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

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

Cultural Indoctrination

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

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

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

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

Hiding in Plain Sight

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

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

Visible Scars

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

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

The Stigma

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

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

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

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

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

Numbing

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

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

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

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

Suicide

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

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

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

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

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

Clustering

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

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

The Setup

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

Performance Pressure

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

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

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

Dense Social Ties

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

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

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

Community Pride

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

Warning Signs

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

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

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

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

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

No Mulligans

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

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

School Responses

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

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

Shaky Ground

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

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

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

Book Review-The Prediction of Suicide

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

The Process

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

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

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

Zeigarnik

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

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

Call Centers

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

The Perception of Control

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

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

Mental Health Disorders

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

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

Actuarial Versus Clinical

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

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

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

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

Psychological Autopsy

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

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

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

The Categories

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

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

Screening

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

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

Predictors and Postdictors

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

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

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

Infrequency

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

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

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

Book Review-Suicide and Homicide

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

Aggression as a Consequence of Frustration

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

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

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

Business Cycles and Status

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

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

Restraints

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

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

Perfectionism

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

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

Social Ties that Bind

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

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

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.