances would have been.

Additionally, the body of research supports Shneidman’s assertion for cognitive constriction.  That is, at the point of suicidal crisis, people aren’t able to see beyond their pain.  They can’t see the joy beyond the cloak of struggle.  It may be that, on objective observation, life is more happiness than sorrow.  It can be that the logical mind can see the pot of gold at the end of the rainbow – but it’s not the rational mind that is driving the decisions of the suicidal person.

The logic of these arguments falls short of stopping guilt and shame from entering into the minds of those left behind.  They play the nasty game of “what if.”  What if I had just called them?  What if I went to visit more often?  What if I had done something, anything, to change the outcome?

Our minds, while marvelous, are limited.  We regret those things we didn’t do more than those things we did.  (See The Top Five Regrets of the Dying, Originals, and Thinking, Fast and Slow.)  Survivors are haunted by the decisions they made to protect their boundaries, their reserves, and their own needs.  What if that one thing they didn’t do was the one thing that would have made the difference?  Even if it was, there’s no way they could have known that at the time.

Guilt is that we’ve done (or decided) something wrong.  Shame is that we are bad.  When guilt stops being about the moment and becomes about us personally, we experience shame – shame that’s often not deserved.  (See Brene Brown’s work in Daring Greatly and I Thought It Was Just Me (But It Isn’t) for more on guilt, shame, and working through those feelings.)

Psychological Autopsies

One thing that can be helpful for families is a psychological autopsy.  Shneidman writes about a mother who reached out to him to do a psychological autopsy in Autopsy of a Suicidal Mind.  In a strange twist of fate, after reading my review, the mother who approached Shneidman reached out to me and let me know that the autopsy and the book were helpful to her.  Despite the value they can bring, I’m still skeptical of them, because I believe they can sometimes bring harm.  (See The Prediction of Suicide and Review of Suicidology, 2000.)

Nina Gutin explains in her chapter that psychological autopsies can feel like fact-finding missions instead of validating experiences for the clinicians.  What families may not be able to appreciate (having their own degree of cognitive constriction) is that the clinicians are hurting, too.  It’s not a comparison or a competition, but the clinicians were in a relationship with the deceased, and that relationship is now gone.

Despite the evidence to the contrary, people often start with the perspective that a clinician has done something wrong if a patient dies by suicide.  (See The Suicide Lawyers.)  The fact is that we’re lousy at determining short term risk of suicide by survey instrument or clinician judgement.  It’s not necessarily a clinician problem.  It’s a problem that our ability to predict is very low.  When a psychological autopsy starts with the assertion that the clinician must have done something wrong, it can be hurtful and unfair.

Right to Grieve

“It is not uncommon for suicide survivors to question their own right to grieve…”  It’s a foreign statement to me.  I feel like everyone has the right to grieve.  The research on emotions seems to indicate that holding back emotions can be bad.  Richard Lazarus in Emotion and Adaptation makes the point clearly that you can’t completely suppress an emotion – it’s still there.  In our work on burnout (see Extinguish Burnout), we traced the problem of not expressing emotions all the way to Freudenberger’s original work, Burn-Out.  Subsequent work, like Burnout: The Secret to Unlocking the Stress Cycle, gets the impact of emotional suppression right (while missing on the role of stress).

People will encounter fewer downstream consequences if they can find a way to let grief take its course.  Suppression generally ends badly – as White Bears and Other Unwanted Thoughts makes clear.

Inadequate Support

If you ask bereaved parents about the support they received post death, you’re likely to hear statements like “inadequate” or “chaotic.”  With the notable exception of the work of LOSS teams, most responses to loss by suicide are haphazard at best.  It’s rare enough that people don’t plan for it – and common enough that they should.

If your child was a member of the military, organizations like Tragedy Assistance Program for Survivors (TAPS) have support programs.  However, even learning about them isn’t guaranteed.  Disconnects prevent automatic introduction to the families that are grieving to the programs that can help them.  The lack of training and centralized resources means that it’s difficult to connect loss survivors to the resources that do exist.

Support Options

There’s no one thing that will be right for every survivor.  For some, having a counselor or clergy is right.  For others, the support group, which necessarily means that you’re not alone in having survived a tragedy, is best.  In a convenience sample of bereavement group attendees, the bereavement group edged out individual support by clergy or mental health professionals.  However, what was more interesting about the survey is the approximately 40% of people still attending bereavement (or survivors of suicide) groups 10 years or more after their loss.

Of course, it can be that these attenders are no longer actively processing their grief and are instead in the group for the community (framed as friendship and personal growth), or it could be that they’ve transitioned to leadership or quasi-leadership roles in the groups.  What is clear is that suicide loss radically changes the trajectory of lives – and, in some cases, those changes may be permanent.

Grief Overload

When a family (or community) faces the loss of a member, it intuitively stretches each member’s coping capacity to – or beyond – their limits.  At an individual level, this is well understood and accepted.  What isn’t quite so clear is the impact this has on the relationships between the people.  In a normative case, a person is impacted by tragedy, and those around them rush into help.  However, in the case of an overwhelming loss by a member of the network, no one has the capacity to help others – they’re working their hardest simply keep themselves functioning.

It can seem like the time people need it most that their network fails to support them.  This can be a frustrating and disorienting experience.  It’s only when evaluating the situation later that people can realize that it wasn’t that their network didn’t want to support them – it’s that they couldn’t.

Fear of Judgement

It’s no myth that people who are bereaved by suicide loss get less support from their friends and community than those of other death types.  It’s also no myth that survivors of suicide loss may self-censor.  Because of the feared judgement, they may not reach out and stay connected to their communities in the same way that survivors of other loss do.  The stigma of suicide sticks to the survivor like syrup.  (See Stigma for more on stigma.)

Clinician Conversations

It’s common for loss survivors to want to talk to treating clinicians.  Survivors often feel an overwhelming desire to understand why their loved one died by suicide; in that quest, a conversation with the clinician is something they find useful.  Clinicians are appropriately concerned about how the conversation will go both because they’re struggling with their own reaction and because the suicide death of a patient is reported to be the largest area of litigation.

In the United States, client confidentiality extends beyond death, but decisions about these confidential records can be made by the executor of the estate.  However, there is much that the clinician can say without impacting client confidentiality.

Clinicians are encouraged to be “fully compassionate” toward the family.  It’s appropriate to collect outstanding fees – but not aggressively.  Advice is shared about initial contact soon after the death to reduce the displacement of anger towards the therapist.  A later meeting, if requested, to allow for the family to organize their thoughts and questions can also be helpful.  Appropriate contact with the family has been shown to be helpful for the clinician’s healing as well.

It’s important to note that, while malpractice litigation may be the most common when there is a loss due to suicide, it doesn’t mean that every family intends to sue.  Many families are simply trying to understand and recognize that bad things happen even when no one has done anything wrong.  There’s no need to blame.

Communication and Exposure

There’s been a lot of information provided about how to communicate about suicide deaths – and how not to communicate.  However, most of this research is shaky at best.  While there is solid research that exposure to a suicide increases the risk for a subsequent suicide by the exposed person, there’s nothing to say that denying that a death was suicide has any impact on the exposure or the downstream consequences.

In fact, the broader research about substance use disorder seems to imply that the more openly and frankly we speak about a topic, the less we shame and stigmatize it. The results are generally a reduction in the undesirable behavior.  (See The Globalization of Addiction and Chasing the Scream for more.)  This is the same experience that we saw in teen pregnancy rates when we started more openly discussing sex and pregnancy in the US.  (Dr. Ruth Westheimer is well known for her frank conversations of sexuality.  Her latest book, The Joy of Connections, provides some context for this.)

My perspective is that much of what we say about how to communicate about suicide is flat wrong.  While well intended, it’s not supported by research and reinforces the very stigma and shame that we’re trying to eliminate.  Guidance that says to treat a suicide death different is hidden in the larger statements to treat all death the same.  The guidance for communication shouldn’t be difficult.  Don’t glamorize it or explain it as a way out of problems.  Don’t report or discuss unnecessary details.  Don’t blame it on mental illness, depression, family, or social pressures.  It’s as unpredictable as accidents – so treat it the same.  (See Rethinking Suicide for more on unpredictability.)

Leaning on Clergy

For many people, they have some sort of a religious experience that includes clergy – both professionals and lay-clergy.  The advice is to lean on clergy for support around grief and grief rituals.  The problem is that the clergy that I know feel woefully unprepared for a death by suicide and only marginally prepared for grief more broadly.  As an ordained elder (lay-clergy), my interactions with professional clergy has led me to realize that they receive only superficial training about trauma and grief and even less about suicide.

The separation of church and state often creates concern for communities trying to respond to tragedy.  Hopefully, greater partnerships between churches, community organizations, schools, and government can use all the resources available – whether they’re clergy or not.

The Tyranny of Hindsight

Perhaps one of the most difficult challenges that survivors face is the tyranny of hindsight.  Suddenly, the significant detail buried in a mountain of trivia burns bright as a star.  Suddenly, the decision to rest and recover seems like the wrong answer.  There’s no way to consistently find the one thing that matters in the middle of millions of details.  We can’t slow down life to make only correct decisions.  It’s not perfect, but what we may be left with is Grief After Suicide.

Book Review-Building a Life Worth Living: A Memoir

It’s rare that I’ll read a biography, autobiography, or memoir.  However, Marsha Linehan’s legacy in suicide prevention warranted a deeper understanding of her, and Building a Life Worth Living: A Memoir is certainly that.  She lays out her life and how she came to develop dialectical behavior therapy (DBT).  (See Cognitive Behavioral Treatment of Borderline Personality Disorder, and DBT Explained for more about the therapeutic approach.)

The Descent into Hell

Central to the amazing work that Linehan did was her own struggle and commitment to the Institute of Living – a psychiatric institution – for two years and one month.  Her experience there is a horrifying story of electroconvulsive therapy (ECT) and its abuse, which left gaping holes in her memory, and the solitary confinement that wouldn’t be allowed today – and wasn’t normal then.  What’s amazing is that, out of this, she became determined to do better by others.

Her work was motivated to increase the success of others – including their happiness.  She explains that you can’t describe hell – you can only feel it, experience it.  She didn’t want others to have this experience.

Beauty

A particularly poignant quote from her mother is, “Beauty is worth the effort it takes.”  While it was used in the context of making a home beautiful, it felt as if, somehow, it was the same with people.  Working your way out of hell takes work – an incredible amount of work.  However, the results are so remarkable that it feels like it’s worth the effort.  This is the response I get from the amazing people I meet who have been through hell and have chosen to climb out – and to help others either avoid the descent or climb back out.

In the Presence

Linehan describes how her father couldn’t tolerate her misery.  It’s, unfortunately, an all-too-common challenge that the time people need others most is when they find themselves abandoned.  It’s not just mental illness.  It’s seen in substance abuse.  Even families bereaved by loss – especially suicide loss – experience their friends, associates, and colleagues pulling back for a variety of reasons that are all rooted in discomfort.

Perhaps the discomfort they are feeling is that they’re concerned it will spread.  Maybe they’re uncomfortable because they believe they should have somehow, magically, prevented it.  No matter what the cause, it’s hard to develop the strength of character to be present when we are uncomfortable – and do nothing to solve it.

Doing nothing to solve it is important, because sometimes it isn’t “solvable” in the traditional sense.  Sometimes, we don’t have the agency to accomplish the change.  Sometimes, the answers on what to do to solve the problem aren’t clear.  Other times, we must rely on others and their expertise to help us through.  For problem solvers, like me, it’s hard to just be in the presence of a problem knowing we can’t solve it – yet it’s perhaps equally important that we learn how to.

The Institutional Paradox

When a clinician is confronted with an actively suicidal person, they have a few approaches.  Those who are trained can start a research-supported therapy like DBT, BCBT-SP, or CAMS.  (See Cognitive Behavioral Treatment of Borderline Personality Disorder for DBT, Brief Cognitive-Behavioral Therapy for Suicide Prevention for BCBT-SP, and Managing Suicidal Risk for CAMS.)  For those who are untrained, it’s often unclear where they should refer to, so they default to the emergency room – which often leads to institutionalization.

Most states have laws that allow for the detention of people when they pose a risk to themselves or others.  Someone with active suicidal ideation is often considered a risk to themselves.  Therefore, they can be deprived of their freedom and forced into an institution, where they can be forced to take psychoactive medications.

There are serious problems with this approach.  First, there are some people for which this strategy is appropriate.  However, there’s no research to support how many people this might be appropriate for – because there’s literally no research on the efficacy of institutionalization.  There is, however, research that demonstrates the highest risk of suicidal behavior is immediately following discharge from an institution.  (Typically, the first 30 days.)  There’s even some research that says that not all this risk is a result of the population.  It’s caused by the institutionalization process.  (See Myth: Inpatient Hospitalization Is Best for People with Suicidal Ideation.)

The problem is that untrained clinicians – which is most clinicians – don’t have much of a choice.  If they don’t refer the patient, they may get sued by the family.  (See The Suicide Lawyers for more.)  Referring the patient to the ER or to inpatient hospitalization may make things worse.  This drives clinician anxiety higher – and makes the referral even more likely.

It’s believed that part of the problem is that institutionalization takes away freedom, thereby decreasing hope.  If you’ve been institutionalized once, you know it can happen again.  (It tends to be easier for someone to be committed to an institution after it happens once.)  Many people who are struggling to believe that their life is worth living feel as if the world is being inflicted upon them and they have no control.  Removing what little control they do have is dangerous.

Valued as You Are

It was Linehan’s Aunt Julia who was the consistent voice saying, “We love you as you are and for who you are.  You do not have to change to be valued.”  These words would reverberate inside Linehan and ultimately break free as an awareness that clients needed to be validated for who they are, what they feel, and what they’re doing.  This isn’t to say that the change aspects of therapy could be ignored.  Rather, they had to be integrated.  This integration is at the heart of DBT.  Instead of trying to eliminate the tension by ignoring an aspect of the problem, it is necessary to find a way to hold two opposing ideas at the same time.

On the one hand, people are inherently valuable as they are.  They have the right to stay as they are.  On the other hand, when they are suffering, we’re pulled towards helping them to make the changes that will result in less suffering, more happiness, and thriving.

It starts with accepting the person.  It’s the foundation of therapeutic alliance.  (See The Heart and Soul of Change.)  You can only help those who are in a relationship with you – and that relationship is based on acceptance.  Change comes after acceptance.

Tenacity

Where did the tenacity it takes to persist through challenges come from?  How did Linehan survive the rejections, snubs, and barriers that presented themselves as she tried to find better ways for treatment?  Her answer is, “You just wait and see.  I’ll show you.”  People would tell her something was impossible that she knew to be possible – but perhaps difficult.  She’d determine that she was going to show them.

Sometimes, this tenacity required taking different directions.  For instance, her focus on borderline personality disorder was because it was a recognized mental illness for which there was funding.  Inside that space, she could work on suicide and get funding.  It’s a tangential approach that allowed her to accomplish her life mission while accepting the current funding conditions.

Not Fitting In

Of the things that I identified with in the book, the most important one is, “But not fitting in was something of a fact of life for me.”  I live in a state between worlds.  (See Straddling Multiple Worlds.)  This existence in multiple worlds means that I don’t fit into any one world completely.  While Linehan’s feeling of not belonging is different than the kinds that I experience, it resonates.

Getting the Help They Need

Sometimes clinicians, exhausted from their workload, complain that they don’t like their patients.  The reasons they provide are directly related to the reason the patient is seeing them.  It’s not fair or right to be frustrated with a client for the very reason they came to see you in the first place – but it is an all-too-common occurrence.

The truth is that people who are suicidal see suicide as a solution.  It’s a solution to some problem they perceive cannot be solved in another way.  In my review of The Cry for Help, I explained that suicidal thinking, ideation, and even attempts can be a cry for help.  It can be a warranted cry for help signaling that they need better solutions to their problems than the ones they believe are possible.

We can either approach people who struggle with suicidality as manipulative and trying to control others, or we can wonder what is it that they believe suicide is a solution to.  That perspective change makes all the difference when it comes to how we interact with others who struggle with suicidality.

Distress Tolerance

Life is suffering.  Buddhist teachings aren’t subtle on the point that we must suffer in this life.  (See The Trauma of Everyday Life.)  Christian beliefs are aligned with this as well.  They believe that Christ suffered to save us – that even he must suffer in this life.  Despite the relative consistency in the belief that life means suffering, we’re not always appropriately equipped and skilled to deal with the distress that is presented to us.

One of Linehan’s observations is that everyone has distress and the patients with suicidality appear to be limited in their ability to tolerate distress.  Part of DBT is teaching a set of skills that allow people to better accept the distress that is in their life.  It isn’t always easy to resolve the source of the distress, but it is possible to improve our ability to respond to it.

Consider the gradual building of skills that is advocated for in Nassim Taleb’s Antifragile or the amazing results that are possible through conscious practice as explained by Anders Ericsson in Peak.  In both cases, it isn’t that there isn’t distress, but rather there’s a goal at the end to become more capable of weathering the storms of distress as they come.

I’m careful here, because there’s a fair amount of discussion about resilience.  Technically, resilience is a return to a prior state after a stressor – and most people acknowledge that Heracles was right when he said, “No man steps into the same river twice.  He’s not the same man and it’s not the same river.”  Our goal shouldn’t be resilience but rather growth.  See Resilient and The Resilience Factor for more on resilience and Transformed by Trauma for growth.

What Nietzche said rings true: “He who has a why to live can bear almost any how.”  We can learn distress tolerance indirectly by learning why we’re living.  We can engender hope that our distress will pass if we’re willing to stay focused on why we’re still here.

A Life Based on Hope

Linehan says, “You can live a life based on hope.”  I’m reminded of the story of Pandora’s box.  Often, it’s seen as a story about how curiosity can end badly.  Pandora released all the evils of the world that were once contained in the box.  However, what is often missed is that there was one thing in the box with these evils.  That was hope.  Sure, hope didn’t emerge triumphant from the box and instead showed the strain of the sustained conflict with the evil in the box – but hope survived.  Hope was able to hold its own against all the evils of the world.  That’s impressive.

The challenge with hope, for some, is that it feels as if it’s some mystical substance that you either have or don’t have.  However, as Rick Snyder points out in The Psychology of Hope, hope is a cognitive process.  It’s an evaluation of both willpower and waypower.  Willpower is generally well understood, and Roy Baumeister’s book, Willpower, provides a more thorough explanation.  Waypower, however, is less commonly used and most closely resembles “know how.”  It’s the sense that you know there is a way for something to happen.  It can come in the form of blind faith in humanity or in a rough vision of what would need to happen.  Snyder asserts that when both of these are present, you’ll feel hope.

I’d like to extend and clarify that while Snyder doesn’t speak about whether the components need to be internal to the person or external from the environment, I believe that both are options.  It’s possible to believe that “God will provide” and thus have hope.  Conversely, you have the perspective of “I’ve been through worse before and survived,” which relies solely on internal tenacity and the sense of problem-solving skills.  In truth, it’s not probably ever one or the other but rather the relative degree to which one has faith in eternal sources and themselves.

She Said “Yes”

Linehan comments that she suggested that her tombstone should have the words “She said ‘yes’” inscribed on it and shares, “Meaning that I lived my life willingly, doing what God wanted me to do for the betterment of people’s lives and the world.”  In short, when the call came to do something, she didn’t turn away.

Brene Brown’s work in The Gifts of Imperfection focuses on the concept of wholeheartedness.  Conceptually, this is the same – fully engaging with life.  Brown’s work is built on the work of Harriet Learner, particularly from The Dance of Connection.  There are people who, under the pressures of life, cave in.  They crumble or retreat.  In Transformed by Trauma, Rich Tedeschi shares stories of those who have grown through their trauma – like Linehan.

Calling a Spade a Spade

There is something to be said for ritual and ceremony.  For instance, Arnold van Gennep in The Rites of Passage describes not just the kinds of rituals (rites) but also their importance for individuals and society.  In more modern terms, Raising a Modern-Day Knight shares that ceremonies can instill important values.  Even bureaucracy can have its place.  It can help to generate needed consistency.  However, there is also the need to be true.

The folktale, “The Emperor’s New Clothes,” provides this powerful lesson from the eyes of a child who could tell the truth without fear of being criticized for being stupid.  In over 30 years of consulting, I’ve seen plenty of ideas destined to fail with teams diligently working.  They’d fallen into “groupthink,” the word that Irving Janis popularized for when everyone fails to see the obvious, because they’re too wrapped up in the need for coherence to question what they’re doing in a truly honest way.

Linehan describes herself as naturally irreverent.  Perhaps that’s why she could maintain the courage to challenge the status quo and move us all forward.

Evidence of Pain in Death

Linehan explains that she would say to clients, “There is absolutely no evidence that you will feel better when you are dead.  Why take the risk?”  The mind-bending response challenges the inherent assumption that exists in the mind of the suicidal person.  The assumption is that death will mean an end to their pain.  Of course, no one can know what death will feel like, and therefore there cannot be evidence about what, if anything, people feel in death.

This kind of irreverence, and questioning the “unquestionable” assumptions, can be the very thing that people need to escape the cognitive constriction endemic of suicidal thinking.  (See The Suicidal Mind for more on cognitive constriction.)

Not a Zen Master

There’s a bit of paradox in becoming a Zen master.  On the one hand, you’re supposed to embody the Zen Buddhist who is detached.  Buddhists know that life is suffering and temporary.  It’s through detachment and acceptance that one can reach Nirvana – or, short of that, be a master.  However, there is a certain air of importance that comes with being a Zen master.  After all, it’s something that a candidate has been striving for.  That’s why a Zen master could offer sage wisdom while speaking to Linehan: “Marsha, you are the best teacher here.  Because you are the only one who does not care if you become a Zen master or not.”

Pausing for a moment, there’s a great compliment.  However, more importantly, the master identified the core factor that was leading to the results being complimented.  Because she didn’t care if she was a Zen master or not, it freed her to be more honest, open, transparent, and real.  She wasn’t attending so that she could achieve another accolade.  She was hoping to learn so that she could share that learning with others.  That is both amazing and at the heart of Buddhism.

Knowing to Accept

The other aspect of Buddhism is acceptance.  It’s learning to accept the world as it is – rather than insisting in beliefs that are inconsistent with reality.  Linehan states, “It is very difficult to accept reality with our eyes closed. If we want to accept what is happening to us, we have to know what is happening to us.”  It’s true, but it takes more than our eyes.  We must be open to experiences and accepting them for what they really are – whether we like them or not.  It’s not until we have a firm understanding of a solid foundation that we can begin the process of Building a Life Worth Living.

Book Review-The Myth of Sisyphus and Other Essays

It’s an odd book, but it’s often seen at the bottom of suicide prevention research articles: Albert Camus’ essay in book form, Myth of Sisyphus and Other Essays.  The myth is of a Greek hero who is subjected to rolling a boulder up a mountain, only to have it roll down from its own weight before reaching the top.  The relationship to suicide is opaque from the outside.  Inside, it’s about whether life has meaning – and therefore suicide interferes with that meaning.

Exit, Voice, and Loyalty

The book Exit, Voice, and Loyalty isn’t about suicide, but it has profound implications on understanding the way that people tolerate the intolerable.  It’s Hirschman’s work on the dynamics of corporations: it explains the option of leaving the organization, using your voice to make change, and the amount of loyalty to the organization that keeps you using your voice before exiting.

The model matches the kind of decisions that are made by those who are considering suicide.  While not every suicide involves a long period of contemplation, some do.  Exit is analogous to suicide.  Voice is the actions that the person takes toward resolving the pains and struggles in their lives that are driving them to consider suicide.  Loyalty is the force that keeps people trying to use their voice instead of exiting.

Death Is There as the Only Reality

A sentence caught my attention.  It made me wonder what it would be like if you only saw pain in your life.  What if you were so consumed by the sense of hopelessness and despair that it blotted out any joy and happiness?  As I read, and as I talk to people, I begin to sense this overwhelming sense of dread for the next day.  Others have called it cognitive constriction.  (See The Suicidal Mind.)

Of course, the reality of the matter may not be as bleak as it seems, but that doesn’t change the feelings of those who are captured by these thoughts.  (See Capture.)

The Best and the Worst

Just because one is reading a truly lousy novel doesn’t mean that all novels are bad.  We can’t discount the good in the world when we discover that not everything is good.  This is the binary thinking that creates struggle.  It’s not “either-or,” it’s “and.”  There is suffering and struggle but also soaring feelings of success and shared experiences.

Futile and Hopeless Labor

The story of Sisyphus is one of an eternal sentence to futile and hopeless labor.  Camus comments that the gods must have thought there was no worse fate than what they subjected Sisyphus to.  It is, of course, absurd to continue to try to accomplish something that you’ll never achieve.

There are ways that working at something can make you better.  After all, Anders Ericsson explains in Peak that purposeful practice can make anyone a master.  Edward Deci explains in Why We Do What We Do that we can be intrinsically motivated when we have autonomy (no one is telling us exactly how to do things), mastery (the belief we are becoming more capable), and purpose (what we’re doing has meaning in some small or large way).  These forces move us towards continuing the struggle with the hope that it will get better if we just persevere.  (See The Psychology of Hope for more on hope.)

The Other Side of the Stockdale Paradox

I first was exposed to the idea of the Stockdale Paradox in Jim Collin’s book, Good to Great.  He explains, “Retain absolute faith that you can and will prevail in the end, regardless of the difficulties, AND at the same time confront the most brutal facts of your current reality, whatever they might be.”  It’s the central dilemma for entrepreneurs.  Should they persist for the ultimate win – or fold early?  When it is time to give up on an idea or change it, and when should you “stick to your guns?”  There are stories of people who have been very successful after a moment of despair.  There are stories of those who have hung on as long as they could and still failed.

Ultimately, the problem with the Stockdale paradox is that it requires unknowable foresight into the future.  Instead, we’re constantly guessing at the right answer.  Prediction is difficult, as explained by Phil Tetlock (see Superforecasting), Nate Silver (see The Signal and the Noise), and Daniel Kahneman et al. (see Noise).  We’re never going to know the future with absolute certainty.

Those who are struggling against suicide are on the opposite side.  They’re not waiting for success and abundance.  They’re hoping for relief of the pain they feel is an inseparable part of living.  They’re in a constant battle between the parts of them that believe there is no hope and the parts of them that realize things are likely to get better – they just don’t know when.  Instead of looking for the next way to flourish (or thrive), they’re looking for the strength to make it through just one more day.

Sidebar: The Stockdale paradox is one of the most pervasive concepts I’ve encountered.  It shows up as a central conflict in so many fields and so many books.  (See books like Think Again, Rethinking Suicide, and Struggle Well for just a few examples of where this concept appears.)  It seems that knowing when to hold on and when to let go is one of the central struggles of life.

Crushing Truths

When Camus wrote Myth of Sisyphus, it was 1940.  It was the time before what I’d call the modern age of suicide prevention.  He was challenging the worth of life and therefore the legitimacy of suicide as a solution.  In the decades since his writings, we’ve failed to learn the essential lessons of suicide.

Much like the problem of stigmatization, demands, and ineffective approaches to the problem of drug abuse, suicide has gone down many bad paths.  We still live in an age where drug resistance programs that have been proven to cause harm are in use.  Most of the general public sees drug abuse as the problem instead of as a broader symptom of despair.  (See Deaths of Despair and the Future of Capitalism.)  Instead of finding out why people suffer and feel the need to use coping mechanisms that ultimately take control of them, we say that they’re weak or bad.  To be clear, addiction in any form is when a coping strategy starts to control the person.  This is true of narcotics, alcohol, shopping, sex, eating, or any other strategy that we use to cope with the slings and arrows of life.  For more on drug abuse and the myths, I’d encourage you to read The Globalization of Addiction, Chasing the Scream, and Dreamland.

As I write this in 2024, the US has released a new national strategy for suicide prevention that is substantially similar to the 2012 plan.  The crushing truth is that the national strategy in 2012 and all the suicide prevention work in the US was an utter failure.  I make this claim not subjectively but rather based on the data that the US rates of suicide increased about 13% between 2012 and 2022 (the last year for reliable data).  During the same time, the worldwide rates decreased by 21.1%.

The national strategy had one evaluation in 2017 that wasn’t focused on efficacy.  The question that it answered was how the plan had been rolled out.  Did all of the states and territories implement the strategy?  Not surprisingly, the plan wasn’t well implemented across the country.  However, the bigger problem isn’t the plan wasn’t implemented – it’s that the plan wasn’t implementable.  The 2012 plan had 4 strategic directions, 13 goals, and 60 objectives.  No one could implement the whole plan, because it wasn’t focused on the things that really make a difference.  Despite the research showing that the 2012 plan wasn’t well implemented, the 2024 plan retained those four strategic directions and expanded to 15 goals and 87 objectives.  This effectively ensures that if the implementation is studied for the 2024 plan, it will go down relative to the 2012 plan – which was a failure on the metric of implementation.

What’s worse is that the 2012 plan was never subjected to any efficacy evaluations.  We know that the overall outcome would have been negative, because the rate increased.  But no one did the work to figure out what was working and what wasn’t – thus, we ended up with a 2024 plan that couldn’t remove ineffective recommendations (objectives) nor focus on what was working.

Even the philanthropic sector struggled.  The American Foundation for Suicide Prevention (AFSP) quietly changed the name of their initiative Project 2025 to The Bold Goal.  The project was intended to span 10 years starting on October 27, 2015, with the goal to reduce suicides by 20%.  Clearly, their work wasn’t effective towards this goal.  Of course, they’ve got a year left to close the gap – but they’re in the hole by about 7%.  It’s not impossible to get a 27% reduction in one year but it would be unprecedented.

I share all this because Camus wrote, “But crushing truths perish from being acknowledged.”  Until we acknowledge that what we’re doing isn’t working, and we need to make a change, the entire field of suicide prevention will, in my opinion, be subjected to the fate in the Myth of Sisyphus.