Book Review-Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope, and Recovery

It wasn’t work with addiction, depression, or hope that led to a Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope, and Recovery.  It was the fact that Adam Hill discussed his suicide attempts – and that his history is from Indiana and Indianapolis.  A colleague recommended the book, and despite my relative resistance to reading stories, I decided it was worth an investment.

Cultural Indoctrination

Context is important.  If you’ve not been a physician, it can be hard to understand the culture of medicine and its training process today.  The training process is bipolar, that on one hand tells us that they’re “baby doctors” and leads them to expect greatness from themselves and their peers, while on the other hand simultaneously asks how they could have made such a stupid mistake.

It starts with the competition to get into medical school.  Hill recounts his struggle as a waiter while he awaited news that he’d be accepted to school – and the internal struggle with inferiority.  Once there, top spots are coveted, because they mean that there are more options.  However, the winnowing process has elevated the competition so that students who were used to being at the top of their class find themselves struggling to get by.  Everyone is clear that the curve has changed.

The final, unspoken, piece is the recognition that peoples’ lives are literally in your hands.  Few professions routinely make life-or-death decisions, and that can weigh on physicians.  It’s one of the reasons why people can be ostracized.  Their peers wonder if they have “what it takes” to be a doctor.

It’s in the context of this culture that doctors are discouraged from admitting their weaknesses and seeking help – particularly if the struggle is a mental one.  It’s okay to get tutoring on anatomy, but it’s not okay to say that you’re struggling to cut into a cadaver.  This destructive system pushes many to the brink and beyond.  Luckily, Hill came back.

Hiding in Plain Sight

Sometimes, the seeds of destruction were with us and visible all along – if anyone were able to put the clues together.  Hill shares his social anxiety and his strive for perfection.  It’s a recipe for concern.  He had learned to hide his imperfections.  Life Under Pressure explains what a culture like that does to create the conditions for a suicide cluster.  Perfectionism explains the dangers of perfectionism itself – in the failure to accept that anything less than perfect is good enough.  In The Paradox of Choice, Barry Swartz explains how satisficers learn to accept what’s good enough while maximizers must have the absolute best – and how the psychological consequences aren’t good.  Maximizers is another way of saying perfectionist.

The problem with hiding imperfections is captured in the saying, “You’re only a sick as your secrets.”  It’s such a prevalent topic that it’s come up in numerous book reviews, including Opening Up, The New Peoplemaking, The End of Hope, Safe People, and more.

Visible Scars

Hill recounts a fractured tibia requiring crutches, and how this was an outer sign of injury.  For this, others questioned and commented – to the point his sister made him a t-shirt with the answers.  However, while the outer injury was visible and the topic of conversation, his internal brokenness was unspoken – by either him or by others.  The visible was easy.  The hidden and the mental were culturally inappropriate to discuss.

Hill suggests what a shirt might look like with the inner struggle: “Yes, I am broken.  It happened during medical school.  It really hurts.  I do not feel like a good person.”  While I struggle to disagree with how someone feels, I do believe that the roots of the problems were present before medical school, like the tiniest of fractures that is barely able to be detected being aggravated by continued stress (abuse).  Athletes – particularly child athletes today – encounter these microfractures and must take time for them to heal.  However, that’s not a luxury we’ve ever afforded to those who are struggling with their own worth as a human outside of what they can do or who they will become.

The Stigma

Stigma is simply different than “normal.”  It’s different than the socially prescribed path that you’re supposed to walk – and it matters.  (See Stigma for more on the concept of stigma.)  It’s important to understand that stigma is resolved by normalization.  The more that we normalize a behavior, the less power stigma holds.  Thoughts of suicide at some point in their lives are present in more than 1/3^rd of the population – and it appears to be growing.  The belief that suicidal thoughts are rare is a myth.  (See https://SuicideMyths.org.)

When I grew up in the 1980s into the 1990s, gays were to be feared.  I don’t know why, but the social message was clear.  (True to my nature, I really didn’t care.)  Books like After the Ball, which advocated techniques for normalizing alternate sexuality, were scooped up by zealots and largely destroyed.  I still think After the Ball is a great guidebook for how to make things more normal – thereby evaporating the stigma.

One of the barriers to anyone speaking out about their struggles is the fear of repercussions; one part of that is the reality, and the other is the fear.  In Dreamland, Sam Quinones shares about the terror tactics used by the Mexican cartels to ensure that people would remain afraid.  The incidence rate was low, but the message was clear.

We face these twin barriers in stigma within the medical community.  There are some real problems with the ways that licensure boards ask questions that violate ADA standards.  These must be fixed, and it’s one of the missions of the Dr. Lorna Breen Heroes Foundation.  Beyond the literal requirements of the ADA, they’re pushing for licensure and credentialing standards that don’t penalize people for seeking appropriate help.

The other barrier is the stories that we hear of people who were penalized or condemned for their stories – and fear that if we share our weaknesses it could be us develops.  That’s where finding approaches that maximize protecting the public (what licensing boards are for) and provider dignity are needed.

Numbing

There are echoes of workaholism throughout the medical industry, whether it’s coming back to work early after surgery, those insane number of hours in residency, or the tendency to slip back into work when things were getting harder to deal with.  But, across the planet, the big tool for numbing is alcohol.

While we find books like The Globalization of Addiction and Chasing the Scream that are focused on narcotics, the number one tool for numbing is alcohol.  Alcohol is not, however, inherently bad.  Neither is numbing.  Numbing is used for procedures to make the process easier.  We encourage it for short-term use – it’s the long-term use that creates a problem.

It’s a hard line.  How much numbing is too much?  How much numbing do you need to be able to process the day-to-day trauma of life?

Numbing as the only strategy doesn’t work, because it becomes less effective over time.  That’s the trap of numbing and how it leads to suicide.  Numbing is used without healing.  Short-term numbing is fine – but only when used in a pathway towards healing.

Suicide

Hill recounts the fellow medical student who died by suicide and how their death was never spoken of in a public forum.  He shares that even in the first few years of his career, he lost five people to suicide.  Between his words you can hear echoes of confusion: on the one hand, some of these people seemed outwardly fine – on the other, he recognizes that he appeared okay on the outside as well.

Suicide happens when the numbing is no longer effective enough.  The pain gets to be too much.  (See Suicide as Psychache.)

The title of the book comes from the pivotal moment for Hill when his wife called him at just the right time to interrupt his suicide attempt.  The literal is a part of his figurative Long Walk Out of the Woods.

Book Review-Life Under Pressure: The Social Roots of Youth Suicide and What to Do About Them

What causes suicide clusters to form?  That’s the fundamental question behind Life Under Pressure: The Social Roots of Youth Suicide and What to Do About Them.  The book follows a community known by the pseudonym of “Poplar Grove.”  It recounts stories and quotes from interviews to understand what has made Poplar Grove such a hot spot for youth suicide – and what can be done about it.

Clustering

Usually, a suicide cluster is two deaths plus an attempt or three deaths in a short period of time in a constrained geographic region.  The real question is what causes them and what can be done to prevent them.  There are several factors that lessen the barrier to suicide for those exposed to one.  First, suicide is brought to mind as an option that may have never been considered before.  Second, the death of someone close necessarily causes grief – and that makes life seem a little less worth living.

But not every suicide death (or any death, for that matter) sets off a suicide cluster – far from it.  While suicide clusters aren’t frequent, they are painful for the people who are left behind and communities they occur in.  Understanding what conditions create or allow clusters to form allows us to design interventions to prevent them – at least in theory.

The Setup

Life under Pressure is a bit repetitive.  It focuses attention to the intense performance pressure and dense social ties of a “must-be-seen as” community as the contributing factors that led to so many youths deciding that death looked better than life.  (See Leadership and Self-Deception for more about “must-be-seen-as.”)

Performance Pressure

Some communities value educational and professional attainment to a degree that they place pressure on their children to be the best, to be involved, and to not show faults.  (See The Years that Matter Most, which was later republished as The Inequality Machine: How College Divides Us, for more.)  The result is that we’ve developed youth with greater anxiety and perfectionism.  (See Perfectionism for more on what it is.)

To be fair, this pressure provides growth opportunities that are needed.  (See Antifragile.)  It can even be argued that peak performers need some degree of pressure.  (See Peak.)  The problem is that this community didn’t create the kind of “air bags” that Robert Putnam describes in Our Kids.  (See also Putnam’s Bowling Alone for background.)

Parents and community members said they were available for youth that needed help – but the youth didn’t believe it, or at least didn’t use it.  They didn’t believe that they were psychologically safe enough to share.  (See The Fearless Organization for more on psychological safety.)  They also didn’t believe that others would or could help.

Dense Social Ties

Generally, we speak of connectedness and social capital in a positive way.  It has protective factors.  (See Analyzing the Social Web for a technical analysis of social ties.)  However, as Richard Hackman explains in Collaborative Intelligence, sometimes teams (his context) have connections and boundaries that are so rigid that they inhibit growth and results.  From Jesuits (see Heroic Leadership) to economics (see Trust), ethics (see How Good People Make Tough Choices), and sociology (see Delinquent Boys), we’ve learned that rigid cultural control of people can have negative consequences, and it sometimes takes real skill to avoid getting wrapped up in them.

Everyone knows everyone else’s business.  That’s the problem.  High performance expectations and dense social ties means that if you admit to a challenge, a limitation, or a fault, everyone will know it in an instant.  This is the driver that makes psychological safety so hard.

Everyone knows that if they admit a problem, everyone will know – and everyone will judge them for it.  Maybe they’ll be overt about it, or maybe they’ll be silent.

Community Pride

There’s a shared ethos of pride and expectations in the community.  They’re all there because the parents wanted to give their children the best chances to succeed.  They’re into athletic excellence as well as academic excellence.  The parents made it far enough in their lives and careers to make it possible for their children to grow up with good schools and support.  They never thought that it would lead to so many with anxiety and so many of their children considering or attempting suicide.  They never saw it coming.

Warning Signs

While the repetitiveness of the book can be frustrating, it’s nothing compared to the promotion of falsehoods.  It says, “To correct another myth, we should address the belief that suicide rarely occurs without warning. There are almost always warning signs. Unfortunately, our society is not very good at recognizing those warning signs and intervening.”  First, if they were dispelling a myth, one would think they’d offer evidence, but no evidence is offered.  Instead, the authors push forward a statement that isn’t based in fact – and is problematic on multiple levels.

The argument is often that, in retrospect, people identify signs.  There are two fundamental problems with this.  First, they’ll claim to see signs that were never present.  Recall-based approaches have been proven faulty repeatedly.  There’s no way to say that what they recall actually happened.  Second, and more importantly, these signs don’t have any predictive value.  Often warning signs include “behavior change.”  The problem is that people change their behaviors all the time – and a vanishingly small number of people are going to attempt suicide because of it.

I have 3+1 signs.  The 3 signs are when they say, “I’m going to die/kill myself/suicide,” “(It doesn’t matter) I’m not going to be here anyway,” and “I want to give you this (prized possession) because I know you like it.”  The +1 is sleep disturbances.  For the first three, we’ve got a clear message we can and should respond to.  For the +1, it’s a reason to check in – and continue checking in.  Sleep challenges lead to cognitive challenges – and cognitive constriction, which can be dangerous.

I’m not suggesting we can’t start a conversation about suicide when we see one of the signs on the numerous “warning signs” lists.  I’m saying we should be starting a conversation about suicide without them.  The warning signs just aren’t predictive of risk in an individual.

The problem isn’t “recognizing.”  The problem is that we’ve included so many signs that they’re meaningless.  If you don’t believe me, you’ll find the evidence at Myth: Every Suicide Attempt Has Warning Signs.  (Direct journal articles and research are linked from this page.)

No Mulligans

In golf, a mulligan is an attempt to do the same shot again.  Live doesn’t have mulligans, but too many parents treat their children like their own personal mulligans.  If they didn’t get the starring role in the high school or college play, their child surely will.  They missed out on an athletic scholarship to college, certainly that won’t happen with their child.  Whatever dream they missed, their child won’t.

The problem is that life isn’t designed to work this way.  They get their shot – and their children should get theirs.  If they force their will on their children, both the parent and the child tend to be disappointed, frustrated, angry, and confused.  It’s not healthy – but it’s something that I see all too often.

School Responses

The school in Poplar Grove was criticized for their responses.  However, even the guide, “After a Suicide: A Toolkit for Schools,” from which the authors draw their perspective isn’t perfect.  There are simple things like treating all deaths the same and ensuring that the suicide isn’t glamorized.  However, as you dig into the guide, you’ll find an inappropriate coupling of mental health to suicide, implying or directly stating that this should be a part of messaging to parents and students.  There is no research support for this approach – and it necessarily further couples and stigmatizes both.

While insisting that all deaths should be handled the same – and they should – the guide continues to prescribe different messaging and approaches for suicide.  The guide itself (and the authors of this book) are inadvertently doing the very thing they’re telling others not to do.

Shaky Ground

Qualitative research is very difficult to get right, and often it suffers from biases.  The questions that are asked (even in structured interviews) are often driven by the perspective of the interviewer.  That’s just a part of the process as we move from qualitative to quantitative research.  However, one can practically hear the rumblings, as statements like, “we are fairly convinced that large, well-attended memorials have unintended negative mental health consequences,” clearly reflect the bias of the authors (as indicated) – but no proof or theory is offered to support these type of statements.

While I can appreciate the delicate nature of interacting with a community in the midst of a suicide cluster, I cannot fathom statements like, “We did not feel it was appropriate for us to attend any of these memorial services or vigils ourselves, so we cannot provide an observational account.”  I liken it to the person who records a video of someone else getting injured rather than rendering assistance.  I see no reason why someone researching how to prevent more death can’t approach an official to ask for permission to listen to the service.  It strikes me that this decision might be based more in fear of the awkward conversation. “How did you know the deceased?”  The answer is simple.  “I didn’t, but I want to prevent others from dying like they did so I’m here to learn from family and friends.  I hope to learn more about him/her.”

There is some good to be learned from pressure.  However, it’s not right to have an entire Life Under Pressure.

Book Review-The Prediction of Suicide

Aaron (Tim) Beck, Harvey Resnik, and Dan Lettieri are the editors of The Prediction of Suicide.  The assembled work brings together the best minds in the prediction of suicide in 1974.  The arguments made then are like the arguments that could be made today.  In the preface, they state, “Despite the voluminous research reports, there is a very flimsy basis of knowledge that can contribute in a scientific sense to the problems of the worker in this field.”  It’s a challenge that hasn’t changed substantially in the fifty years since this publication – but hopefully it’s one that will change soon.

The Process

The point is made that, “Suicide is the end result of a process, not the process itself.”  This belies the problem of prediction and identification.  We speak of the outcome, but even today, we struggle to articulate the pathways that lead to this outcome.  It’s understanding these pathways that provides hope for our ability to do some level of prediction of suicide.

The one differentiation that can be made about the process – even in 1974 – is related to the outcomes.  “But the unsuccessful suicides are no doubt quite different from the successful, and the former cannot be regarded as representative of the latter.”  The categorization is that attempts must be categorically different than deaths, because the outcomes are different.

I think this hides the reality of the randomness to the process.  Silvia Plath arguably wanted to be found and her attempt to be aborted.  (See The Savage God and Suicide and Its Aftermath.)  Even though she eventually died, her process may have been closer to that of an attempter who didn’t die.  In short, while we can presume that there’s a difference between attempts and those who die, we can’t really know.

Zeigarnik

Blume Zeigarnik was a student and colleague of Kurt Lewin.  She noticed an odd thing about the memory of servers.  They could remember orders without writing them down – until they relayed the order to the kitchen.  After that point, they promptly forgot the order.  This led to the discovery of what we call the “Zeigarnik effect,” where uncompleted tasks are held more prominently in memory.

Joseph Subin, in the first chapter, hypothesizes that the Zeigarnik effect may have an influence on attempters, providing some subtle draw towards “completion.”

Call Centers

Suicide call centers are an important part of the overall system of care to try to prevent suicide, but the book notes that “only 4 percent of suicide attempts and even a smaller percent of the eventually successful suicides called suicide prevention centers.”  So, they’re an important part of the overall strategy – even if the overall match to those who make attempts is low.  We see this same sort of calling pattern in 988 today.

The Perception of Control

We often underestimate our need for the feeling of control.  The belief that someone has control and the presence of options has consistently demonstrated a positive effect on mood for people.  We see this in places where there are suicide options for those with terminal illnesses.  The number of people who use the suicide option after having been approved is very low.  (See November of the Soul.)  They’ll go through great lengths to acquire the ability to die by suicide – and simultaneously decide not to use the option.

At its heart is our perceptions of control.  When we feel we have control, we have a greater capacity for self-soothing and down-regulation of fears.

Mental Health Disorders

Mental health disorders are, for the most part, time-limited with or without therapy.  That’s striking, but not totally unexpected, news.  For most of human evolution, mental health disorders have occurred before the introduction of psychotherapies and the like.  This is not to say that mental health assistance is a bad thing – far from it.  Antibiotics, in most cases, merely decrease the time it takes to heal, but we still use them anyway.  Similarly, mental health supports are good things.  But understanding that mental health disorders typically self-resolve can help us to understand how suicidal crisis can also self-resolve.

To be clear, this is not to say that all mental health disorders will self-resolve – they won’t.  However, the argument made by Zubin is that they largely self-resolve.

Actuarial Versus Clinical

One of the big challenge in the prediction of suicide is the difference between aggregating various risk factors to develop a risk score for an individual and the need to sit next to someone and make a decision about whether they are a risk to themselves.  (Ideally, sit next to them rather than across from them, as still often happens – see Motivational Interviewing and Managing Suicidal Risk.)

In the development of actuarial risk, demographics and history are combined into a single score based on previous research and factors that can be identified to raise or lower the risk.  Being an “old white guy” raises one’s risk – my risk.  Other factors are loaded into the assessment to create a score.  However, this score has nothing to do with me personally and everything to do with the statistical abstractions made for groups of people.

Time and time again, we’ve demonstrated that such actuarial risk summarizations have almost no utility in the assessment of individuals.  Compiling the most comprehensive profile still doesn’t yield the ability to predict which individuals are at risk.  The statistical (actuarial) process simply has eliminated all of the distinctiveness in the data and with it the ability to see the risk of individuals.

Later in the volume, Beck states it clearly: “The belief that suicidal behaviors are predictable can be valid only as a belief in principle, not in fact.”

Psychological Autopsy

Even in 1974, the limitations of psychological autopsies was well known.  Alex Pokorny explains the difficulty of discovering intent: “It also appears to require a ‘psychological autopsy,’ which is not practical for general use and which also introduced the possibility of circular reasoning.”  He first identifies the effort and therefore cost of doing psychological autopsies.  They’re time consuming.  They require willing participants of the survivors, which isn’t always the case.  That makes them somewhat impractical for broad use.

The more challenging aspects of psychological autopsies are the problems of retrospective reasoning.  After a determination of suicide is reached (preliminarily), the scales tilt towards that, and there is some bias towards confirmatory evidence.  This is held back by the stigma and extra pain associated with suicide death, but the degree to which one of these forces is more powerful than another is both situational and effectively immeasurable.

We’re left with serious doubts about whether psychological autopsies create a real picture of the person’s mind or whether they create a fiction that roughly fits the facts.  This fiction may help us feel better about understanding – but it does not necessarily create actual understanding.

The Categories

One of the challenges of creating good research on suicide is the need for clear and consistent categories.  The categories proposed are completed suicide (CS), suicide attempt (SA), and suicide ideas (SI).  These are good, broad categories, but they miss some of the nuances and challenging situations.

In particular, non-suicidal self-injury (NSSI) is problematic in this framework.  There is a relationship between NSSI – particularly cutting – and later suicidal behavior, but the narrow and coarse framework proposed here doesn’t connect NSSI to suicide.

Screening

Aaron (Tim) Beck was one of the earliest proponents of finding scales to measure risk.  He was developing what became the first risk screening tools – some of which are still used today because of their efficacy.  However, he states, “Nevertheless, even the best of these produces a very high proportion of false positive errors, that is, cases that are unjustifiably labeled as high suicide risks.”  Later, he continues by saying, “For there is currently no detection scheme that can be set to identify half of the available genuine suicide risks without erroneously identifying along with them a lot of people who are not suicide risks at all.”  He acknowledges that because suicide is a statistically rare (and tragically too common) event, it’s hard to develop tools to identify it.

He argues that, in order to get sufficient sensitivity to detect people who may have suicide in their immediate future, many must be identified and later assessed out of the system.  My “back of the napkin” calculations put the false positive rate at about 300-600 times the number of actual positives based on current tooling.  Despite the insistence on the use of these tools, the behavioral health system can’t cope with the false positives that must be screened out.  Even if these clinical assessments were 100% accurate, the sheer volume of work puts a strain on an already burdened system.  The tragedy is that even clinician assessment is a poor predictor of outcomes, as is explained in The Practical Art of Suicide Assessment.

Predictors and Postdictors

Hindsight is 20-20.  It’s a common cliché that pushes us towards an understanding that we can see things in the past that might have never been identifiable before the event.  We can understand the factors and methods that lead to outcomes only after the kind of careful study and clarity that comes after the event.  One of my great frustrations is with lists of suicidal risks, because they include things that frequently occur, including in a proportion of those who attempt suicide.

Things like a change in mood or behavior is often listed.  The problem is that, when applied to teenagers, this is almost universal – with or without suicide risk.  Also listed are statistics like 95% of people with suicide have a mental illness.  That’s misleading, because a very small percentage of those with mental illness will die by suicide (<5%).

David Lester makes the point that what we call “predictors” are all assessed after-the-fact and therefore should more accurately be called “postdictors.”  They have little predictive value.  They do, however, encourage a great deal of guilt and shame on the part of loved ones who feel that they missed signs that they should have seen.

Infrequency

Chapter after chapter in the book has authors saying that suicide is a statistically rare event and is therefore nearly impossible to predict at an individual level.  George Murphy explains how a statistically good screener would be unacceptable clinically owing to the intersection of statistics and outcomes: “From the numerical standpoint, a prediction of ‘no suicide’ in every case would be highly accurate (1,336/1,350 x 100 = 98.96%). It would also be entirely unacceptable clinically.”

Extending out some basic math approaches, he concludes, “More to the point, the predictive accuracy assumed (80 percent) is far beyond our present capabilities. The population chosen for the example (suicide attempters) is one of relatively high risk, and yet prediction of the infrequent event, suicide, is poor. It would be very much poorer in a population unselected for risk.”  The threshold he used of 80% accuracy exceeds the capacity of our tooling even today, 50 years later.  Screening is still required by accrediting bodies in high – and not so high – risk situations despite our awareness that they simply aren’t effective.

The funniest thing is that the more we pay attention to the details, the more we can recognize that it’s a fool’s errand to believe in The Prediction of Suicide.

Book Review-Suicide and Homicide

Suicide and Homicide: Some Economic, Sociological and Psychological Aspects of Aggression proposes that both suicide and homicide are acts of aggression that flow through different channels based on either external or internal constraints.  There are others who have held – and do hold – this perspective.  Karl Menninger spoke of suicide in Man Against Himself as murder in the 180^th degree.  More recently, Thomas Joiner in The Perversion of Virtue highlights the common component of killing in both suicide and homicide.

Aggression as a Consequence of Frustration

There are three theories about where aggression comes from.  Freud’s theory places aggression as an outcome of “Thanatos” – death instinct.  Konrad Lorenz challenged Freud’s perspectives based on his observations of how animals controlled their aggression.  The second theory is that aggression comes from frustration.  The third theory is Albert Bandura’s social learning theory.  He proposes that we learn aggression by seeing it in others.  (See Moral Disengagement – The Cases for more.)

Given Lorenz’ criticism of Freud’s theory and mine of Bandura’s, we’re left with the theory that aggression comes as a result of frustration.  One might conceptualize this as “Nothing else is working (or can work), so I’ll try the risky thing.”  Aggression is risky.  Certainly, at a physical level, one can get hurt while attacking another; but at a societal level, even non-physical attacks can backfire.  One can become labeled as difficult to get along with or problematic.

However, this sense that what is being tried is being blocked or is simply ineffective leads to an escalation through aggression.  We’ve been taught not to back an animal – particularly a wild animal – into a corner, because the behavior that we’ll see out of the animal in those conditions – when they feel as if they have no other options – can be harmful to us.

Business Cycles and Status

Much has been made of how suicide relates to business cycles.  It turns out that when business cycles are down – and things are more challenging – we do tend to see a rise in suicide deaths.  While there is some disagreement on the specific timing, the general relationship is generally well accepted.  Conversely, when the business cycle is at its peak, we tend to see more homicides.

We also see that upper and lower ends of the socioeconomic scale tend to be more and less sensitive.  In the low times of a business cycle, suicides increase in the higher socioeconomic status (SES) more than in the lower.  The theory is that those in the higher socioeconomic status are more greatly impacted.  During the peaks, we tend to see greater homicide rates but initiated by those in a lower SES.

Restraints

The fundamental theory is that weak external restraints drive suicide and strong external constraints drive homicide.  In the case of suicide, those who are most at risk as those who are the most affluent.  In terms of homicide, it occurs mostly in those who are at lower SES and therefore have greater external constraints.

Conceptually, those who have fewer external constraints need to impose more internal constraints to function.  If these internal constraints become too tight or difficult, the aggression felt is self-directed.

Perfectionism

The internal constraints that drive suicide may come in the form of perfectionism and the constant failure to meet impossible standards.  (See Perfectionism.)  It could be that we’ve become exhausted on our way to peak performance, realizing that we’ll never reach the goals we set for ourselves.  (See Peak.)  Even in the general form of maximizing rather than satisficing, we know that we’ll be less happy.  (See The Paradox of Choice.)

These are the kinds of constraints that we can impose on ourselves.  It’s not the outside world setting our standards.  It’s our own drive and determination that sets goals that we can’t meet and therefore suicide is a concern.

Social Ties that Bind

Social ties and strong communities are important protectors against suicide that may function in part due to their strong social conformity bond.  Robert Putnam described the erosion of social capital in Bowling Alone.  He later revisited how the decline of social capital wasn’t occurring evenly, with upper-middle class families finding ways to work together and insulate their children from some of the challenges of the world.  (See Our Kids.)

Perhaps if we pay attention to what and who binds us, we’ll realize how little difference there is between Suicide and Homicide.