Book Review-Suicide Among Gifted Children and Adolescents: Understanding the Suicidal Mind

It’s a concerning question for parents of children who are considered “gifted” intellectually.  Suicide Among Gifted Children and Adolescents: Understanding the Suicidal Mind doesn’t answer the question about whether these children are more or less likely to die by suicide.  Citing conflicting research, no conclusion is drawn.  However, there is work to surface the factors that lead to these conflicting results.

Theory of Suicide – Suicide Trajectory Model

One serious limitation to the book is the choice of primary model.  They chose the suicide trajectory model put forth by Stillion and McDowell.  This isn’t a popular model, rarely appearing even in the child development context under which it’s borne.  It has some similarities to Rudd et al.’s fluid vulnerability model (see Brief Cognitive-Behavioral Therapy for Suicide Prevention), and it seems to map out Pathways to Suicide, like Ron Maris’ book.  However, while predisposing, contributing, precipitating, and protective factors are reviewed, they don’t form a pathway as much as they represent a set of factors at the individual, family, peer, school, community, and sociopolitical levels.

The problem is that these aren’t discriminating factors.  While citing articles of M. David Rudd and his colleagues, it seems as if Cross misses the central point that we don’t have discriminating factors, and we need to find them.  More recently, Craig Bryan explains why our capacity to predict suicide is unlikely to get specific.  (See Rethinking Suicide.)  This is consistent with research showing that many attempters (who survived) didn’t think about suicide for more than an hour.  Commonly, around 70% of attempters hadn’t considered it more than an hour or two before the act.  It’s hard to build a prediction framework with these kinds of timeframes.

The Myths

Like many others, Cross falls into the trap of describing “myths” about suicide.  The first “myth” is that “Suicide occurs without warning.”  Clearly, that’s true for some people (≥70%).  “Myth” four is, “If a gifted young person wants to commit [sic] suicide, very little can stop him or her.”  Here, nuance is important.  Certainly, if they are determined to die, they will.  They’ll lie, or they’ll find lethal means that you wouldn’t think to protect them from.  (See Suicide: Inside and Out for more.)  However, the nuance is whether or not they’ll have an honest conversation about their suicidal ideation with you.  Techniques like Motivational Interviewing can help open people up to the idea – as long as the coercive forces aren’t too strong.

The “myths” reflect historical thinking about suicide.  While many continue to believe the myths as stated, we’re beginning to realize that the old ideas aren’t necessarily true.

Perfectionism

The most consistent finding for impact in suicidality is perfectionism.  This occurs among the gifted and the normal.  However, perfectionism flows through the sense of agency or growth mindset that Carol Dweck explains in Mindset.  It’s consistent with Harris’ work in No Two Alike.  In short, a small amount of dispositional difference – even among twins – will result in tendencies towards and away from things, like academic excellence.  (See Perfectionism for more on the topic.)

The Meaning of Gifted

Cross’ work is challenged by the lack of a consistent definition of what “gifted” means.  Is it high IQ or mental aptitude in a certain way?  (See Howard Gardner’s Extraordinary Minds for more.)  Is it performing above the required standard?

One relatively common understanding is the experience of being gifted.  The experience is often described as “feeling different.”  I certainly felt – and feel – that.  To be clear, for most, it’s not necessarily better – it’s different.  It’s a curiosity about what is wrong with me, or why am I different?

Psychache

Cross ends with a call back to Shneidman’s work on psychache and the need to eliminate it if we want to take care of others.  (See The Suicidal Mind for more on psychache.)  The need to increase feelings of a life worth living in the person and eliminate their pain is, however, universal to all humans.  It’s not specific to either gifted or youth.  It can be that if we want to prevent Suicide Among Gifted Children and Adolescents, we’ll need to just prevent it among all children and adolescents.

Book Review-Managing Suicidal Risk: A Collaborative Approach, 2e

The first highlight is “helping people find their way out of suicidal despair.”  That is a wonderful testimony and summary of Managing Suicidal Risk: A Collaborative Approach.  Sometimes when you read a book, you get a real sense for the heart of the author, and this is the heart of David Jobes: to reduce the pain and suffering that leads to suicidal despair.

(It’s important to note that this review is about the second edition of the book, and a third edition has recently been released with substantial revisions.)

Throughout this review, I’ll frequently simplify interactions as clinician and patient interactions, as Jobes targets a clinician audience for his book.  However, I strongly believe that the approaches and techniques that he teaches through the book are appropriate and applicable to anyone who is committed to helping others.  Suicide prevention is an odd space of behavioral health where there is no diagnosis.  There’s no need to diagnose someone with suicidal ideation, because they directly state it.  There’s no need to compare a set of symptoms against a syndrome listed in DSM-V.  Rather suicide risk is seen as a side effect or symptom of other listed disorders.  Caring individuals would want to steer clear of providing psychotherapy – but supportive human contact would be appropriate for everyone.

Carl Rogers

Though Jobes only refers to Carl Rogers a few times, there are echoes of his influence throughout.  I was introduced to Carl Rogers’ work through Motivational Interviewing.  Words like acceptance, worth, autonomy, empathy, and affirmation pervade Rogers’ work.  The hallmark that summarizes his perspective is “unconditional positive regard.”  This is in stark contrast to the traditional way that people who struggle with suicidal ideation are treated by clinicians.

To be fair, clinicians themselves are fearful.  As clinicians, they’re concerned for their license and their livelihood in the event that someone under their care dies by suicide.  Jobes addresses this concern later in the book.  More importantly, from a human perspective, they care.  You don’t go into a profession that requires so much work and exposes you to so much trauma if you don’t have a heart for helping others.  The fear of connecting with someone deeply and losing them is a fear that we all share as humans and one that too frequently creates a distance and difference.  These natural tendencies in service of the patients is one of the things that Rogers saw and called on his colleagues to fight against.

Sometimes, this shows up as simple courtesy of not interrupting; other times, it shows up as acceptance that the patient’s perspective is real and correct to them at the current moment.  Whether the clinician agrees or not isn’t the point, and directly disagreeing with a patient about their perspective won’t be helpful.  Jobes uses other words to describe the same sense of empowerment, support, and care and the need for clinicians to accept the limits of their control.

Limits

The truth is that if a patient wants to die by suicide, they can.  No clinician is going to stop them if they make the decision.  What the clinician – and human helper – needs to recognize is that no matter how well intended, trained, or skilled they are, it’s not their life.  We can support others through their difficult times and encourage other choices, but, ultimately, the choices are not ours to make.

Clinicians should seek agreement that suicide is an option for later – not now – without pushing for a “no suicide contract.”  The thought is that the clinician and patient are collaboratively looking for other alternatives and ways to change the patient’s life such that suicide no longer appears to be a viable option.  The agreement is not coercive but rather a statement of shared commitment that life should be the preferable option to death – if the important problems in life are resolved.

Understanding the Suicidal Struggle

Whether the person is a patient pursuing clinical treatment or they’re a someone who has disclosed their suicidal thoughts to another human, there is an inner conflict transpiring.  The person doesn’t want to die, but they don’t want to continue living the way that they’re living today.  Simply understanding the reasons why life seems unbearable is a good foundation for the work on perspective-taking and problem-solving that will lead someone away from the idea of suicide as an option.

Shneidman called it “psychache” – that psychic pain that pushes people towards the precipice of pursuing suicide.  (See The Suicidal Mind.)  The enlightened workers in substance use disorder (SUD) realize that SUD starts as the numbing of some psychic pain, and, progressively, the person becomes trapped by the behavior.  (See Chasing the Scream, The Globalization of Addiction, and Dreamland for more on SUD.)  While we focus on SUD from a drug addiction perspective, other addictions like eating, sex, and gambling share the same roots.  We’re avoiding a painful psychic reality.  These may – or may not – be less urgent and life threatening, though they’re more socially accepted.  Even more socially accepted is the idea of being a workaholic.  However, all of these expose an underlying pain that is trying to be suppressed – and that can only happen for so long.  Eventually, the object of numbing becomes ineffective or overpowering.

Techniques like Motivational Interviewing are effective at managing SUD.  It shares similarities in the suggestions of Jobes, and it’s based on Rogers’ work and perspectives.  It’s fundamentally a listening process that focuses on what is the most important to the patient – and it helps them address the circumstances (or, more often, perspectives) that are causing them pain.

Stress, Press, Overwhelmed, and Trauma

Conceptually, we all think we know what stress is – right up to the point where we’re asked to form a formal definition.  (Trust is the same way, as Robert Solomon and Fernando Flores explain in Building Trust.)  Stress is something inside – an evaluation, as Richard Lazarus explains in Emotion and Adaptation.  Stressors exist in the environment, but stress is evaluation of the potential impacts of that stressor.  (See also How Emotions Are Made.)  Stress is bad, as is thoroughly explored in Robert Sapolsky’s excellent book, Why Zebras Don’t Get Ulcers.

What Shneidman connected to stress was Henry Murray’s “press,” which is the stressor.  I struggle with Murray, because much of his professional work seems as much built on fancy as fact, as I explain in my reviews of The Cult of Personality Testing and Love’s Story Told.  However, that doesn’t remove the validity of the basic concept of “press.”  So, press – the stressor – is invariably connected to stress, but not without the mediating factor of internal assessment.  Unfortunately, we know from Superforecasting, Predictably Irrational, Noise, The Signal and the Noise, and other works that our perceptions are notoriously warped by seemingly innumerable biases.  Capture takes this further into a personal spiral that can lead us to despair.  It’s the personal equivalent of what Cass Sunstein describes in Going to Extremes.

In short, the precipitating factor, whether called a stressor or press, is mediated by our assessment, and that assessment is frequently distorted.

Trauma, psychological trauma, is often poorly understood as well.  Psychological trauma is simply being briefly overwhelmed.  (See Trauma and Recovery.)  Thus, being overwhelmed is trauma, and we frequently evaluate stressors in ways that are at least temporarily overwhelming.

Sidebar: Being overwhelmed can be more long-term and connected with burnout (see Extinguish Burnout) or can be of a shorter-term duration that is more of a traumatic event or moment.

SSF-4

The SSF-4, the Suicide Status Form, is at the heart of the Collaborative and Management of Suicidality (CAMS).  The form is eight pages long, with the first four pages being dedicated to assessment and treatment planning.  A second section helps to track risk through the process, and the final two pages track outcomes and disposition.

It’s important to note that integrated into the form is the core principle of collaboration.  In places, it encourages the patient to fill out the form.  In places, it’s explicitly collaborative.  In places, it’s also clinician-led.  This, along with strategic repositioning of the clinician during the process of completing the form, conveys a sense of partnership that’s often missing in clinical settings – and one of which Rogers would likely approve.

There’s a substantial amount of research and wisdom packed into the form as a framework for guiding interactions.  From a learning perspective, it’s a sidekick productivity aid.  (See Job Aids and Performance Support.)  Its consistent use allows clinicians to focus on their clinical treatment approach while being supported and guided in the CAMS framework.

The SSF-4 also serves another important purpose for clinicians.  It encourages the proper documentation that limits malpractice exposure.  People will be upset when their loved one is lost due to suicide, but the form encourages the documentation that appropriate care was given.

For non-clinicians, understanding the components can help shape the kinds of support that can be offered to others.  Jobes selected some of the most important indicators of risk for inclusion from a list of hundreds if not thousands of possibilities.

The Big Five Variables

The SSF-4 starts with asking the patient to evaluate their psychological pain, stress, agitation, hopelessness, and self-hate.  This is followed by an overall summary rating of risk.  Psychological pain is the psychache discussed above from Shneidman’s work.  Stress is, as we also saw above, a frequently misunderstood phenomenon; here, it’s combined with being overwhelmed.  The remaining three factors are addressed separately in the following sections.

Agitation

A child blows air into a wand, forming a bubble of water and soap.  The bubble floats aimlessly along until a moment of weakness causes a single spot on the bubble to fail before the entire bubble collapses in an instant.  The failure isn’t subtle or slow. The child can themselves accelerate the collapse by disturbing the bubble, like poking it.  Agitation, which Shneidman calls “perturbation” after the word’s use in the physical sciences, doesn’t itself cause suicide, but it hastens the path towards it if a person is already so inclined.

Hopelessness

To understand hopelessness, one must first recognize that hope itself isn’t an emotion but rather a cognitive process, as Rick Snyder explains in The Psychology of Hope.  He explains that it builds on both waypower – knowing how to do something – and willpower – the desire or energy to do it.  A dimension often missed in Snyder’s work is the possibility that these can come from outside the person through their relationships or society in general.  For instance, in Trust, Fukuyama explains that different cultures focus their trust on the individual, family, and society, and the greater degree that trust is focused externally, the greater the degree that hope has seeds outside one’s own capacity.

For willpower, we find that Roy Baumeister has a work with the same name.  In short, it’s an exhaustible and regenerative resource that can be strengthened like a muscle.  (See also Antifragile for more on strengthening.)  Baumeister’s work is also represented directly by Jobes in the concept of self-hate.

Self-Hate

Understanding how people can become self-destructive rather than having self-esteem is a challenge.  Self-hate leads to self-destructive behaviors – which is obviously a concern for suicide.  In Delinquent Boys, Albert Cohen explores the need for status and the inevitable disappointment that sometimes leads people to a path of self-hate and delinquency.  Albert Bandura’s work on Moral Disengagement creates an opportunity to see how people can do reprehensible acts based on structure and how they might come to develop self-hate as a result of their acceptance that they have done bad things.

A stop nearer on the path to self-hate is shame.  Brené Brown has described herself as a shame researcher at times, and her library of authored works is extensive – see Daring Greatly, Rising Strong, The Gifts of Imperfection, Braving the Wilderness, and more.  The key to understanding the difference between guilt and shame is that guilt is about “I’ve done wrong” and shame is that “I am wrong.”  Left unchecked, shame can easily develop into self-hate.  If people with shame aren’t able to separate what they’ve done from who they are and accept their good attributes, they’ll land in a place of self-hatred – and therefore vulnerability to suicide.

Acceptance

Before continuing, it’s important to note that the antidote to shame and self-hate is acceptance.  As Richo explains in How to Be an Adult in Relationships, acceptance is critical for our relationships with others and ourselves.  No one is perfect.  We cannot expect to be successful if our goal is constant perfection.  In The Paradox of Choice, Schwartz explains how maximizers – those who have to have perfection – are less happy with their lives.

For those with high standards, the immediate pushback is that perfection is possible.  This is true in the short term but is necessarily incorrect across long periods of time.  The goal for anyone should be the best they can do – excellence.  Carol Dweck’s work on Mindset and Mihaly Csikszentmihalyi’s work on Flow make that clear.  We can grow, change, and be incredibly productive.  However, we cannot do that if we’re focused on blaming ourselves.

Another, more fundamental, perspective is to recognize that one of the key tenets of meditation and mindfulness is the acceptance of thoughts as they pass followed by a release.  Instead of judging our thoughts, we simply observe them.  We accept them as a natural and normal part of consciousness.  (See Altered Traits.)  The more we can accept that even good people do bad things, the more we can release self-hate.

Preoccupied with Others

One of the observations about suicidal people is that they can become overly concerned or even obsessed with others’ perceptions of them.  Reiss might describe this as someone who is high on status or acceptance (inclusion, in this context).  (See Who Am I? for more.)  Some are motivated by the perceptions of people around them and, as a result, are particularly sensitive to bullying and other forms of social discrimination.

There has been good and credible criticism of social media and the rise of both depression and anxiety.  (See Alone Together for more.)  However, so, too, has there been research showing that technology and our always-on, always-connected world can help people find connections with others that wouldn’t have been possible before.  So, while our technological world has the potential for harm, it has the capacity to help as well.

It’s important to note that it’s the preoccupation that’s the challenge.  The tendency to ignore other perspectives – whether external or internal – is problematic.

Preoccupied with Thoughts

Another type of person is “in their own world.”  They’re consumed by their own thoughts and perceptions.  While there’s a validation of some objective – if potentially cruel – facts with those preoccupied with what others think, there’s no objectivity when someone is preoccupied with their own thoughts.  There is no automatic mechanism that leads to an accurate and grounded sense of the world.  While focusing on oneself and improvement can allow for the kind of advances that are discussed in The Rise of Superman, so, too, does the disconnection from external signals represent a risk.  This is the sort of problem that Capture is concerned with.

Reasons for Living and Reasons for Dying

When you see suicide as the fight between reasons for living and reasons for dying – rather than a binary sense of a desire to die – one can see how there is a constant internal battle.  In Principles of Topological Psychology, Kurt Lewin explains force fields and the forces that move people from one state to another or tend to keep them in the current state.  Some research implies that the reasons for dying are more powerful than the reasons for living.  That may be the case.  It may also be the case that the reasons for living in suicidal people aren’t as strong as reasons for dying.

Research seems to indicate that suicidal people have less aspirational and inspirational reasons for living.  They’re less inclined to follow themes of hope, future, plans, and goals compared to those who are not suicidal.  In short, the reasons for living are hollow – and they’re also the same reasons people would give for dying.

Prohibition of Self-Harm

Thomas Joiner’s Myths About Suicide catalogs a set of myths.  The first one is that “Suicide is an easy escape, that cowards use.”  In Why People Die by Suicide, his interpersonal theory of suicide explains that people who die by suicide develop a capacity for self-harm.  They somehow override the biological imperative to live.  Managing Suicidal Risk shares, “The eye-blink response data show that multiple attempers were extremely reactive to the unpleasant images.”

We don’t know whether this is a result of causing them to recall their own attempt or if it’s just a particularly strong natural aversion to harm, including self-harm.  However, it is interesting how it may be that there may be some visceral, intrinsic, and immovable aversion to self-harm that keeps these multiple attempters alive.  To be clear, I feel sorrow that their lives are such that they’ve been forced to come against this barrier.

Detachment

A hallmark of Buddhism is the need for detachment.  It’s not disengagement.  It’s still doing the best you can – but recognizing that you don’t control the outcomes.  (See The Happiness Hypothesis and Resilient for more.)  Therapists confronted with a suicidal patient feel the humanistic pull to save the other person’s life, but the problem is that they can’t.  They can influence – and should.  They can care – and they should.  However, it’s always the person’s decision to live or die.

One of the hardest things for new therapists to accept is that they can’t accept responsibility for the behaviors of their patients.  They’re there to support, but the choices are ultimately the other person’s to make.  If a therapist can’t detach, then their emotions will become entangled in the situation.  They’ll change their responses to defend their own feelings – whether or not that’s in the best interest of the patient.

Legitimate Pain

Consider this statement: “I have never talked to a suicidal person who did not have legitimate needs behind his or her suicidal words, thoughts, and behaviors.”  This direct quote leads us to the most important and appropriate path.  Rather than simply prohibiting the option of death by suicide, perhaps we should focus on understanding the factors in the person’s life that lead them to consider it – or want it.  We can remain focused on measures to prevent suicide, but shouldn’t we focus on the items that would remove the burdens, barriers, and pain that make them want suicide in the first place?  Instead of trapping them in a living hell, shouldn’t we fix the things that are, to them, making it a living hell?

John Milton said, “The mind is a universe and can make a heaven of hell, a hell of heaven.”  While it’s often not appropriate to change the objective circumstances that a patient (or friend) is in, it can be that we can help them change their perspective on things that are relatively neutral.  There’s a fine line here.  It’s not the idea of polishing a turd.  Instead, it’s about finding ways to accept the reality and make the best of it.  (Acceptance is another of Richo’s “Five As” in How to Be an Adult in Relationships.)

Managing Means

Whether it’s a firearm or a stash of medications, having means available to someone is not ideal.  We know that most people who have suicidal ideation and plans won’t change their means.  If they’ve already expressed “the” method that they’ve chosen, it’s appropriate to prioritize focus on (at least temporarily) reducing access to that method.  If it’s a firearm that’s the chosen method, finding strategies to reduce access, from locking it up to removing it from the home, are appropriate.  If medications can be safely locked up by other members of the home, that should be pursued.  It’s possible to leave a small quantity unlocked for legitimate needs and keep the larger quantities off limits.

Some methods are relatively impossible to restrict means for.  If someone decides to die by suffocation (hanging), there’s almost always something around that can accomplish that goal.  If they decide they’re going to crash their automobile into something, you can look for ways to limit access to their automobile, but if they need to live, this may be impractical.

In short, while means restriction is a good idea, it may not always be as practical as we’d like it to be.  Jobes makes the point that, as a clinician, it’s your decision whether to continue treating if they’re unwilling to restrict access to means – and he’s clear this is a tricky issue.

Observationally, I’d say that there will be some people who you won’t find a way to reduce their chosen means.  However, I believe there are strategies that can be employed that will signal you understand the reasons for not limiting means – like I feel I need my gun for protection – and simultaneously engage them in strategies that will have a protective effect.

Consider someone who says that they’ll die by firearm – but it will be a specific one, and they have multiple.  In this case, perhaps this firearm can be locked up in their home in a way that they don’t have immediate access – like having a friend change the combination and keep it, or keep the keys to a key-based lock.  They can keep another gun for protection, but the one they’d use for suicide isn’t available while everyone is working on keeping them alive.

Gun owners are very resistive to the guns leaving their homes in most cases.  Strategies that leave the guns in their home but locked in ways they must ask for access from another person can sometimes navigate this space.

Coping Ideas

The development of a coping idea list is a part of the recommended practice.  It’s simply a list of suggestions for things that someone can do when they feel particularly suicidal.  It can be simple, like take a walk or phone a friend.  Jobes makes the point that he’ll sometimes flip over his business card and write these ideas on it so that they have these ideas – and access to resources when these ideas aren’t enough.

Episodic

Key in understanding suicide is that suicide is often episodic.  It’s something that comes and goes in waves.  Intense suicidal ideation may last an hour or less.  We need to make sure that we enable people with skills and resources that they can access during these times of intensity.  It’s important to understand and plan, but it’s equally important to encourage and enable people to be successful as partners in Managing Suicidal Risk.

Book Review-The Anatomy of Suicide

With an initial publication date of 1840, The Anatomy of Suicide is perhaps the oldest book I’ve ever reviewed.  A fair question would be what such an old text could teach us today.  The answer is both universal truths that haven’t changed in nearly two centuries and the things that have changed.  It’s good to know what was believed so we can see how we’ve made progress in our understanding and acceptance of suicide over time.

Antiquity

Since antiquity, there have been three “causes” for suicide:

1. Avoiding pain or personal suffering
2. Vindication of one’s honor
3. To provide an example for others

The first is perhaps the most common and the heart of Shneidman’s psychache (see The Suicidal Mind).  In more recent times, less has been said about honor.  In America’s Generations, I summarized a progression of honor over time – and it’s not moving in a positive direction.  The idea of suicide as an example for others is definitely an extreme case of the protection against people taking advantage of others that is often exposed in the ultimatum game.  (See The Evolution of Cooperation and SuperCooperators.)

Justifiable Suicide?

While most people would agree with a general prohibition of suicide, many recognize that it’s not absolute.  In historical times, suicide was justifiable if one expected to fall into enemy hands and therefore to be tortured and murdered.  The water gets murkier when we speak of people who believed that they could no longer contribute to society or who were completely destitute and therefore decided to end their own life.

Today, in some countries, there is the concept – often well regulated – of suicide when a person is afflicted with a terminal illness.  So, while we share a general aversion to suicide, in some countries for some limited circumstances, we do accept that it should remain an option.

Compelled to Live

No one can be compelled to live.  Suicide: Inside and Out demonstrates how it’s impossible – even in an inpatient setting – to compel someone to live.  They must want to live.  You can reduce means.  You can try to remove every harm.  But in the end, you can’t prevent someone from suicide if they want to do it.

There’s a consensus that people who are suicidal learn what to say to inpatient doctors to allow them to get out.  (See How Not to Kill Yourself as one example.)  While the illusion of control is comforting (see Compelled to Control), it’s not reality.

Law and Consequences

No law can be made without the threat of some consequences.  The most dangerous situation is when the other person has nothing to lose.  Laws prohibiting suicide are problematic because the consequences must mean something to someone for whom not even life means something.  Threats of exposing the bodies to public display or some form of humiliation is one avenue that has been tried – with limited or no apparent success.  Being prevented from being buried on church grounds or even requiring burial at a crossroads has not made a measurable impact.  So, too, have penalties and forfeitures been levied upon the families of those who die by their own hand.  The result of these strategies has provided strong disincentive for coroners to accurately report suicides because of the repercussions.

Suicide is something that remains largely beyond the reach of the law.  Perhaps that’s just one reason why it’s not against the law in most parts of the world – the consequences don’t work.

Irredeemable

What if you “knew” that nothing that you could possibly do would ever make up for the pain, hardship, and sorrow that you had caused others?  What if nothing that you could do could get you back to having at least a neutral impact on the world?  Being hopeless, self-loathing, or irredeemable would seem to lead to a sense that suicide is the right option.  After all, if you can’t make it better, you can at least exit the situation.

Of course, it’s not possible to say that you’re irredeemable, but in the throes of cognitive constriction and suicidal crisis, it may seem that way.  (See Capture for more.)  Rick Snyder in The Psychology of Hope explains that hope is a cognitive construct that relies both on waypower – or know-how – and willpower – the desire and drive to do.  Roy Baumeister explains in Willpower how willpower itself is an exhaustible resource.  In most cases, not knowing how to compensate for past harms (real and imagined) leads to an exhaustion of willpower.

How He Lives

It’s not how a man dies that matters, it’s how he lives.  It’s a simple cliché with a deeper meaning.  Often, suicide is evaluated as the final and ultimate act of a person’s life.  In doing so, it invalidates all the other good that they have done and minimizes them to a single moment.  Too often, suicide is the result of people believing that they’ve not lived well.  Whether that’s because of unrealistic expectations or the belief that living well means a life without struggle and loss doesn’t matter.  What matters is that those that choose suicide have judged themselves and their circumstances harshly.

False Medicine

Before ending, I should say that one must overlook the quasi-medical practices of the past that we’ve long since discovered did more harm than good.  There are references to bleeding people to let out the bad humors.  Similarly, there are references to disproven theories about phrenology.  It would be irresponsible to take medical advice from a text that is nearly two centuries old – but also irresponsible to discard the entire text because of some errors.  The truth is that every work has some errors.  Some are larger and some are smaller.  Our goal should be to take what’s valuable and leave the rest.

When Life Is Unbearable, Death Is Desirable, and Suicide Justifiable

Too often, the brief and momentary troubles are perceived as persistent, personal, and pervasive.  (See The Suicidal Mind).  Our goal in preventing suicide shouldn’t be the absolute prohibition or punishment of those who consider it.  Instead, we should endeavor to reduce suffering, to make life more bearable, and to make death undesirable.  Instead of removing the scales between reasons for living and reasons for death, we should find ways to pile on more reasons for living.

Maybe if we can look deeply at how people see themselves and how they’ve seen themselves over time, we’ll finally find a way to reduce suffering through a better understanding of The Anatomy of Suicide.

Book Review-How Not to Kill Yourself: A Portrait of the Suicidal Mind

“I believe for a vast majority of people, suicide is a bad choice.”  It’s not the first highlight in the book, but it’s close.  In How Not to Kill Yourself: A Portrait of the Suicidal Mind, Chancy Martin exposes his thinking after a lifetime of suicidal thoughts and attempts.  He shares the losses and poor choices that led to his extreme suicidal thoughts and his rationale.  This isn’t the first book I’ve read written from the perspective of a suicidal person attempting to illuminate the mental machinery of the chronically suicidal, but it is perhaps the most direct and raw.

The World as It Is, Not as I Would Have It

Most people stop the serenity prayer before its conclusion.  They recognize, “God give me the courage to change the things I can, the serenity to accept the things I can’t, and the wisdom to know the difference.”  It continues, “…taking the world as it is, not as I would have it.”  It’s a constant source of challenge for humans, whether addict or not.  We all want the world to be the way we want it – not the way that it is really.  It’s easier when the world conforms to our beliefs and expectations than when we need to shift our expectations and behaviors because of the world.

We’re eager to ascribe a reality on the world when it’s just our perception.  We assume that our friend overdosed rather than died by suicide.  We would prefer to believe that our friend got distracted rather than ghosting us.  It’s easier to take our predictions and believe they are reality.

The End of Unhappiness

It’s not a novel idea that people consider suicide to eliminate the pain in their lives.  Shneidman called it “psychache.”  (See The Suicidal Mind.)  However, the degree to which this desire to end unhappiness drives not just the suicide attempt but also suicidal thinking cannot be overstated.  When we’re in intense pain of any kind, our natural response is to end the pain.  Since emotional and physical pain are almost indistinguishable to the body, there’s no limit to the approaches we may try to eliminate the pain.

Survivors often ponder whether the person who has died by suicide thought of them or what the loss would mean to those who remained.  The short answer is no.  The longer answer is complicated.  In the long answer, they thought about those they’d leave behind, but it happens in a way that is not nearly as important as the need to end the pain.

Psychological pain is different.  It’s hard to quantify and hard to understand when others seem to have everything going well.  It’s hard to understand how the longings of their heart cannot be quieted or how they blame themselves for something they’ve done or the current state of their life.  These pains are often hidden from the view of others.

Emotional Pressure Vessels

For some people and some families, emotions aren’t safe.  Somewhere in their history, they’ve learned that emotions aren’t to be trusted.  If you expose anger to the light of day, it may lash out and harm others.  If you express fear, sorrow, or longing, you may infect others and the infection may consume them.  Like a Chinese finger trap, the inability to deal with emotions becomes a self-fulfilling prophecy.  There’s no opportunity to learn how to have healthy responses to emotions, because it’s not possible to experience or share them.  (See Descartes’ Error for more.)

Over time, we know that the pressure of not having emotions builds, and it can do severe damage to psyches and relationships when emotions finally force their way to the surface.  Invariably, when emotions are contained, they’ll find their way out.

In the world of suicide, we realize that unresolved, unexpressed, and unmanaged emotions can be the source of suicidal impulses.  Like the proverbial white bear that can’t be considered, so to do the things that we deny get bigger.  (See White Bears and Other Unwanted Thoughts for more.)

Irrationality

Many are quick to describe suicidal thoughts as irrational or the result of mental illness.  However, as Dan Ariely explains in Predictably Irrational, we’re all, well, predictably irrational.  This, however, isn’t always a bad thing.  Martin explains how he was afraid of a gun and not afraid of death.  It might be more accurate to say that he had a different fear relationship with death than most.  (See The Denial of Death and The Worm at the Core for more about the fear of death.)  No matter what his fear of death, he explains that he was afraid of his gun.  This seeming contradiction makes sense when you evaluate the fear of guns as a tool for violence separately from death.

Shifting the Hand of Fate

To this point, I’ve written as if Martin’s perspective was one of always wanting to die, always wanting to silence the voices of unhappiness, but that’s not fair.  Like everyone, Martin struggled with a desire to live and a desire to die.  It’s ambivalence, not knowing whether it is better to live or to die.  (See The Suicidal Mind for more on ambivalence in suicide.)  It’s quite possible, as Martin asserts from his own experience, that the person doesn’t know for sure whether they want to die or not.  It can be that there is no clear winner in the battle to live or die.

One way to bias towards death without overtly making a suicide attempt is to make risky decisions.  Risky choices can be thrill-seeking rather than a wish to die.  It’s more socially acceptable to die in an accident than to die by suicide.  (See The Rise of Superman for many deaths that were connected to risky behaviors.)

Consider for a moment an automobile accident where a car runs off the road and strikes a tree.  Was the person asleep at the wheel and drifted into the tree – or was the turn towards the tree intentional?  We cannot know.  Was it carelessness and risk-taking to drive while extremely sleep deprived?  Was this, as Menninger describes, “suicide by degrees?”  (See Clues to Suicide for more.)

One way to bypass internal prohibitions about suicide is to set up situations where death is a possibility rather than to directly make an attempt.  Who would be the wiser?

How to Speak with a Suicidal Person

Martin embeds clues to how to speak with a suicidal person.  He shares the widely held belief that you should be direct, specific, and fearless.  There’s absolutely something to be said for fearlessly asking whether someone is considering suicide.  There’s more to be said for the person who listens and hears yes but doesn’t run away.  It’s scary for everyone.  You don’t want to be responsible for someone else’s death, and even though you wouldn’t be, it doesn’t make the fear go away.

Martin is right that it’s the secrecy of the thoughts that provide the energy, and simply holding space for the thoughts can move towards resolving them.  What’s harder to see is that you shouldn’t directly try to contradict their perceptions that lead to the desire.  If they say that they feel unloved, you cannot tell them they’re wrong, you need to invite them to discover the cognitive constriction of their thinking.  (See Capture for more on cognitive constriction.)

The tools in Motivational Interviewing are particularly useful here.  Rather than trying to convince them they’re wrong, you can and should ask them for evidence supporting their conclusion – and for the evidence that contradicts their conclusions.  The process itself unwinds the thinking that leads to poor conclusions.

Heritage and Legacy

Martin shares some of this family history of mental illness and violence not as a way to justify his struggles but for further context.  These stories are startling because of their raw nature.  I’m not sure how I could respond to learning that my mother was the woman with whom my father was dancing at prom after he had tried to kill his own mother just hours before.

We all have a heritage we’ve inherited from our ancestors, for better and for worse.  The question is always what legacy we leave for others.  Perhaps Martin’s legacy is teaching people How Not to Kill Yourself when you want to.

Book Review-Loving Someone with Suicidal Thoughts

The thought of someone you love dying is terrifying.  The thought of them dying by suicide is even more so.  Too many people suffer and consider suicide.  Too many people who love them are tortured by their inability to stop the person they love from considering or attempting suicide.  The heart of Loving Someone with Suicidal Thoughts is learning to live in these terrible circumstances.

The Worry

Friends of ours, whose son died, admitted guilt about their feelings.  There were the unfathomable feelings of loss.  The feelings of disorientation existed, too.  They had the feelings that you expect with any death of someone you love.  It was doubled by the fact that parents aren’t “supposed” to outlive their children.  But what they were troubled by was the sense of relief.  They’d lived for years terrified that there would be a middle of the night phone call or a knock on the door at 3AM.  They were troubled by the sense of relief they felt, because their fears were finally over.  They would pick the worry every day over the actual loss, but they couldn’t help but admit that the relief was a part of what they were feeling.

I won’t pretend to fully understand.  I understand that sometimes the waiting is the hardest part.  While a rejection is infinitesimally small compared to the loss of a child, sometimes the rejection is better than the waiting for someone to decide.  The fear of what may happen is worse than what does happen.  When it comes to suicide, this isn’t true.  The hardest part is the finality of the loss of someone you love.

I do not share this to encourage people to die by suicide.  I share it so that we can recognize that those who love someone with suicidal thoughts are in their own torture.  Healing for the suicidal loved one is healing for everyone.

Am I Not Enough?

Widows of husbands who have died by suicide are prone to ask, “Wasn’t I enough?”  In the frame of the present, loving someone with suicidal thoughts leads to natural self-doubt.  If I were better, then they wouldn’t have suicidal thoughts.  Love is supposed to conquer all, just like in the movies – so if it doesn’t, then I must be doing something wrong.  Brené Brown explains in I Thought It Was Just Me (But It Isn’t) how we all question our value and how we need to accept our inherent value and know that we are enough.

That leads to a painful realization that there may be times when we don’t have enough control or influence to prevent the results that we don’t want.  We love the illusion of control.  (See Compelled to Control.)  However, the truth is that we have much less control than we would like to believe.

The Impostor

“Nobody would like me if they really knew me.”  Impostor syndrome is the sense that you don’t really belong where you are.  You don’t think you know enough.  You don’t think you’re good enough.  You wonder how you’ve managed to fool everyone for so long and, more importantly, when they’ll figure out that you’ve been pulling the wool over their eyes.  (See The Years that Matter Most for more.)

The fundamental premise is that there’s a gap between the way that someone is appearing and the way they really are.  It starts small.  We hide a part of ourselves, because we don’t expect that others will appreciate it.  (See No Bad Parts for more about different parts of our psyche.)  Over time, we’re reinforced that people like the person we’re showing them, and we begin to progressively believe that they only like the image we’re projecting – not the real person.  This leads, ultimately, to people believing that the parts they’ve hidden must stay hidden, and that people wouldn’t love them if they knew the real them.

In most cases, the people who love you already know what it is that you want to hide and are just allowing you to hold it back in respect for your choices.  We hear this all the time as parents have a child come out as homosexual.  Friends sometimes comment that they’ve known for years but respected them enough to wait until they were ready to discuss it.

While this isn’t a universal reaction, it happens often enough that it calls into question the idea that people don’t really know you.  Sometimes, they can know more about you than you do – and they love you still.

Always a Choice

Once suicidal thoughts have come to someone, particularly if they’ve ever made a plan, it’s always on the menu.  When they stub their toe, waiting on it to stop hurting, taking medication, or dying are the options.  It’s not that suicide isn’t a very bad option – it’s that because it’s been recognized, it remains a recognized option.  It takes some conscious effort to remind oneself how bad an option it is – and that it might be good to take that option off the table for now.

One of the problems with suicide screeners is that they can’t distinguish between people who have had a plan and know better than to use it and those who have newly formulated a plan.  It’s hard to discern the difference between someone who has their world well under control and those who are barely hanging on.

Universal Warning Signals

There’s a persistent myth that everyone who dies by suicide has sent detectable warning signs.  (I prefer signals to signs because signs sound clearer than the average suicidal person is.)  The problem with the desire to find this is laid out in Rethinking Suicide and in Myths About Suicide.  Some people, possibly more than 50%, don’t consider suicide more than a few hours before their death.  If they don’t know themselves, what kind of signals are they sending?

Not only must the suicidal person send a signal about their intent it must be detectable.  Most of the warning signs list include a dozen or more things, and those things have a very low predictability for whether the person is or is not suicidal.  In fact, the American Association of Suicidology (AAS) once proposed an acronym, “IS PATH WARM?” as a set of warning signs for suicide – that is, until the research showed that it wasn’t effective.

For me, I focus on clear, loud signals like the following: directly indicating they’re planning to die by suicide, giving away all their possessions, or explaining that it doesn’t matter because they won’t be around.  Those are clear, detectable signals; things like changes in mood or behavior aren’t, because many people change their moods and behaviors without considering or attempting suicide.

Feelings, Beliefs, and Facts

How we feel, our emotions, are undeniably our experience.  We feel the way we feel – and no one outside of us can say we do or don’t feel a certain way.  However, that doesn’t mean that the feeling is congruent with reality.  We can feel unloved and be loved deeply.  We can feel lonely in a crowd.  We can be alone and not feel lonely at all.  (See Loneliness for more.)  Because we feel it, we think it’s truth when it may not be, as Lisa Feldman Barrett illustrates in How Emotions are Made.

Similarly, we trust our beliefs as facts when we shouldn’t.  In fact, research shows that we routinely fail to search for ways to disprove our hypotheses.  In the famous Wason selection task, less than 10% of participants could correctly identify how to properly ensure that the provided conditions and rules matched.  There’s plenty of other research to indicate that we’ll sometimes cling onto beliefs that we should know are wrong, but we’ve invested too much in them.  Going to Extremes walks how this can be used to create radical groups.

The natural bias to accept our feelings and beliefs as facts sometimes leads us to believe we’re unworthy or unloved when the truth is radically different – and we can cling to this even if we’re faced with irrefutable evidence that this isn’t true.

Detachment

One of the most important tenets of Buddhist philosophy is the idea of detachment.  The idea is that the more attached you are to your views and the outcomes, the more suffering you’ll feel.  (Suffering is another major tenet.)  (See Resolving Conflicts at Work for more on detachment.)

When loving someone who has suicidal thoughts, detachment may be more than you can muster – and you wouldn’t be alone.  The one step that you may be able to take is to listen without judgement or resistance.  Maybe you can listen without becoming attached to the words in a way that you feel you’re responsible or have any control of the outcomes.

Courage

Many people don’t understand that courage isn’t the absence of fear, it’s the presence of fear and proceeding anyway.  (See Find Your Courage for more.)  I can’t think of anything more courageous than loving someone with suicidal thoughts.  You are constantly afraid that they’ll decide to take their own life, and the best you can do is love and support them through it.  It’s an impossible situation in which too many are placed.

It’s courageous to say to your loved one that you want them to feel better, so they’ll stay, instead of trying to coerce or manipulate them into compliance.  (See Motivational Interviewing for more on non-coercive, effective strategies.)

911

There’s a temptation – even among therapists – to treat every mention of the word “suicide” as an emergency requiring a call to 911.  However, we know that many 911 calls end in tragedy – particularly with people who have mental illness or are suicidal.  (See People in Crisis for more about suicide by cop.)  While being present with someone who has suicidal thoughts is scary, it doesn’t mean that 911 is the right answer.  Calling 911 may be the right answer if they’re in imminent physical harm or they’ve made an attempt that you’re aborting.  If they’re pre-attempt and you need help, the national mental health hotline at 988 is an option to get tips and support for your loved one.

As the moments move to days, there’s another pull to have someone committed to inpatient treatment.  In the cases where it can be done, it may still not be the best answer.  It necessarily deprives the person of their freedom and sense of autonomy.  It often substantially damages relationships to the point they cannot be repaired.  To make the decision to have someone involuntarily committed to an inpatient program is very risky for the relationship and not particularly protective of the person, as the probability of suicide after exiting an inpatient program is roughly 300x.

Sometimes, the best you can do in the moment and in life is to keep Loving Someone with Suicidal Thoughts.

Book Review-Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living

It’s a worthy question.  What are the alternatives to suicide?  That’s the question that Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living attempts to answer with its subtitle.  How do we transform the pain that people feel and their desire to die?  Though an academic volume with multiple authors and the readability challenges associated with both of these aspects, the answers that you find may surprise you.

Flip a Coin

One of the depressing and discouraging statements about the predictability of suicide is that even the best work on screening, assessing, and predicting who will die by suicide in the short term is only slightly better than the odds of flipping a coin and getting heads.  Estimates vary about the ability of assessment to predict suicide, but they’re in the 50% range.  While the behaviors we’re doing imply that we’re much better at determining who will and won’t die, the realities are different.

Interact with healthcare, and you’re likely to be confronted with a set of questions about your suicidality.  It may start with depression and hopelessness, or it may directly ask about suicide thoughts, but you’re likely going to be asked.  Frequently, we see PHQ-2 (Patient Health Questionnaire-2) asked – and if the person answers in a way that’s concerning, they are automatically asked the PHQ-9 (Patient Health Questionnaire-9) questions.  Sometimes, people use the Columbia Suicide Risk Screener (CSRS) or the Ask Suicidal Questions (ASQ) screens.  The stories of patients being encouraged not to answer in a way that would trigger concern are perpetual.  No healthcare provider wants to do the extra work, nor do they want to see the person held for extended periods of time waiting for one of the few people trained to do a formal assessment.

It’s called universal screening, and it’s a requirement by accreditation bodies.  They require that you have the process if you want to receive their stamp of approval.  And because their accreditation means that you can bill insurance and the Centers for Medicare and Medicaid Services (CMS) – which is almost all of a hospital’s business – hospitals do what the accrediting body requires whether there’s efficacy or not.

That Which Needs to Stop

Shneidman described suicide as a way to stop psychic pain that he called “psychache.”  (See The Suicidal Mind.)  One of the common factors in suicide is a desire to stop something – whether it’s directly called out as psychological pain or not.  With the cognitive constriction that accompanies a suicidal crisis, people may not be able to see other solutions to stopping their pain – except suicide.  (See Cognitive Therapy for Suicidal Patients for cognitive constriction.)  The key to finding alternatives to suicide is to find alternative ways to stop the pain without stopping their heartbeat.

Dysregulation Vulnerability

The research is inconclusive.  Some believe that all suicidal people exhibit signs and create invitations for others to intercede for them.  Others look at research on suicide attempters that leads to the conclusion that many attempts – greater than 50% – were not considered a few hours before the attempt.  Because of these numbers, studies have attempted to connect suicide with impulsivity – with very little success.  The measures we use for impulsivity seem to not effectively capture the possibility that someone will consider suicide.

However, when the focus is changed to skills for emotional regulation, the story changes.  It appears that those who are more capable of emotional regulation are also more capable of riding out the short term storms that seem to lead too many to suicide.  It’s like Mischel’s Marshmallow Test has an impact on preventing suicide as well.  Learning that things will likely get better if we can just wait a bit seems to protective.  Rick Snyder in The Psychology of Hope explains that hope is made of willpower and waypower.  Waypower is understanding the path forward.  Willpower is that capacity to hang with it and keep trying.  (See Willpower and Grit for more on the power and makeup of willpower.)

Meaning in Life

Viktor Frankl famously wrote that “Those who have a ‘why’ to live, can bear with almost any ‘how’.”   (See Man’s Search for Meaning for more.)  Meaning in life – even a little meaning – can be a powerful protective force.  Simon Sinek believes that everyone should Start with Why.  It’s about finding meaning in your life, and that meaning can be small.  As Atul Gawande explains in Being Mortal, giving patients even something as simple as a plant to take care of can help them live longer lives.

We crave the idea of being useful.  Thomas Joiner’s Interpersonal Theory of Suicide (IPS) posits that lack of connectedness, feelings of burdensomeness, and ability to inflict self-harm all drive suicidal behavior.  (See Why People Die by Suicide.)  Being helpful to something or someone else directly combats that feeling of burdensomeness.

Connectedness

Robert Putnam signaled a problem when he wrote Bowling Alone.  Social capital – our connections with others – were eroding, and no one knew what to do about it.  Sherry Turkle takes it further in Alone Together, as she describes how we are becoming technologically connected and interpersonally disconnected.  There’s been an assault on our feelings of connectedness – and it’s not getting better.  In 1990, about 75% of us felt we had a best friend.  By 2021, that number is down to about 59%.  In short, if connectedness to others is a protective factor against suicide, its impact is fading.

Three Step Theory

Klonsky and May built on Joiner’s IPS theory and proposed that it’s a three-step process to get to suicide.  The three-step theory posits that pain and hopelessness move people to the first stage of suicidal ideation.  To get to the second step, they propose that pain must outweigh connectedness.  The final step of attempting suicide requires the capability to attempt – or the capacity for self-harm.  Generally, this is the integration of an ideation-to-action framework with Joiner’s IPS theory such that the process of getting from idea to action has a path.

The caution that I’d have with the three-step theory is that the process of the three steps can potentially happen very, very quickly.  It’s still a framework, since pain and connectedness aren’t quantified into scales that can be measured against one another in an objective way.  It’s about the person’s perception – and that is often colored by cognitive constriction.

Who Failed Who

Bumper stickers of people who have rescued dogs ask the question, “Who rescued who?” implying that the dog may have saved the person’s life.  While, in the case of the bumper sticker, it’s not meant in the literal sense, there’s often a reversal that happens when a treatment fails to move from blaming the practitioner or the process and instead transferring the blame to the patient.

We know that this isn’t right, that it’s frequently not the patient who failed but rather the poor therapeutic alliance, the skills of the professional, or the technique itself.  However, that doesn’t prevent many people from defecting the blame and placing it on the patient.  (See Mistakes Were Made (But Not By Me) for more.)

Once There’s a Plan, There’s Always a Plan

One of the challenges with suicidal ideation is that even the mental health professionals, whom you would typically seek out for help, are often disturbed by the word suicide and reflexively move to defend themselves.  Litigation around suicide encourages providers to suggest emergency rooms and hospitalizations at rates substantially more frequent than would otherwise be prudent.  Instead of focusing on the patient and what they need, the provider moves to protect themselves – whether it’s good for the patient or not.

One of the bigger problems with suicide assessments is that once you’re high risk, you never move back down the risk scale.  Whether you’ve made a previous suicide attempt or you’ve just developed a plan for your suicide, there’s no backing down from the high-risk category.  You see, if you’ve tried once, you may have figured out what you did wrong in your plan.  If you’ve “only” planned a suicide, they know you’ve got an idea how you’ll do it.

This neglects the basic understanding that once you’ve created a plan, it will always stay with you.  It’s not the sort of thing that you forget.  You can’t.  (See White Bears and Other Unwanted Thoughts for more.)  Therefore once you’ve developed a plan once, you’ll always be at an elevated risk – no matter what your risk for suicide is in the moment.

Tactics like suicide contracts for those professionals willing to treat people who dare say the word “suicide” are more for their benefit than the patients.  It absolves them of some responsibility if they believe that the patient committed to telling them despite ample evidence that safety contracts make patients none the safer.

Ultimately, this is the result of professionals who believe that they’re responsible for preventing patients from dying by suicide.  The truth is that if someone really wants to die by suicide, you’re not going to stop them.  (See Suicide: Inside and Out.)  Instead, it’s healthier for the person who is suicidal to accept that it’s their responsibility to keep themselves alive and the professional is just someone on the team to help make that happen.  It’s powerful for the professional to admit to themselves and their patients that they’re unable to save anyone at all – they always have to save themselves with help.

Suicide is the Solution, Not the Problem

Okay, it’s a bad solution.  However, suicide is a solution to problems and pain.  Only the patient themselves truly knows the entirety of their life, their experiences, and their pain.  We can, from the outside, only get glimpses of what’s inside.  It’s not unlike addictions, which are largely seen as the problem when they are, in fact, poor solutions to other problems the person is facing.  Often, these are the same kinds of pains that suicidal people struggle with.  (See The Globalization of Addiction, Dreamland, and Chasing the Scream for more about substance use and addiction.)

When we recognize that people see suicide as the solution and they’re the experts on their lives, we can bring to them things that are outside their perspective and experiences that may give them at least a few Alternatives to Suicide.

Book Review-Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients

What we wouldn’t do to be able to classify suicidal risk over someone’s life.  The ability to see when a person is – and isn’t – suicidal would be a great boon to our work to prevent needless deaths.  This is the grand vision to which Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients aspires.  We’re not there now – and we may never get there – but there’s value in continuing to attempt to understand suicide before it claims even one more life.

Most of Those who Died by Suicide Were Mentally Ill

It’s hard to study whether someone who died by suicide was – at the time – afflicted with a diagnoseable mental illness.  The person is no longer around to discuss the situation, and therefore the psychological autopsy process – with all its limitations – must be used.  (See Review of Suicidology, 2000.)  The primary problem with the psychological autopsy approach is that it is subject to the biases of the investigators – and if they believe there should be mental illnesses, they’ll look for it.

DSM-5, the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychological Association, is frequently referred to as “the book of woe” and is further characterized as leading clinicians to over-pathologize normal responses.  If you’re supposed to find something, and you look in the DSM, you’ll probably find something.

So, the retrospective interviews with family members, friends, and colleagues often led to identified mental illness.  Perhaps the most telling aspect of the results that found mental illness is that the primary finding was alcoholism – what would now be called alcohol use disorder (AUD).  This is telling, because in 2019, 25.8% of people in a general population survey reported having indulged in binge drinking in the preceding month.  This means they’d likely qualify to be diagnosed with at least mild AUD.  In the studies referred to from Suicide Over the Life Cycle, the percentage of patients diagnosed with a primary diagnosis of alcoholism is substantially similar to that number.

Certainly, alcohol use could be considered a mental illness, and it is also correlated with suicide deaths.  However, few would characterize it as a severe mental illness – what people often think of when they believe someone is impacted by a mental illness.  If we lower the bar to any kind of mental impairment, we could perceivably make most people who die by suicide have a mental illness.  It would, however, necessarily include nearly every adult.

The second primary diagnosis in the referenced studies was depression, something that many people in the United States struggle with today.  Again, it’s something that most people would not characterize as a serious mental illness but something that is included when categorizing most people who die by suicide as having a mental illness.

And that’s not all.  The other challenge is in the identification of those who are suicidal.  The approach used was coroner determination, which is known to be quite inaccurate.  It’s entirely possible that a coroner will decide to mark something as a suicide only when they suspect mental illness, thereby biasing the samples.

So, is there research that says most people who died by suicide had a mental illness?  Yes, that’s true.  However, the research is fundamentally flawed in at least two dimensions, and the conclusion that someone had a mental illness might include more of us in the general population than anyone would like.

Alcoholism

Let me return to the problem of alcoholism as a factor for suicide risk.  On average a person who has alcoholism who dies by suicide have been alcoholics for 20 years and die at age 47.  It’s hard to separate the impacts of alcoholism from the disorder itself.  We know that alcoholics often have unstable home, professional, and social lives.  Their disordered drinking leads them to lose their jobs, their homes, and their relationships.  These are all substantial factors that lead towards suicide – with or without the introduction of alcohol.

To be clear, it’s not that there isn’t a relationship between alcohol and suicide – there definitively is.  The challenge is that alcohol can induce alcohol myopia whether or not the person is an alcoholic, and it’s difficult to separate the work, home, and social losses from the alcohol use when determining how correlated they are.

Roles and Responsibilities

Durkheim’s assertion that suicide seemed to increase during periods of economic downturn has been well replicated – for men.  Men’s expectations are shaped by society such that their worth is driven by their ability to work and provide for themselves and their families.  Economic downturns obviously make that harder, and it’s easy to accept that men will choose suicide rather than face and address their inability to find work – presuming there is a solution.

Women, on the other hand, are often shown to be more distraught over relational or family-relational issues.  They’re more likely to be influenced by divorce or estrangement than moderate fluctuations in the business cycle.  This seems to be driven by acculturation.  We expect that women will be more focused on family and relationships and disruptions are more impactful.

These are, obviously, stereotypes.  However, both fall into the key category of missed expectations.  We’ll find that people are more likely to die by – or attempt – suicide when their expectations aren’t matched with the results that they’re getting – and that applies to men or women.

On the Same Team and No Suicide Contracts

It’s subtle.  When you insist on a contract with a person, you’re acknowledging the potentially adversarial direction of the relationship.  Contracts are used as instruments to document an agreement – but more frequently, they’re the basis for determination of right and wrong.  When we pressure someone into a contract, we’re acknowledging the very kind of adversarial relationship that we should be avoiding with a suicidal person.  On the surface, asking for a contract that says the other person won’t attempt suicide is pointless, since they’re not likely to think of the contract during a suicidal crisis.  More importantly, what consequences can the contract extract from a dead person?  (The answer is none.)

Rather than a focus on no-suicide contracts – which don’t work – we can do something that will potentially improve our outcomes.  We can find ways to signal that we’re on their team.  We’re there to support them.  We don’t think that suicide is the right answer, but we want to better understand them and help them solve the problems that may make them believe that death is a better option.

Blame Seeking Messages

Often after a suicide death, there’s a rush to figure out who is to blame.  It’s a bad outcome, so someone must have done something wrong.  The problem with this is a belief that, for something bad to happen, then someone must have done something wrong.  We don’t expect there is someone to blame if a tsunami wipes out a village, so why do we believe that there is always someone to blame when someone dies by suicide?  I’m not saying there are never people to be held accountable for malpractice, but this is much rarer than we seem to give credit for.

Seeking the answer to “why” is an unfortunate artifact of our evolution and our desire to predict the future.  Rare events, whatever their cause, are met with skepticism and confusion, since our prediction engines have failed.  (See The Black Swan, The Signal and the Noise, Superforecasting, and Noise for handling rare events.)  We look for someone to blame, so we can incorporate their malfeasance as a part of our models.

Hopelessness

Suicide Over the Life Cycle oversimplifies the response to the hopeless person and says, “The clinician should not expect to dissuade patients of their hopelessness; rather the clinician must win the patient’s cooperation to undergo, and stick with, treatment.”  Certainly, there’s no point in developing a direct conflict with a patient.  However, there’s a path between directly disagreeing with the hopelessness that someone feels and basically ignoring it.  In fact, both cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT), the most common treatments, encourage patients to challenge their own thinking and to remove cognitive distortions – with the assistance of the therapist.

Rather than dissuading patients from hopelessness, it may be enough to just try to understand it.  As the research around Motivational Interviewing shows, sometimes listening is all that is needed.

Habitual Errors

Sometimes, the cognitive distortions facing a patient can be identified and addressed.  Habitual errors in thinking are termed “cognitive distortions” by Aaron T. Beck. They include the following:

• arbitrary inference, drawing a conclusion based on insufficient or even contradictory evidence;
• selective abstraction, attending to only a portion of relevant information;
• overgeneralization, abstracting a general rule from a single event and applying it to both related and unrelated events;
• magnification and minimization, exaggerating or underestimating the magnitude and importance of events;
• personalization, attributing causality to oneself when several factors contributed to an outcome; and
• dichotomous thinking, categorizing people and events in absolutistic, black-and-white terms (e.g., good versus bad).

What to Do When a Client Dies by Suicide

When a client dies by suicide, the counselor, therapist, social worker, or coach will feel the loss themselves and need to process these feelings – but they’ll also need to consider how they will engage with the family.  Some will try to minimize contact and pretend that nothing happened even to the point of failing to address the next of kin’s questions and requests.  Suicide Over the Life Cycle makes it clear that this is a bad strategy.

In our own situation, Alex’s social worker elected to not be responsive when we reached out.  That failure to respond was very problematic – enough that there was a cross-agency escalation.  Even if you don’t feel comfortable answering questions, it’s a good idea to be responsive as possible to the family, because you want to avoid becoming adversarial with them.

While we cannot foresee suicide as an outcome in most cases, it’s important that we begin to see Suicide Over the Life Cycle as best we can.

Book Review-The Neurobiology of Suicide: From the Bench to the Clinic

By the late 1990s, a great deal was being learned about the neuroscience of the brain.  Magnetic resonance imaging (MRI) became popular in the 1980s, and it was extended to functional magnetic resonance imaging (fMRI) in 1990, which opened up new doors in learning about not just the structure of the brain but also the patterns of neurological firings.  As we began to learn more about the brain, it became important to share that with the broader clinical community to encourage research-informed care.  The Neurobiology of Suicide: From the Bench to the Clinic, published in 1997, was a step towards that goal.

Adverse Childhood Experiences (ACE)

In 1996 and 1997, the people who would participate in the landmark adverse childhood experiences (ACE) study were just being selected.  The long-term follow-up would continue for years.  However, it’s an understanding of the developing awareness that people with trauma– or even instability – in their childhood would have problems in their adult lives.  (See How Children Succeed for more on the ACE study.)

The language of the book is “chaotic” family situations – the kinds of trauma and instability the ACE study was destined to find later.

Suicidal Behavior Family Clusters

One of the places where the answers get fuzzy is when the book claims that suicidal behavior clusters in families – like so much else in psychiatry.  Here, the evidence proposed is a twins study: the twins who are paternal (coming from one egg) are compared with those that are maternal (coming from two eggs).  The concept is straightforward.  If they came from one egg, then they have the same genes, and therefore we can say that there is a genetic cause to something if both members of a twin pair are affected.

However, as Judith Rich Harris carefully explains in No Two Alike and The Nurture Assumption, there are many other confounding variables that tend to make all twins alike.  The environment that the children are raised in matters.  In other tests, even identical twins diverge in their interests sometimes – and sometimes not.

There seems to be some evidence that genetics play a factor in suicide – but no more than the typical 50% genetics, 40% environment, and 10% unknown that we often see for anything else in psychiatry.  So, it may be true that there are clusters of suicides around family trees, but it’s not necessarily clear whether this is due to genetics, cultural cues – both societal and familial – or something else entirely.

Like many things in suicide research, just because there’s a correlation there is not necessarily a causation.

Low Base Rates

In Rethinking Suicide, Craig Bryan explains why prediction may be a fool’s errand, and that reason is a low base rate.  To be an effective screening tool, it would need to be substantially more precise than any of our existing tools for any mental illness.  It’s like trying to shoot a 9” plate on the Moon – technically possible but very technically challenging.  It’s no surprise, then, that in 1997, it was explained that the tools of the day weren’t very predictive.

Behavioral Intent

The challenge with whether something is – or isn’t – a suicide often hangs on the idea of intent.  Did the person intend to strike the tree with their car, or did something else happen?  It’s incredibly hard to know if someone was truly intending the accident or whether it just happened.  Who is to say it wasn’t texting and driving instead of a willful act?  There is no way to know for sure.  While it’s possible to guess – through a psychological autopsy (see Review of Suicidology, 2000) – that doesn’t mean that the psychological autopsies are foolproof.

Given the very low incidence of people writing suicide notes (<25%), it’s no wonder that the question of intent during accidental circumstances can be so challenging.

Research

The real challenge that was facing researchers in the late 1990s was that the degree of risk that researchers’ institutions were willing to take for suicide research was very low.  This often prohibited the researcher from doing the best science they wanted to do, and instead hamstrung them into research approaches that were less clinically demonstrative for the sake of lowering the risk.

Funding was also a challenge, as other conditions like cancer and AIDS were receiving substantially more funding.

In the end, The Neurobiology of Suicide is a good map of the headwaters of what we were starting to learn about neuroscience and suicide.

Book Review-Suicide and Its Prevention: The Role of Attitude and Imitation

The idea that suicide is a global health problem isn’t new.  Many organizations had noticed the ongoing and escalating problem of suicide, and in 1989, the World Health Organization published Suicide and Its Prevention: The Role of Attitude and Imitation.  The collection of chapters from different authors was intended to represent the state of the art in suicide prevention at the time.  Some of the work recorded here continues to be explored today.

Only the Internal Matters

The book explains that one of the limitations of considering suicide a mental illness (a concept itself that has fallen out of favor for good reason) is that it restricts focus on the external factors that are leading people to be suicidal.  I strongly disagree with the assertions of the author of the chapter, Menno Boldt, because what most of the research says is that it’s not our circumstances that matter, it’s what we make of our circumstances that matter.  Whether it’s Kahneman’s work in Thinking, Fast and Slow about the relativeness of our perception of our situation or Rich Tedeschi’s work in Transformed by Trauma, Lisa Barrett Feldman’s work in How Emotions are Made, or Richard Lazarus’ work in Emotion and Adaptation, we know that what we make of the circumstances is more important than the circumstances themselves.  In the introduction to Man’s Search for Meaning, Viktor Frankl quotes Nietzsche with, “He who has a Why to live can bear almost any How.”  A why is necessarily about the internal beliefs of someone, not in their external circumstances.  (See Start with Why for more.)

Unendurable

It should be clear by the preceding that the idea of unendurable pain isn’t some fixed point but rather changes with other factors of a person – most notably, their sense of purpose and hope.  We’re implored to save people from unendurable circumstances, but there’s no way to know what those are.  The methods by which one saves others from the unendurable may be equally traumatizing.  It may be possible that someone’s loss of freedom with commitment to an inpatient facility is worse than whatever conditions they’re being saved from.

Aristos

It’s a Greek word that means the best possible solution given the circumstances, and it’s the way that I’d describe excellence.  Some people assume that excellence approaches perfect – but it’s not that.  It’s the ability to make the best possible outcome with what you have.

Unfortunately, at the point where the book was written, the meta-analysis showed that there was little improvement in the treatment of suicide in the preceding 25 years.  That’s not exactly doing the best possible in the circumstances.

More than Mental Health Professionals

However, one of the small wins that had been made by 1989 is that it was clear that the need for suicide prevention training needed to extend beyond just mental health professionals.  If we were going to identify people at risk for suicide, it would require that we engage everyone in the process.

Resignation

One of the observations is that physicians in private practice were more likely than those in employed positions to die by suicide.  The story of Ralph and his resignation to his position from Work Redesign seems particularly appropriate.  Ralph didn’t want more freedom and power even when it was offered because it would have invalidated his prior decision to give up.  Perhaps it’s that the pressures on an employed physician are different than those in private practice, but it may be equally likely that those who have taken employed positions have resigned themselves to the state of affairs.  Of course, it’s also possible that they’re disproportionately different, and these differences caused them to self-select into either private practice or corporate employment.

Marching Forward

While there’s little to share from a 30 year old book on suicide prevention, it’s important to recognize that we’ve been working for a long time on Suicide and Its Prevention.