Book Review-Discovering Suicide: Studies in the Social Organization of Sudden Death

J. Maxwell Atkinson’s Discovering Suicide: Studies in the Social Organization of Sudden Death is unusually candid about the state of suicide prevention in 1978. Rather than insisting that we could predict suicide risk when we can’t, Atkinson offers comments like, “…there was something strange about the willingness of sociologists and criminologists to proceed to make generalizations in spite of known difficulties.”

Statistics

Atkinson was equally critical of the inferences made by statistics.  Building on the work of others, he points out that the statistical foundation upon which some assertions rested were untenably fragile.  We can’t go back too long before we discover that the registration of deaths wasn’t required at all.  The degree of expertise necessary in coroners was highly variable, and the key indicating factor for suicide is intent – which is difficult to assess postmortem.  (See also Postmortem.)

He suggests that, rather than relying on such unreliable sources, we needed to begin with more contemporary studies – and allow for similar distortions of the data.

A General Theory

Atkinson even criticizes the idea that there could be a single theory of suicide by using an example: “to construct a general theory to explain why people dig holes would be to put one’s judgement severely in question.”  He explains that, like suicide, the reasons for digging holes varies widely.  Because of that, no single theory could suffice.

Scholars after him would struggle to find unifying theories of action.  Today, we struggle to have theories of suicide that are broad enough to encompass all suicide attempts and narrow enough to be useful.

Indicators

Atkinson, while acknowledging the difficulties, still sought indicators.  In the case of a drowning in the river, he’d look for whether the clothes of the person were neatly folded on the shore or simply tossed in a pile.  He believed that neatly folded indicated suicidal intent.  I, however, think it indicates some level of need for order.

Other examples, like an overdose taken in the middle of the woods, are a slightly more generalizable and potentially reliable indicator.  Except in cases where the person became disoriented, it’s more likely that the preparation of going someplace secluded indicated a degree of planning.  That planning seems to have little other purpose than to ensure that they’re not interrupted.

There are no easy answers to explain the phenomenon of suicide.  Atkinson offers solid critical approaches to the research being done.  Discovering Suicide doesn’t have answers, but its criticisms of the field are useful.

Book Review-The Practical Art of Suicide Assessment

It is always interesting to read about the right way to do things from authors that acknowledge nothing is foolproof.  The Practical Art of Suicide Assessment explains a process – one which admittedly doesn’t have empirical support.  It also acknowledges that our ability to predict short-term risk of suicide is poor.  (“Current research shows that clinicians have little ability to predict imminent suicide.”)  Like many things, this is a book I purchased but hadn’t read until a recommendation by Skip Simpson – the one discussed in The Suicide Lawyers.  While I knew that there wasn’t any clinician (much less framework) that could consistently and accurately predict suicide risk, it was a good thing to inspect a standardized process – that one could support in court if that ever became necessary.

The Promise

The goal is clear: we want to identify those at risk for suicide and provide care for them.  However, Shea states, “It has always been hoped that risk factors, if studied collectively in a specific client, would also serve as reliable risk predictors alerting the clinician to an immediate danger of suicide.  Such is not the case.”  Later, Shea identifies the core challenge: “We do not know for certain what is going on in our client’s mind.  We never will.”

While there are things to be learned from improving the assessment of patients for suicidal risk, we cannot fool ourselves into thinking that the process is foolproof – or in some sense ever will be.

Chronological Assessment of Suicide Events (CASE)

The core of the book is explaining the CASE approach, which involves a structured interview.  That is, there are a series of areas, phases, or questions that are intended to be asked.  It’s a framework designed to help a clinician ensure they’re not missing anything.  Much like The Ethnographic Interview approach that is recommended for anthropologists, it has no forms to fill out and recognizes the dynamic unfolding of conversations.

The use or non-use of forms is problematic.  Shea makes the point that without forms, you can focus on the client.  However, without forms, it’s also almost impossible to not drop something.  Approaches like CAMS, explained in Managing Suicidal Risk, explicitly use a joint form that the patient and clinician work together on to ensure fidelity, accuracy, and collaboration.  It’s my strong belief that this is a much better approach than having the clinician do an interview without the support of a memory, documentation, and understanding confirmation aid.

Stage 1: Setting the platform

In the show before the show, Shea recommends preparing for the CASE part of the interview by building rapport and setting expectations.  It’s called therapeutic alliance or therapeutic environment.  A more detailed understanding of this concept is in Motivational Interviewing, and support for the efficacy can be found in The Heart and Soul of Change.

Stage 2: The CASE Approach

The CASE approach itself has four regions.  They are intended to be addressed sequentially.

Region 1: Presenting Events

The patient’s current condition, including their suicidal feelings, death wishes, ideations, plans, intent, and actions.

Region 2: Recent Events

The items that preceded the presenting events, including immediate or imminent danger in the patient’s method of choice, time spent contemplating the method of choice, and actions taken on the method of choice.

Region 3: Past Events

A review of a patient’s past suicide attempts.

Region 4: Immediate Events

This region captures the patient’s thoughts and intentions concerning suicide that come up during the interview itself.

Ideation to Death

There’s a general belief in the suicide prevention space in an ideation to action framework.  This framework says that first people think about it, then they do it.  Shea states, “Roughly less than one percent of people who have had suicidal ideation go on to kill themselves.  This is an extraordinarily important number.  It is a measure of hope.”  Shea vastly overestimates the percentage of people who die by suicide as a ratio of those who have suicidal thoughts.  If we assume that 1/3 of the population considers suicide (which is conservative based on the research), it’s easy to see that the number who go on to die cannot be 1%, because the base rate is roughly 14 per 100,000.  At 1%, those only considering suicide would be 3,333:100,000.  Clearly, it’s substantially less than 1% of people who have suicidal thoughts die by suicide.

Causes

Consistent with the fluid vulnerability theory of suicide, Shea believes that suicide is triggered by external stressors, internal conflict, and neurobiological disfunction.  (See BCBT-SP for the fluid vulnerability theory of suicide.)  Despite the coherence, it’s difficult to understand the mechanisms of internal conflict – and therefore hard to predict the probability of suicide.

Fear of Suffering

There is a fear of death that is inherent to humans.  (See The Denial of Death and The Worm at the Core.)  However, as The Top Five Regrets of the Dying implies, death isn’t the largest fear.  Shea recounts the testimony of an elderly person who answers whether he fears death.  “No. I fear suffering. The older one gets, the greater the likelihood that one will be kept alive without purpose.”  This is one of the reasons why people want the option of suicide – even if they don’t intend to use it.  (See Undoing Suicidism.)

Making Your Way in the World Today Takes Everything You Got

The opening song to Cheers contains the lyrics, “Making your way in the world today takes everything you got, taking a break from all your worries sure would help a lot.”  That’s the way that some people with suicidal ideation think.  Shea says, “Consequently, the common vicissitudes of daily living may present these clients with a bewildering array of unbearable pains.”  He insists, “Most people do not kill themselves in response to a single, catastrophic stressor. It is the stress of living with oneself that more often leads to despair.”

I don’t agree here.  While there are too many lives lost after a long period of pain, there are also those whose journey to suicide is very short.  (See Myth: Suicide is Never Decided Suddenly.)

Swing of Suicidal Ideation

While defining the art of prediction of suicide, Shea also argues against its efficacy.  “Within the span of five minutes, Anna went from feeling wonderful to feeling suicidal. That’s how quickly such a descent into a suicidal maelstrom can occur when fed by a borderline rage created from a bevy of cognitive distortions.”  This statement is supported by research that demonstrates that suicidal ideation intensity can vary quickly and rapidly.

Involuntary Commitment

The greatest fear in disclosure of suicidal ideation is the fear of institutionalization.  There are good reasons for this fear.  Shea exposes the validity of this fear with, “In this type of questioning, besides determining lethality, the clinician is searching for information that would fulfill involuntary commitment criteria.”  As innocuous as it may sound, it’s problematic.  It subtly signals to the patient that the clinician isn’t necessarily looking out for their best interests – they may be protecting themselves from a future lawsuit.

This is particularly challenging when we look at the evidence (or lack of evidence) on the inpatient commitment process.  (See Myth: Inpatient hospitalization is best for people with suicidal ideation.)

Environmental Factors

Shea explains why we need to look beyond the individual for risk: “Suicide is often an interpersonal phenomenon. As we saw with Jimmy, an evaluation of suicide risk involves not only consideration of the identified client but also assessment of the people surrounding the identified client.”  He’s right that some people have environments around them that protect them and help them to avoid suicide attempts.  Other environments are not so friendly.

The environments that people find themselves in can be a huge factor for whether they’re at risk or not.

Indicators

Looking for indicators of risk is good – but expecting them is not.  Consider Shea’s comment, “Perhaps the most important indicator that Kell is probably not imminently suicidal is the fact that she denies current suicidal intent and has no organized plan to harm herself.”  The missing piece of this is “that she has disclosed.”  As mentioned earlier, you cannot know what is in the mind of a client.  We cannot know what they are or are not thinking.

Relying on a few indicators to be present – and shared – means that many people will slip by.

Suicidal Risk Is Messy

Shea admits that clinicians are wary of asking about suicidal intent, saying, “If we uncover serious suicidal intent, we are potentially creating a mess for ourselves.”  The “mess” is, of course, the additional work to assess their imminent risk – requiring institutionalization, enhanced documentation, and the time necessary to stabilize the patient if inpatient hospitalization isn’t called for.

While it’s appropriate to recognize the extra work, people are worth it.

Documentation

Shea recommends seven principles for suicide assessment documentation to keep clinicians out of trouble.  They are reproduced here:

1. Good clinical documentation is the primary shield against malpractice litigation.
2. There can be no good clinical documentation, unless there has first been good clinical care.
3. Even if good clinical care has been provided, if there is poor documentation then the risk of malpractice litigation rises steeply.
4. There are two types of poor documentation:
   • The clinician didn’t document the assessment.
   • The clinician did document the assessment, but documented it poorly.
5. The first legal purpose of a sound written document is to keep the clinician out of court.
6. The second legal purpose of a sound written document is to effectively defend the clinician if the case goes to court.
7. The most important reason to write a sound written document is to convey information to other professionals that may help the care of the client or may serve as a quality assurance checklist for the clinician which, if done effectively, will also result in a sound legal document.

In the end, the right thing for a clinician to do is to create appropriate documentation.  It’s the best defense against a lawsuit and a judgement.  This is true even given the limitations in The Practical Art of Suicide Assessment.

Book Review-The Suicide Lawyers

I had picked up The Suicide Lawyers some time ago but hadn’t read it.  I have friends and clients who are attorneys.  I like them.  I couldn’t really understand why I hadn’t read the book.  Then I realized that there was some sense of disconnect between the research about suicide prediction and holding accountable a mental health professional for not detecting suicide.  An introduction to Skip Simpson from a trusted colleague moved the book to the top of the list.

Misunderstanding Suicide

“Suicide may be one of the most misunderstood acts, and subjects, on the planet.”  It’s certainly very misunderstood.  They claim that they want juries to deliver verdicts on fact, not myth.  I agree.  It’s a small part of the reason we developed https://SuicideMyths.org.  We wanted a place where people could get the truth in a way that is sufficiently authoritative that people may stop believing the lies that are costing lives.

Ample Warning

A place that I’ll disagree with the author and Skip is that “nearly every person who commits suicide provides ample warning about his or her intention.”  I think those are the kinds of cases that they get involved with – but I don’t think that’s true of every suicide death.  Consider that roughly half of all deaths by suicide weren’t engaged with the mental health system.  Given their role of suing mental health providers, it makes sense that there’s a whole other grouping of suicidal people they’ll never (or rarely) see.

Minor Tragedy

“There’s usually a lot more behind a suicide than some minor event. If a high school or college student commits suicide after getting a poor test grade, chances are that his or her decision was just the final straw of a rather hefty set of problems he or she was facing.”  The tricky part here is that “usually” is probably right.  However, this doesn’t eliminate the possibility that someone was thinking in a cognitively constricted way and made a hasty decision.  (See The Suicidal Mind and Capture.)

The Copout

Responding to the author in an interview, Skip said, “That can be a copout. Most suicides can be prevented, and a caring, compassionate individual is going to do everything in his or her power to stop people from killing themselves.”  The issue at stake is whether you can save someone else from suicide.  The answer – as a technical matter – is no.  No set of constraints that anyone can put on another will prevent them from dying by suicide.  They can, if they’re determined, find a way.

That being said, Skip has a point.  We should work towards preventing suicide in others where we can.

Foreseeability

Skip clarifies that the issue at stake in legal terms is foreseeability, not predictability.  Foreseeability is about whether the consequences of an action or inaction could reasonably have been anticipated.  In clinical settings, the key consideration is whether the clinician can predict the behavior of a patient which is a higher and more important standard.

Skip’s statement, “Professionals, who properly assess for suicide do, however, have enough knowledge to foresee a likelihood that someone will commit suicide in the near future,” can be troubling.  It’s troubling, because when viewed from the prediction lens, this is incorrect.  Research routinely characterizes our ability to predict short term risk as low.  This applies both to screening tools and to clinician assessments.

The gap is that Skip is speaking of foreseeability.  In tort law, if the harm was foreseeable and the person did not take reasonable steps to prevent it, they could be held liable for negligence.  What are reasonable steps?  The quip I’d expect from my attorney friends is, “Whatever the jury says.”  In practical terms, it’s more complicated than that.

“Reasonable” is determined – in part – by the standard of care.  That means that the standards brought forward by the National Action Alliance for Suicide Prevention’s recommended standard care matters.  So, too, do the recommendations of The Joint Commission – an accreditation organization for health care organizations.

“Reasonable” can be as small as having considered the short-term risk and ruled it out based on a set of reasons that are written into the patient’s record.  According to the colleague who introduced me to Skip, this is more than most do.

Proper Assessment, Diagnosis, and Treatment

Skip appropriately criticizes the mental health industry for failing to train clinicians on suicide risks.  However, there are some overreaches in terms of the capacities of the assessment and diagnosis components.  In addition to the assessment issue addressed above, diagnosis – using the standard DSM-V – is notoriously fickle between clinicians.  There are criteria, but they’re broadly written and interpreted in ways that lead to poor reliability.

The good news is that Skip’s spot-on with regards to treatment.  We have clinically validated treatment approaches (DBT, BCBT-SP, and CAMS) that are appropriate for those clinicians working with patients with suicidal ideation or attempts.  I don’t agree with Skip’s statement, “Psychiatric treatments can be just as effective as those for other illnesses, if the clinician is competent.”  We’ve got a long way to go to get to those levels of clinical efficacy.

Safer Cars

Skip says, “Why do we have safer cars today? I’ll answer that…one of the main reasons is because of trial lawyers. It was trial lawyers who forced automakers to design safer cars.”  I’m relatively certain that Ralph Nader would disagree.  In Unsafe at Any Speed and in his other advocacy work, he and others transformed public perception.  As much as it pains me to say it, the claims made against carmakers were written into a cost of doing business rather than taken as an imperative to change their way of business.  Do I think trial lawyers help to encourage accountability? Yes.  Do I believe it stops there?  No.

Firearms

When it comes to firearms in the United States, people can get sensitive.  However, the facts aren’t equivocal.  More than 50% of suicides in the US are completed with a firearm.  However, like most things in suicide, it’s not that simple.  It’s not as simple as saying that access to firearms causes suicide deaths.  Skip explains, “Firearms account for more than 55 percent of suicides. However, guns are easily obtained in Texas, and it ranked 39th in per capita suicides.”

In the US, there’s probably not a more sensitive topic.  Folks like John Lott write books like Gun Control Myths to combat what they feel like is excessive gun control.  It’s a response to sometimes inflammatory writing, like Gun Country, which blames unrestricted capitalism for the explosion of guns and the resulting problems.  More balanced approaches to the challenges of the topic, like Guns in America and America’s Gun Wars, are often drowned out in the competition for headspace.

Ultimately, I’m less concerned about ownership of guns (because that ship has sailed).  I’m more concerned about making sure that guns are safely (or securely) stored.  That means when not on one’s person, they should be locked.  (See Guns and Suicide for a more nuanced conversation.)  If we could just get everyone to store their guns safely, we might find that we don’t need as much from The Suicide Lawyers.

Book Review-November of the Soul: The Enigma of Suicide

For many people, suicide is something they’ve considered at some point in their life.  They’re likely to know someone who has died by suicide by the end of their life.  More disturbingly, they’ll rarely, if ever, talk about it.  November of the Soul: The Enigma of Suicide seeks to unravel the mystery around suicide and to lay out the truth, as we know it, about suicide.  From the simple answer that most suicide deaths don’t occur in the fall or winter to more complicated nuances of this human experience, the misperceptions we hold are gently but firmly corrected.  (See Review of Suicidology, 2000 for peak suicide deaths occurring in spring.)

Public-Private

Throughout much of written civilization, suicide wasn’t a private affair.  At times, it was the only available protest against an unjust system or ruling.  With so little voice, some would choose to die so that the injustice could be known.  Slowly, over the ages, the reasons for suicide have become less public and more private.

Some suicides were (and still are) economic suicides.  In other words, the suicide is brought about because the person believes that they’re better off dead.  (See burdensomeness in Thomas Joiner’s Interpersonal Theory of Suicide in Why People Die By Suicide.)  Inuit elders would walk away from their tribe into certain death if they felt they could no longer contribute or sensed that the resources of the tribe were strained.

Today, however, suicides are more likely to be motivated by a perceived sense of loss.  They result in a cognitive constriction that causes people to believe that their death is worth more than their life.  But this operates on a more personal level than the benefit of the tribe.  (See Capture.)  They may also choose suicide because of the perception that the pain they’re experiencing is unbearable and will somehow last forever.  (See Suicide as Psychache.)

The relationship to suicide seems to be one that is a personal loss of hope.  Problems are seen as permanent, pervasive, and personal – no matter what the reality is.  (See The Hope Circuit and The Psychology of Hope.)

The Great Wall of Stigma

The idea of “us vs. them” is hardwired into us.  (See Mistakes Were Made (But Not By Me).)  We can’t help jumping to conclusions.  We can’t stop breaking the world into in- and out-groups.  The result is the basis of stigma.  (See Stigma.)  We seek out differences to allow us to push people into the out-group.  Robin Dunbar, in his work with primates, states that our neocortex size drives the number of stable social relationships that we can have – and, as humans, we’re well above those numbers.  (See High Orbit – Respecting Grieving.)  This forces us into a state of cognitive overload that we defensively try to avoid.

As a result, we see characteristics of someone that we feel can never apply to us, and we push them into an out-group.  Suicide is a sufficiently rare event that they can’t see it in themselves or their family, so they can – they believe – safely create an out-group of suicide attempters and those who have suicide in their family.  The problem is that suicide prevalence in the population indicates that roughly 1 in 100 people will die by suicide.  In today’s world, where we interact with thousands of people in our lifetimes, we’ll see more than ten families suffer through suicide – and with large families, at least one of those people may be in your family.

Prevalence

We like to think that suicide is a rare event – and it is statistically rare and tragically too common.  If we use 14 people per hundred thousand per year of suicide deaths per year as a starting point, we can estimate the number of suicide attempts there are.  Some estimate that it’s 20 attempts per death by suicide.  That means we’re at 280 per 100,000 or about 1 in 360 people who make an attempt each year.

The prevalence becomes more real when we start to look at the number of people who consider suicide.  Some might call this “suicidal thought” or a stronger form, “suicidal ideation.”  Studies from Alberta, Canada, decades ago estimated this rate at about 1 in 3 people.  More recently, the CDC surveyed US high school students and found 19% had seriously considered suicide, 15% had made a plan, 9% made an attempt, and 3% made an attempt that required medical attention in the preceding year.

High schoolers are not the general population.  However, a 19% rate in a single year is strikingly high and an indicator that our estimates about the number of people in the population who consider suicide may be lower than the real rate.  (High schoolers have less social pressure to hide their true suicidal thoughts due to lower perceived consequences.)

The message here is that the start of a suicide journey is much more common than any of us would like to believe.

Crazy Correlations

There are so many correlations that are tracked in the suicide space.  Some of these correlations are confusing.  Consider that many believe the rate of mental illness in suicide deaths is greater than 90%.  The problem is that, viewed from the other direction, the percentage of people with serious mental illness who ultimately die by suicide, the rate is less than 5%.  Yes, mental illness, and particularly some forms of serious mental illness, are risk factors for suicide – but it’s not a death sentence.

One factor is that it’s estimated more than 20% of Americans have some diagnosable mental illness.  Additionally, another 10% of Americans could be said to be suffering from alcohol use disorder.  Sometimes, this number is included in mental illness statistics, and sometimes it’s excluded.

As a practical matter, it doesn’t help to know that more than 90% of people who die by suicide have a mental illness if you can’t use that criteria to help you target prevention resources.

Another place where the statistics are hard is that prior sexual abuse is estimated to be 9% to 20% of the total number of the suicides.  (See also The Assault on Truth for more about the prevalence of sexual abuse.)  Abuse of all kinds is a key societal problem, with nearly half of all abuse victims developing two or more disorders by the age of twenty-one.

It Will Hurt Less to Die

One of the challenges is that cognitive constriction can cause people to believe that suicide will hurt less than what they feel today.  The statement is, I suppose, technically true, because they’ll feel nothing.  However, it misses the essential point that there will also be no joy.  The focus on their current pain blinds them to the fact that it’s temporary.  No pain or circumstance is permanent, pervasive, and uniquely personal.  It will always change, it isn’t everywhere, and it’s not completely about you.  (See The Resilience Factor for more on permanent, pervasive, and personal.)

A variation on this theme is the sense that if I can’t control anything in my life, at least I can control my death.  This defeatist attitude fails to acknowledge that, in doing this, you’ll never have any control over your life.  People, when they feel as if they’re trapped or helpless, can’t see a time when they’ll have control – or influence – over their lives.  (See Compelled to Control for more about control.)

Appropriate Constraints

Home is where the heart is – but where is that exactly?  Parents in the US spend less time with their children than parents in other countries – but more challenging is that it appears we’re more mobile.  This presents a challenge when you’re faced with where someone should be buried.  Are they buried where they were born, where they are currently living, or where they spent the most years living?  It sounds like an academic exercise until you realize the underlying challenge, which is that we feel less grounded, less rooted, and less sure of our position in the world, both figuratively and logistically.  The research around attachment points to secure attachment leading to more exploration – and exploring and learning is associated with a richer, more rewarding life.  (See Attached for more on secure attachment, and see Creative Confidence for more on the results.)

We need roots and rules, as do our children.  It’s every child’s dream to have no rules, no one telling them what to do.  Well, it’s everyone’s dream to have no rules – until they have it.  Having no rules and no structure is terrifying to a child.  Having no rules and structure – to many children – means that there’s no one that cares.  That’s even worse than not having rules.

Suicidal Crisis

Most people believe that people’s desire to die is a fixed quantity, that they either are or are not suicidal.  The truth is substantially more complicated.  First, suicidal ideation is the result of the ambivalence between a desire to live and a desire to die.  Everyone has some degree of both at all times.  It’s when the desire to die temporarily exceeds the desire to live that we have a crisis.  If the person finds an acceptable means before this imbalance is corrected, they may make a suicide attempt.

A crisis may have temporarily focused us on the pain and troubles we’re facing, constricting our vision so we can’t see the positive parts of life.  It can be that we’ve misinterpreted something small that makes us believe we won’t have more joy in the future or that one of our relationships is fading.  In either case, when the balance shifts, so do our thoughts about suicide.

Someone can, because of shifting perceptions, be firmly in the camp of the living with no real suicidal ideation and ten minutes later have shifted their entire perspective.

Suicide as an Escape Route

If it gets too bad around here, I still have the option of suicide.  It sounds odd, but the laws legalizing suicide, like Oregon’s Death with Dignity Act, have had a strange effect.  Many people complete the prerequisites and get access to lethal means – and then decide that they don’t want to use it.  According to Suicide: A Modern Obsession, assisted suicide in Oregon accounts for 0.2% of all deaths.  People want to know it’s an option – but they don’t necessarily use it.

The Suicide Prevention Promise

What could be wrong with a suicide prevention program?  If it’s teaching people about suicide, how can that be bad?  The answer is in the hidden assumption that there is such a thing as a single solution.  A checklist for protecting teens, students, and coworkers doesn’t truly exist.  We can stitch what we know together in a way that implies certainty and a linear process that doesn’t allow for individual variation – but we know that this cannot be right.

That isn’t to say that all suicide prevention programs are bad – far from it.  Suicide prevention programs today need to acknowledge the limitations of their knowledge and effectiveness.  The moment that you feel that you have it figured out is the moment when you know that you’re wrong.

Suicide Capital of the World

It’s easier to sweep suicide under the rug.  Don’t talk about it.  Don’t try to solve it, because to do so would require you to admit that it’s a problem.  Sometimes, when loss survivors start to talk, it makes planners, politicians, and people uncomfortable.  The dynamic becomes that, on the one side, you have people who want absolute silence about a topic, and on the other side, you have people who believe that speaking about it is a must.  One side suppresses, and the other side shouts.  (See Going to Extremes and Why Are We Yelling? for more.)  The result is the suppressors see so much communication about a topic – like suicide – and the side sharing the information continues to shout it, because they know it’s not reaching the people.

Caught in Customs

Suttee is a ritual where a widow dies by flinging herself on the funeral pyre of their husband.  The Japanese have several of their own forms of culturally-sanctioned suicides that signal something to others.  These suicides are, ostensibly, individual decisions.  However, the force of the cultural expectations can be overwhelming.  (See How Good People Make Tough Choices, and Trust: Human Nature and the Reconstitution of Social Order for more.)

In The Happiness Hypothesis, Jonathan Haidt explains the powerful effects that cultural norms can have through his elephant-rider-path model.  (See also Switch.)  If we want to change suicide rates in a meaningful way, we must take on the difficult but important task of changing the culture.

Must Be Insane

Arguments have been made across history that to die by suicide, one must have been insane.  Some people still believe that 100% of deaths by suicide have a mental illness.  This is a logical fallacy.  (See Mastering Logical Fallacies for more.)  The presumption is that there’s no valid, logical reason to die by suicide.  It ignores debilitating amounts of pain and sorrow that skew perception of the world so that there can be no hope left.  (See The Psychology of Hope for more about hope.)

Avoiding the Label

For some, the desire to die by suicide is strong, but their values prevent them from doing it.  (See Who Am I? and The Righteous Mind for values.)  Instead, they resort to risky or self-destructive behavior that is likely to lead to their death but they can claim they didn’t die by suicide.  Rarely is drinking oneself to death ruled a suicide.  More often, it’s a tragic, “accidental” poisoning.  When someone drives recklessly, their death is often ruled an accident.

All kinds of folklore has sprung up around the way to determine an accident from a suicide – but there’s no way to really know.  If there are tire marks indicating hard braking, does it mean they changed their mind at the last moment, or did they realize they were about to have an accident?  There’s no way to really know.

There is a relative fascination with psychological autopsies.  They were first created by Shneidman (and simultaneously by Eli Robins at Washington University in St. Louis) at the request of the coroner.  The goal was to infer intent through interviews and a review of the evidence.  (See Autopsy of a Suicidal Mind.)  While these may provide some information and utility, at the end of the day, there is no way to know what was running through the head of the person at the moment of their death.

The problem with categorizing these self-destructive approaches is that there is no clear line.  Playing Russian roulette normally has a 1:6 chance of dying.  Climbing Mt. Everest has a 1:10 chance of dying.  Many would call playing Russian roulette a suicidal activity – but what about climbing Mt. Everest?

Answering the Call

Call centers for people in psychological crisis are an important part of our overall suicide prevention approach – but their efficacy is difficult to determine.  Some studies have shown improvement, others none.  Professionals feel ill prepared to respond to the calls they receive.  Sometimes it seems that laypeople do better answering the phone than people with clinical training.

This surprising discovery may be a result of the expectation gap.  Professionals believe that they’re expected to solve the problem.  Laypeople believe that all they can do is listen.  They expect that the person is still responsible for their own life.

The research on call centers places the number of people who are suicidal at less than a third of the callers, with those who are seriously suicidal much smaller than that.

Lock them Up

The professional response to someone discussing suicide is often an immediate move for involuntary hospitalization.  The professional can’t risk their reputation and their malpractice insurance on a suicidal person.  The problem is that there has never been any research on the efficacy of inpatient hospitalization for suicidal ideation.  More troubling is the research is clear that the chances of death by suicide after inpatient hospitalization is substantially higher.  So, while the instant answer is to lock people up – for their own protection – that may not always be the best approach.  In Suicide: Inside and Out, David Reynolds explains how he could have tried to kill himself while on the inside.

The more pressing problem is prevalence.  One high school social worker explained, “All the students come in at some point and talk about suicide, I can’t put them all in the hospital.”  This striking realization is the same problem with attempts to screen everyone who interacts with healthcare.  The instruments we have are overly sensitive and identify more than 300 people who won’t die by suicide – along with the one who will.  We want to lean on dramatic interventions, but that doesn’t always make sense.

Screening and Assessment

The problem, as just mentioned, is that screening identifies too many people.  The solution to this problem is to follow it with an assessment.  Even presuming you can staff up to support the dramatic rise in the number of assessments that need to be done, there’s another problem.

The problem is that our ability to accurately assess the likelihood of suicide is pretty lousy.  Sure, Edward Shneidman wasn’t bad at it – but the average clinician being asked to do these assessments has an only slightly better ability to predict who will and who won’t attempt than random chance.  This starts with our bias to believe we’re better than we are, as Thomas Gilovich explains in How We Know What Isn’t So.  It exposes the same difficulty we see in all predictions (see Superforecasting, Noise, and The Signal and the Noise) – they’re difficult.

If we know that experts can’t predict suicide, one has to ask why we’re spending so much money teaching non-professionals to do it.  One wonders why we have so many indicators about suicide when they’re not very predictive.

The Basics

Still, even non-suicide specific behavioral health professionals get no training in suicide.  A basic understanding would help them identify critical cases and learn how to validate in a way that deescalates the crisis.  General practitioners or your everyday doctor, on average, get absolutely no training on suicide whatsoever.  It would be good to help them, too.  Understanding the basics without expecting prediction will naturally improve our ability to identify people who are asking for help – without using the words.

Here, too, programs that help laypersons identify and support suicidal individuals can be powerful – as long as we don’t expect too much.

The Enemy

Too frequently, we fall into making death our enemy.  We see the dark robe and scythe, and we decide that it must be bad.  Certainly, it’s not the right first choice.  However, the real enemy is inhumanity.  Even Gandhi gave poison to a suffering calf to hasten its death.  We routinely euthanize our pets and livestock when they are in pain.  However, when it comes to humans, it’s more complicated (as explained in Final Exit).  That being said, it’s important to allow for the conversation about what is and isn’t humane.  If we don’t, perhaps we’ll all be caught in the November of the Soul.

Book Review-Suicide Prohibition: The Shame of Medicine

Thomas Szasz was a controversial and sometimes contrarian personality who ended his own life in 2012 following a fall.  Suicide Prohibition: The Shame of Medicine lays out a set of criticisms on mainstream medicine for the way that suicide is approached.  He does not, however, constrain his attacks exclusively on medicine.  He shines a light in the places where we seem to hold contradictory views.

Birth and Death Control

We have no control of our birth (or our conception, for that matter).  Szasz argues that “the state” insists that we die that way.  His arguments are similar to those made in Undoing Suicidism, but the arguments are more pointed.  He speaks of our work to prevent death row inmates from dying by suicide and then executing them.

With the recent US Supreme Court decision overturning Roe v. Wade, the state governments have moved in to seize greater control of birth rights from mothers.  Szasz’ argument is that governments want control of things that should rightfully belong to individuals.

We have a set of rules that apply to suicide that apply to no other condition, argues Szasz.  Police officers can detain a person against their will on the suspicion that they’re a harm to themselves or others.  Consider a hypothetical situation where an officer is 80% convinced of harm to self or others.  The result is – effectively – imprisonment.  (Detention against will.)  No other condition except suicide carries the same consequences.  There’s no officer detaining someone on the 80% chance that they might want to drive drunk.

Doctor–Patient Relationship

The foundation of any relationship is trust.  (See The Righteous Mind, Trust, and The Science of Trust as a start.)  The doctor–patient relationship has protections to allow patients to be able to share openly.  However, suicide, for too many doctors, isn’t safe.  It’s not something that everyone believes can be discussed, so they directly avoid patients talking about it.  They intentionally ask screening questions in ways that lead the patient to know how to answer.

For those patients that push through and speak about suicide openly anyway, they find that they often are involuntarily detained as a risk to themselves.  Instead of listening and understanding the life concerns that lead to suicidal thoughts, the doctor moves to deprive them of their freedom.  These are, unfortunately, not isolated cases.

Even mental health professionals sometimes move in ways that shame patients.  No-suicide contracts ask patients to commit to contact when symptoms worsen.  The outcome is clearly institutionalization (loss of freedom), but patients are compelled to sign these contracts, because if they don’t, the providers will refuse to treat them.

I pause here for a moment to recognize how counter this is to everything we know about good mental health.  We know that the best indicator of outcomes is therapeutic alliance – how the patient and provider relate – and this signals a complete breakdown.  (See The Heart and Soul of Change.)

Carl Rogers implored therapists to treat their patients with “unconditional positive regard” and to acknowledge that they are the experts in their lives.  (See A Way of Being.)  Both David Jobes in Managing Suicidal Risk and Marsha Linehan in Cognitive-Behavioral Treatment of Borderline Personality Disorder explain that clinicians should work with their patients to support them – not to lord over them.

Mental Illness and Suicide

It’s odd.  90+% of people who die by suicide have a mental illness.  95% of people who have a mental illness won’t die by suicide.  The reason both of these statistics can be true is because the number of people with mental illness is large – and the number of suicides (relatively speaking) is small.  There’s another problem with these statistics: the number of people in the general population that qualify as having a mental illness.  20% or more of adults in the US admit to having had mental illness in the preceding year.  That likely doesn’t include others who would be included if substance use disorder and alcohol use disorder were added in.

The problem is that mental illness and suicide have become tightly coupled in the minds of the public – and both have stigmas attached to them.  Suicide has a long history with stigmatization, the escape from which was to claim mental illness.  (See Stay and A Sadly Troubled History for more.)  The result is that there’s little chance that a person suffering with suicidal ideation will be treated with compassion, should they reveal this fact.

Szasz highlights the missteps by President Bill Clinton on June 7, 1999, when he said, “As we’ve heard again today, mental illness can be accurately diagnosed, successfully treated, just as physical illness.”  The problem when a public official makes outlandish claims is that the public trusts less of the truth – not more.  The truth – despite what some may believe – is that we can’t get reliability of therapists diagnosing with the same condition much less agree on treatment.  The DSM outlines the criteria for various conditions, but the criteria themselves leave so much room that it’s often hard for clinicians to make decisions.  Twenty-five years after Clinton’s claim, we still can’t meet the idealistic standard that he proposed.

Prediction

Perhaps the hardest truth is that we still cannot accurately predict which individual will make a suicide attempt and who will not.  There are some cases when we’re clear that someone is at risk – for instance, if they directly tell us.  However, in most cases, we just don’t know.  We know what leads to increased risk, but not which people will be responsible for the next iteration of those risk statistics.  While we’ve not learned how to predict it, we have learned what won’t work to reduce suicide rates – Suicide Prohibition.

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.