Book Review-A Sadly Troubled History: The Meanings of Suicide in the Modern Age

It’s an unfortunate reality that we can’t escape.  The odds are likely that you’ll know someone who dies by suicide – even if you don’t know their death was suicide.  The truth is that we’ve had A Sadly Troubled History with suicide.  For centuries, we’ve grappled with our inability to predict who will die by suicide and who will not.  We’ve struggled to understand what drives some to suicide and others away from it even amidst anguish.  This 2009 book doesn’t offer clear answers, but it does provide more clues that will hopefully, one day, allow us to reduce the pain and suffering that leads to suicide and the grief in the aftermath.

Inside or Outside

There are two problems with detecting suicide.  The first one is outlined by Craig Bryan in Rethinking Suicide, which is that even the person themselves may not know about their suicidal desires.  The second one is whether the suicidal desire stays inside or whether it’s outwardly expressed.  In other words, do they keep it to themselves?  The answer is sometimes.  Despite Shneidman’s claims that 90% of suicidal people leave clues, we find that the number leaving clues is much smaller.  (See The Suicidal Mind.)

Sometimes, internal forces like loyalty to a country or others can decrease suicide, like in times of war.  Sometimes, persecution and the creation of an inner sense of worthlessness can lead to what amounts to little more than indirect murder.  That is, the reasonable outcome of the persecution is suicide.  We see these tragic results of bullying in the news all the time.

Careful with Causation

As humans we often confuse correlation – things that occur together – with causation.  (See Thinking, Fast and Slow, The Black Swan, Antifragile, Competing Against Luck, and The Signal and the Noise for more.)  One of the correlations that was discovered was that regions of France with high levels of literacy had high suicide rates; those with lower literacy rates had fewer suicides.  It sounds like teaching people to read is a bad idea – until you realize that the real cause may be hidden in things that are also correlated.  Higher literacy rates are associated with higher affluence – and perhaps that’s one of the driving factors, not literacy itself.

One of my biggest complaints about suicide research is that it often correlates non-changeable parameters with the suicide rate, offering us nothing in terms of what to do about it.  Being an older white male may statistically be correlated with higher rates of suicide, but there’s no explanation of what we’re supposed to do about it.

Instilling Fear is Insanity

Another early, frustrating, approach is the installation of fear in the mind of those who were considering suicide.  Instead of inquiring about their problems and attempting to help them solve them, fear is used.  In my review of The Anatomy of Suicide, I shared the burial at the crossroads and the penalties levied on the families of those deemed to die by suicide.  In my review of The Fifth Discipline Fieldbook, I explained why fear is a lousy motivator, but there’s more to the story.

Fear – and stress – are harmful to the body and the nervous system.  In Why Zebras Don’t Get Ulcers, Robert Sapolsky walks through both the physical and mental impacts.  What’s harder to understand is that there are many things that can cause people to appear to have mental illness when other factors are at play.  Certainly, fear causes people to respond in ways that reflect bounded reality.  That is, the behaviors only make sense from the point of view of the person who is fearful.  Their beliefs may not match other objective reality – but their decisions still make sense from their beliefs.

Recently, a good friend lost her husband, and she was over for dinner.  Our daughters, who have been taught cognitive assessments as a part of their work, were concerned.  They wondered if our friend had cognitive impairment.  The direct response to that is yes, but the implication that it’s a part of a long decline or that it’s permanent aren’t true.  The intense grief was causing her brain to function in a way that was abnormal for her.

Similarly, infections and low blood sugar often cause confusion.  There’s a belief that if someone has died by suicide, it’s because they have a mental illness or because they’re weak.  However, the answers can be simpler – or more complex.  It may be that the person didn’t know how to cope with grief or simply that their blood sugar was low.  It’s hard to really know what circumstances came together to create the tragedy.

Strength

When a person breaks their arm in an automobile accident, no one seems intent on blaming them for their lack of bone density.  No one is disappointed that their bones broke under the trauma caused by a rapid deceleration.  However, too often, we blame people who’ve died by suicide for not being strong enough.  We have a completely different view of psychological trauma than we do with physical trauma.

It used to be that women had “hysteria.”  It was believed that it was something about their physiology that made them uniquely susceptible to psychological trauma.  That was until 40% of the men being sent home from war were suffering from similar conditions.  For them, it was given the name “shell shock.”  (See Trauma and Recovery for more.)  It would be the 1980s before post-traumatic stress disorder was officially recognized, and we began to separate the sense of strength from the impact of psychological trauma.

Despite decades of professional recognition of the problems that unresolved trauma causes, the public still often blames people for their mental illnesses.

Suicide and Homicide

Suicide and homicide are not reciprocal.  They do not pull from one pool of violence and flip a cosmic coin to determine whether it will be suicide or murder.  Even Man Against Himself doesn’t make this claim.  We instead, must look at suicide and homicide as two separate – but tangentially related – phenomena.  In most cases, the cause of a suicide attempt isn’t an attempt of violence but, as Shneidman explains, an act of escape.

The Personal Significance of Trauma

One of the often overlooked aspects of trauma is that the degree to which someone experiences trauma from an event is the degree to which they’re connected to it and perceive it impacts them – or the degree to which they feel compelled to change their views of the world.  That’s why two people who experience the same event may perceive it very differently.  It can be that it doesn’t feel connected, personally impactful, nor changes one’s fundamental beliefs – or it can be the complete opposite.  (See Trauma and Recovery for more.)

It’s not that someone is stronger or weaker when it comes to experiencing events – it’s that one is more greatly impacted by the nature of the randomness of life.

Correcting Coroners

One of the challenges of historical records of suicide is that coroners don’t use the same standards as one another – or even between two cases.  Because suicides were historically shunned, there’s a not so subtle bias of coroners to not record something as a suicide when it probably should have been.

Assessing whether something is a suicide is difficult to be sure.  As it relies on intent, it’s hard to assess post-mortem.  Is that car accident the result of a slippery winter morning or a willful decision to smash into a tree?  There’s honestly no way of knowing for sure.

This variability in recording means that suicide statistics must be viewed with a degree of suspicion.  It must be assumed that the statistics are biased away from suicide.

Lagging Unemployment

While financial hardship is also associated with higher rates of suicide, it takes time for overall economic increases in unemployment to show their impacts in a suicide rate.  There are, likely, many causes of this, not the least of which is living on reserves and the charity of the community and friends.  Despite the lag, it’s clear that the financial pressure associated with unemployment has a negative impact on self-esteem and an unfortunately positive impact on suicide.

Own Worst Enemy

When it comes to suicide, we’re often our own worst enemy.  As Capture explains, we get into a negative spiral and have trouble seeing anything else.  We judge ourselves unfairly.  We believe we should get more done, be more important, and be more successful than is reasonable.  Instead of stopping to try to evaluate ourselves fairly, we get wrapped up into evaluations that lead us to believe that suicide is not only a viable option but the only viable option.

If we want to reduce suicide, we need to teach everyone to be fair with themselves and to accept that they have intrinsic and inherent value that makes the world a better place.

The true tragedy is that mostly we create our own challenges – we create A Sadly Troubled History in our own minds.

Book Review-Suicide: A Modern Obsession

A disproportionate number of the books that I read are written by American authors.  This is particularly true when it comes to books on suicide.  Even though the London Anti-Suicide Bureau opened nearly six decades earlier than the Los Angeles suicide prevention center, the work seems centered around America.  That one of the reasons why I was interested in Suicide: A Modern Obsession: it was written by a pair of authors from Ireland.  I could get a different perspective.

The Questioning

For professionals who encounter patients that attempt or die by suicide, questions about competency are bound to arise.  It doesn’t matter whether they engaged as a medical professional or a behavioral health professional, it’s difficult to lose a patient.  It’s easy to think that a bad outcome must have been from something you did or didn’t do.  It’s easy to look for the ways where you let the patient down.

However, the truth is that none of us are perfect, and even the venerable Edwin Shneidman lost patients and assessed incorrectly.  We’ve got to learn that we can’t know everything, try everything, or positively control the outcomes with suicidal people.  Sometimes, there is truly nothing to be done.

Practical Help

One of the challenges in working with people who have suicidal ideation is that some of them are facing real challenges.  Divorce, unemployment, medical, and financial challenges are real.  One of the early observations of the London Anti-Suicide Bureau was to recognize that sometimes people who are considering suicide just need material help.  Whether it’s food, shelter, medical, or other services, the Bureau started referring people to get their material needs met.

This is an often under-discussed aspect in suicide prevention.  Of course, there’s cognitive therapy to help people view their situations differently, but what if they’re viewing their situation accurately?  The answer is sometimes to help them see that there are others in the world – outside of themselves – who are willing to support them, who believe in every human life and in them specifically.  We can’t forget that sometimes there are real needs that need to be met.

Abortion

I was somewhat surprised by the appearance of the abortion discussion.  The United States has had abortion legalized since 1973 until somewhat recently.  The result was that it rarely came up in the context of suicide.  In Ireland, however, abortions are prohibited except where the mother’s life is in danger – and suicide represents a real danger to the mother’s life.  The belief is that the mother may attempt suicide because she is pregnant and doesn’t want the baby.  Because of this, there’s a consideration about whether the mother is – or isn’t – inclined to attempt suicide.

There are some things to know about unwanted pregnancies.  In the United States, approximately one in four women will have an abortion prior to her forty-sixth birthday.  It’s also important to note that Malcolm Gladwell argued in The Tipping Point that New York’s drop in crime in the 1990s was due to aggressive policing and fewer “broken windows.”  Others, including Steven Levitt in Freakonomics, argued that fewer unwanted children were around owing to the 1970 legalization of abortion in New York.  Others argue that the drop was due to longer prison sentences.  Of these arguments, subsequent research seems to support Levitt’s assertion regarding the availability of legal abortion – though the other possibilities can’t be eliminated.

There’s research from the UK and the US that indicates a variety of impacts as a result of unwanted pregnancies, including mental illness and suicide.  This is particularly the case when the mother was raped.

The concern expressed for Ireland’s law is that, by claiming suicide risk, mothers could avoid the intent of the law.  More broadly, it would lead mothers who are not suicidal to manipulate professionals to avoid the ban.  The argument, known as the slippery slope, is a difficult one to accept without any additional foundational evidence.  (See Mastering Logical Fallacies for more.)

I Can Fix Them

Patricia explained of her marriage to Michael, “I thought I could fix him with care and love, but I was wrong.”  It’s a reflection of the same sort of sense of control of others that professionals struggle with.  We believe that we can protect our loved ones, heal their wounds, and enable their strengths, but there’s a limit to our ability to influence – even positively – the success of others.

We cannot accept ultimate responsibility for someone else’s suicide.  It’s theirs to own.  We can be disappointed, angry, devastated, and despondent – but it’s not ours to own.

Unemployment and Death

The relationship between unemployment and suicide seems relatively consistent.  We’ve seen it happen time and again in multiple countries.  The problem is that it doesn’t seem to happen everywhere.  Some countries – those with stronger social support – seem less prone to increases in suicide during higher unemployment.  There may be a lesson to be learned here.  We may be able to reduce suffering if we’re just willing to support those who are suffering economic consequences better.

The Media

There is, appropriately, concern about which things encourage and which things discourage copycat suicides.  The Werther effect is the impact that media has on additional suicides.  (See also Assessment and Prediction of Suicide.)  The opposite effect, called the Papageno effect, is the ability for the media to encourage a reduction in suicide rates.  These effects are real and warrant the involvement of the media in suicide reduction efforts.  Unfortunately, the effects, except in extreme cases, are modest.

Irrational Barriers

A mistake made by one suicidal individual exposes a quirk in the thinking of some suicidal people.  Having decided to jump from the opposite side of the bridge that he found himself on, the individual was afraid to cross six lanes of traffic to get to the other side of the bridge and jump.  Pause for a moment to consider this.  Dying was the point, but the idea of being hit and killed by an automobile while crossing the bridge was not acceptable.  It’s an extreme form of protection of the selected means – but it’s also a statement that there’s a disconnect between death and pain.

It could be argued that they would have been hit by a car but not killed, and that would have increased their pain.  Joiner argues that people must have a willingness to inflict self-harm and pain.  (See Why People Die by Suicide.)  It may be that the ability to disconnect pain from suicide is limited.

Alcohol

I grew up in the 1980s and 1990s with the conflict of Ronald Reagan and Mikhail Gorbachev.  I can still remember Reagan’s plea to dismantle the Berlin wall.  I was aware that Russians were quite fond of their vodka, but I didn’t understand the extent to which they used alcohol to cope with the conditions in the country.  Nor did I know about Gorbachev’s work to curtail alcohol consumption or the radical impacts it had on reducing suicide.

There’s no doubt there’s a relationship between alcohol use – and particularly abuse – and suicide.  While it’s not true that everyone who dies by suicide has abused or is abusing alcohol, there’s a non-accidental prevalence.  Some are quick to point out that the actual intoxication rates of those who die by suicide are relatively low – on the order of 30%.

Legacy

No doubt that losing someone to suicide will have an impact for the rest of your life.  Any death loss is impactful, and some argue that a loss due to a suicide is more impactful, because the person chose to end their life.  However, there is the opportunity for those left behind to find their way to purpose.  Invariably, when I ask a room full of people who work on reducing suicide, everyone raises their hand at having experienced a loss due to suicide – either personally or professionally or both.  The positives being acknowledged, no one would agree that them finding their purpose is worth a Suicide.

Book Review-Suicide: The Social Causes of Self-Destruction

Suicide is the most destructive thing that most people will encounter.  It can destroy families.  But It can save others.  It can also be a powerful statement that can be used to transform the world.  The question that Suicide: The Social Causes of Self-Destruction aims to answer are the motivations and desired outcomes people have for ending their lives.

Cry for Help

Attempted suicide is a cry for help.  Signals sent about suicidal ideation are a cry for help.  The question is what is it a cry for help for?  In other words, what is it that the person is seeking to change?  Are they seeking to change their personal pain, which Shneidman calls “psychache?”  (See The Suicidal Mind.)  Are they instead trying to right a moral injustice that they are partially or completely impacted by?

When Mohamed Bouazizi died by self-immolation (setting himself on fire), he did so out of both personal despair as well as a strong statement about a corrupt and harmful system.  Bouazizi was successful in his societal quest, setting off a series of protests and political changes across multiple countries that would be called Arab Spring.

Self-Control via Punishment

Another direction that we can see suicide come from is the results of self-control through punishment.  Some people have a degree of self-hate and frustration that causes them to create punishments for themselves like they might do to others.  It may be depriving themselves of their favorite activity, assigning themselves more work, or other attempts to internally implement the kind of social controls for their behaviors (and thoughts) that they feel are lacking.

The problem with this approach is that they’re forced to be their own enforcer.  This means they’re left with no one – not even themselves – to turn to for comfort or to support them while they’re struggling.  Tragically, some of those struggles end in suicide.

Economic Value

Society today – and perhaps in the past as well – has valued what we do more than what we are.  Though we’re called “human beings,” most people struggle to just be.  We’ve got a strong bias towards action that leads people to believe that they should be called “human doings.”  (See Change, Antifragile, and Cognition and Suicide for more.)  It’s no surprise then that when people retire, become unemployed, or become disabled, their risk of suicide spikes.

It’s unlikely that we’ll be able to change society to value people on their intrinsic merit rather than what they can or will do.

Falling Behind

Since the 1940s, the phrase “Keeping up with the Joneses” has entered popular use.  It refers to our desire to acquire the same material positions as our neighbors.  Daniel Kahneman’s work shows that our measure of doing well isn’t driven in abstract terms but rather by the degree to which we’re seen as doing better than our neighbors.  (See Thinking, Fast and Slow.)  Even in cases where we’re keeping the status quo, if we see our neighbors, contemporaries, or Facebook friends doing better, we’ll feel the same sense of loss and inadequacy as if we had really started a backwards slide.

Reputations

Sometimes, it isn’t a material challenge that creates a problem.  Sometimes, the challenge is a claim that damages our reputation – false or not.  While in large towns, it’s possible to escape the velocity and voracity of reputation, those in small villages, towns, and communities realize that reputation changes swiftly permeate the community, and once those perceptions have been formed, they’re permanent.  Nothing is as good as new gossip.  Nothing can make someone forget an accusation, whether true or false.

This sets up a situation where you’re not able to make mistakes, because they’ll always be with you and creates a sense that once you’re alienated that you’ll always be alienated – even if you don’t see that you’ve done anything to deserve it.

Marital Conflict

As I covered in my review of Divorce, in the United States and most of Western Europe, divorce has become much easier to obtain.  That has freed many from the bonds of a marriage that is abusive or simply leaves people with a sense that they’re not connected.  This creates a pathway to freedom for both spouses.

In some countries and cultures, the same cannot be said.  Sometimes, lopsided rules allow for men to have mistresses and initiate divorce, where women are perceived as property and have no freedom for sex outside their marriage or the capacity to divorce.  (See Anatomy of Love for more.)

Arranged marriages mean that neither party feels good about the arrangement, but men’s options are frequently broader.  This sometimes traps women and causes them to use their life as the last bargaining chip.  They know that their suicide will cause the community to consider whether the husband was being fair or not.  Sometimes, at least there are repercussions for the husband.

Judgement

In my review of The Available Parent, I shared the story of the manager whose child was playing soccer because he missed out on a scholarship.  He decided that his daughter would help him live his dreams.  I’ve long since lost track of him – but I wonder how much he accepted her as an individual separate from him, who could make her own decisions as she grew.

There’s some degree of enmeshment.  (See The Gift of Failure.)  He can’t see how she’s a different person than he is.  As a result, he’s likely to apply his judgement of himself to her – and that’s not fair.  There’s a common refrain from children that are overtly loved but have trouble making their own choices that parents should just accept them for who they are.

Suicide may be seen as the only way to escape their perceived control or persecution because the children aren’t making the choices that the parents want.

Relationships are a Zero-Sum Game

Have you ever noticed that when your friends get into a new romantic relationship, whether that’s dating or marriage, they seem to pull back from friendships?  It’s not you.  It’s not intentional.  You’re not imagining it.  Robin Dunbar spoke of the number of stable social relationships of primates – including humans – and said there is a number of relationships that we can maintain.  (See High Orbit – Respecting Grieving for more.)

Once we reach our capacity for relationships, any new relationship we form requires energy to maintain.  Maintaining that energy takes away from some other part of our lives – primarily, the relationships with others.  Certainly, there are some people who aren’t at their capacity for relationships – particularly in terms of time – but for many of us, to intensify a relationship requires that another must de-intensify.

This is why new romantic relationships can strangle out existing ones and destroy marriages.

Interdependence

If we want to be the most resistant to the pulls of suicide, one of the best approaches is not just strong relationships but a degree of interdependence on others.  The completely independent person would not need to worry about their impact on others.  They can stay inside their mind and decide that suicide is the best option.  However, when others will be caused hardship by your loss, it creates an opportunity to reach out to them – and to be dissuaded.  Mothers, with the exceptions of those caused by incest and rape, are less likely to die by suicide.  There’s a dependent who needs them; even if they themselves are feeling miserable, they know they need to help their baby.

Similarly, the degree of risk in close-knit groups is lower (but not zero).  The kind of relationship that creates the interdependence isn’t the primary concern.  What is the primary concern is the presence or absence of these relationships.

Homicide with a Willing Victim

Too many suicides slip into the range of being careless or reckless with one’s life.  Whether it’s the person who drives their car too fast, the motorcyclist who takes the curves while the bike is sliding out from under them, or the person who takes risks in other ways, not caring whether you live or die is relatively indistinguishable from any other form of suicide.

Too many suicides, whether suicide by cop or jumping in front of a train, creates a situation where someone must commit homicide and kill the willing victim.  In many cases, it cannot be avoided.  Once a train is moving, it’s impossible to stop quickly.  However, these often traumatize the engineers who know it was their train that killed the person – even if that was their intent.

Maybe it’s time we look further back from the intent of suicide into the social factors that led the person to the precipice in the first place.  Maybe it’s time to stop the conditions that create the desire for Suicide.

Book Review-Stay: A History of Suicide and the Philosophies Against It

I’ve never met a suicide survivor who wanted to congratulate the person they lost on a great decision.  Universally, the word that they wanted to tell them was “Stay.”  That’s why Stay: A History of Suicide and Philosophies Against It was so interesting.  What has history said about suicide and its acceptability to society?

Jennifer Hecht, who also wrote Doubt, starts by recounting a few of the influential people in her life whom she’s lost and some of the impact on her.  She longingly calls out to the people she’s lost to stay.

Suffering

I firmly believe that people who die by suicide are dealing with pain.  Whether it’s physical pain or the psychological pain that Shneidman called “psychache,” there’s something that makes death look more appealing than life.  (See The Suicidal Mind for more on psychache.)  I also believe that the best way we have of ensuring people do stay is to give them hope and reduce their pain.  (See The Psychology of Hope for more on what hope is and how to generate it.)  While reducing pain is individualized, there is a commonality in that changes don’t always need to be objective to make a difference.  Sometimes, just seeing things differently is enough.

Hecht starts with, “Suffer here with us instead.”  I struggle with that perspective, because it necessarily puts the requestor in the position of contributing to the hurt of another person.  That’s not to say that it’s necessary harmful in the long-term sense.  (See Hurt, Hurting, Hurtful for clarity on hurting.)  However, there’s also a sense of one up-one down.  (See Compelled to Control for more on one-up one-down.)  The person making the statement is necessarily saying they know better than the person themselves what is best for them.  As Motivational Interviewing points out, this isn’t a good position to be in.  (See also A Way of Being.)

The rest of the statement is, “We need you with us, we have not forgotten you, you are our hero. Stay.”  While I think that it’s a bit overstated, it’s a positive affirming statement about how much you want the person to continue to live.  However, the hyperbole of “hero” may cause someone to challenge the statement.

Future Selves

What we know about pain, stress, and suicide is that they cause people to focus on the current moment.  They may be hopeless because they see no way out of their current pain – even if there are viable options.  While Hecht calls the suicidal person to consider their future self who may want to live, her grief at her losses blinds her to the research that indicates, in the moment of passion, no one is going to be able to see their future selves.

One could say that they could have this argument preloaded into their thought processes, so that when the crisis arises, they’re prepared.  However, without some sort of a prompt, this, too, may be difficult to operationalize in the mind of the person struggling.

Collateral Damage

Another rational plea that is often used is that the person who is considering suicide think about how others will react to their death.  The first barrier is that they have the same perception as others, and that they don’t believe they’re a burden.  (See Thomas Joiner’s in Why People Die By Suicide.)  The second barrier is back to the constriction that prevents them from seeing anything but their current pain and the absolute desire to stop it.

Some say that suicide transfers the pain of the person who dies to their loved ones.  (See Suicide and Its Aftermath.)  And while this statement is not literally true, it’s both figuratively true and irrelevant.  The person who is struggling to live can’t see how their death will harm others.

Pain as the Path

Another argument is that the person should endure the pain, because it’s the pathway to wisdom.  While this may be true, it may not be enough.  We’re wired to make sense of the world, including the tragedies we face.  (See Trauma and Memory.)  However, when the pain becomes too severe, this is little solace.  Some will say that which doesn’t kill you makes you stronger.  However, as Antifragile explains, that’s not truth.  There are bands of strain and challenge that can help you grow – but there are also levels of struggle that do nothing more than harm you and beat you down.

If we’re supporting someone with suicidal ideation our goal should be to ensure that their pain is minimized to a level where it can create growth.  (See Posttraumatic Growth for more.)

Hold Your Ground

Plato suggested that we are assigned guard posts, which we should attend until we are dismissed.  To die by suicide is to abandon our post and leave our community vulnerable.  The general principle is that we’re responsible to the community and choosing the time of our own death deprives the rest of the community of our life.

While this is a sound argument for the person making a determined decision to die by suicide, it won’t dissuade the impulsive person from dying by suicide.

Christian Suicide

Christianity has a problem with suicide.  Given Saul and Samson both in the Old Testament as well as Judas in the New Testament, suicide is both mentioned in the Bible and also not condemned.  Even Jesus’ death on the cross was one that he could have avoided.  The language is that he gave up his life – an active choice.  That means or at least implies suicide.  It’s no surprise, then, that early Christianity had no problem with suicide – particularly for martyrs.

Then the Church started shifting away from suicide being acceptable.  Through scholars and meetings, suicide became gradually less acceptable until it was outlawed, and those who died by suicide couldn’t be buried in the church graveyards.  Those who attempted but lived would be excommunicated.  It’s only in very recent times that the Church has accepted that people who die by suicide aren’t evil.

While suicide isn’t accepted by the Church, the prohibitions for the normal rites of burial are no longer denied.  The Church accepts it like they accept sin.  They don’t like it, but they accept that it’s impossible to prevent.

Islam

Islam’s position on suicide hasn’t changed much.  Islam prizes people who endure unbearable lives.  Suicide is therefore abandoning one’s opportunity to be honored and praised.  The specific rules regarding the disposition of bodies of those who died by suicide may vary from sect to sect, but the general disdain does not.

Dramatic Tragedy

There are multiple historical accounts where suicides could have been prevented if only we were more patient.  Marc Anthony thought Cleopatra was dead and therefore killed himself – and she killed herself upon discovering Marc Anthony’s death.  Had Romeo waited just a few more minutes, he would have seen that Juliet was still alive and desperately committed to him.  This forms the historical foundation of the aforementioned future selves argument.  Suicide is – as Phil Donahue said – “a permanent solution to a temporary problem.”  (See also Choosing to Live for permanent solution to a temporary problem.)  It cannot be undone.

From a prevention standpoint, we know that any time we put between a person and their chosen means reduces suicidal outcomes.  Suicidal crises – when people are willing and able to complete the act – are, relatively speaking, brief.  (See Alternatives to Suicide for more on suicidal crises.)  If someone can be helped or delayed in these moments, their chances of ultimate survival are quite good.

Third-Party Suicide

Since suicide was prohibited but being executed was not, many people got creative.  Women would commit murder to be sentenced to death.  That was until a law was enacted requiring that a person receive life imprisonment if they killed someone just to be killed.  Men would sometimes falsely claim bestiality, since that was a capital offense.  We know that these approaches were used from records.

In more recent times, it’s more common to see suicide by cop.  That is, a person creates a situation where police have no choice but to shoot and kill the person.  Often, this is because they’re brandishing a weapon or threatening others.  (See People in Crisis for more on suicide by cop.)

Our Own Dungeons

Some may believe that they’re their own dungeons.  They believe their bodies or their circumstances have trapped them.  In my review of The Neuroscience of Suicidal Behavior, I acknowledged that there’s no telling what a trapped animal will do – including the human animal.  When trapped, animals and humans are willing to do anything to escape.  In my review of When It Is Darkest, I explained that, sometimes, being trapped is only in their mind – but that doesn’t mean it’s not real to them.  Viktor Frankl in Man’s Search for Meaning sheds light on how the external circumstances could be the same – a prisoner in a death camp – but individuals can respond very differently.

John Milton in Paradise Lost said, “The mind is its own place, and in itself can make a heaven of hell, a hell of heaven.”  If we want to help people stay, we need to simultaneously acknowledge and accept the way that they see the world and try to influence them in ways that turn a hell into heaven – rather than vice-versa.

It’s possible for a body to feel as if it’s imprisoning us when infirmities come upon us.  However, research shows that the mood of accident victims who become paralyzed will likely return to a baseline after a few years.  None of us have perfect or ideal situations, but there’s often some good in any situation.  If we can gently guide people to it, we can help them be more positive.

Life Worth Living

In the end, rather than imploring people to stay, we should focus on helping them find that their life is worth living.  If they can find passion and purpose, then they’ve got a chance.  If they can develop a habit of service, they’ll realize that the world needs them.  If they can see the positives of their experiences, then maybe they won’t have to be asked to stay.  Maybe they will want to Stay.

Book Review-Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying

Some books acquire their own mythology.  Groups become so polarized about them that they gain their own mythical qualities.  In the space of suicide prevention, Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying has this air to it.  It’s a book that many people in suicide prevention won’t get near or read.  Some claim that they don’t want to financially support instructions for suicide – others just can’t get past the sticky, taboo feelings.  I have no such prohibition.  If I am to speak completely and honestly to people who are struggling, I can’t deny or ignore the sources of information that they’ll be consuming.  I need to at least understand it, too – even if I don’t agree.

The stumbling path that led me here has me considering After the Ball – a book that I deeply appreciate – and Undoing Suicidism.  The latter book is, in part, a manifesto and a call for greater openness to the idea of suicide as an option.  It forced me to evaluate under what conditions a society should prohibit and allow individuals of the society to execute their rights – including the right to self-terminate.

Limits

Before beginning, it’s important to note Humphrey’s stated intention, which is to provide clarity and direction only for those he deems worthy of taking their own lives – or at least those who society more or less accepts may take their own life.  More specifically, he’s referring to those who are suffering from a terminal illness.  He acknowledges that people not in this intended category have used the book, but he takes no responsibility for their use of the knowledge.

A few decades ago, the book may have been the only vehicle to get this information.  Tragically, this is no longer the case.  Today, there’s no effective way to prevent the same information from being found with an internet search.  While this doesn’t support the idea of publishing a book, it is simply an acknowledgement that it’s hard to put all the evils of the world back into Pandora’s box.

I found that Humphrey did wash his hands of responsibility – but not concern.  There are, throughout the text, repeated warnings that there are a finite set of people that he’s targeting, and that if you’re not in the target audience, you should stop.  While this may prod some to continue, the intent to focus on the terminally ill seems sincere.

A Good Death

Humphrey asserts (and I disagree), “What separates a chosen ‘good death’ from a bad one almost always comes down, upon analysis, to the amount of planning, attention to detail, and the quality of the assistance, all of which are vital to decent termination of life.”  First, let me say that while he says “death” here, I believe he’s constrained himself to the type of self-termination that he proposes.  That isn’t to say a firefighter who dies rescuing a family or the police officer who saves someone and then, through overexertion, dies of a heart attack didn’t die a “good death.”  Where Humphrey is focused, it seems, is upon the certainty of death and the mess that those who are left behind must address.

So, while he describes it as a “good death,” I’d propose a “successful plan.”  In the narrowly defined group of people who are making a well-considered, appropriately-consulted plan, I can take no issue that the death should be as certain, pain-free, and lovingly supported as possible.  This is at the heart of Undoing Suicidism – and it’s a good point.  Should suicide be the last option?  Yes.  However, that doesn’t preclude it from being an option.

Watching Them Die

Humphrey explains that “it is not a crime in America to watch somebody kill themselves and do nothing to stop it.”  In short, some of the concerns that Baril has in Undoing Suicidism – that the person should not be alone – doesn’t appear to be a problem in the US.  I can’t say that, even with the precautions that Humphrey recommends, there won’t be some uncomfortable moments and difficult questions when the police arrive – if they do.  However, in short, they can’t convict you of the crime of watching a death, because that crime isn’t on the books.

Separately from the legal concerns, there’s the concern of how one will process the death of someone they care for.  They wouldn’t be present if they didn’t care, and because they care, there’s bound to be some emotional impact – predicted or not.  Most people have never been present when another person dies.  It can be a profoundly sacred space – but it isn’t always.  Those who choose to watch – regardless of their degree of involvement in assistance to the suicide (or not) – are likely to be impacted in ways that they can’t predict.

Accidents

One of the confounding issues when it comes to gathering statistics on suicide rates is the problem of whether something is an accident or a suicide.  In the United States, over 90.7% of vehicle miles traveled are with a seatbelt.  Seatbelts and other safety features in cars have steadily reduced traffic fatalities.  (See Unsafe at Any Speed.)  The lack of seatbelt use in an accident is sufficiently odd that it raises suspicion.  (Still, I can say from secondhand experience that this is not always enough to override an accidental mode recorded on the death certificate.)

If someone runs their car into a tree or abutment at full speed, did they intend to hit it, or did they lose control?  In the context of Final Exit, what are the chances of survival?  The chances for survival without a seatbelt aren’t great.  However, from the point of view of Humphry’s framework, it’s unclear how much pain one may suffer before unconsciousness.

Prosecution

Humphrey is careful to recommend approaches that limit the chance of prosecution of those who survive.  It includes multiple strategies for demonstrating a clear sense of intent.  However, he also offers that close relatives are treated more favorably than friends.  (He doesn’t say so, but non-heirs even more so.)  He also indicates that less violent means reduce the chances of prosecution.

I think it’s fair to say that most people don’t want to leave problems for those who care about them (and therefore they are likely to care about).  The considerations for prosecution are worthy of mention.

Just Stop

Humphrey asserts that, “A willingness to die is insufficient alone to bring about death.”  Here, I both agree – and disagree.  I’ve seen enough people make decisions to let go of their struggle with their illness to recognize that there’s a set of conditions where the person is being kept alive by their sheer force of will; when it evaporates, their end is near.  (My experience is within weeks, if not days.)

Humphrey continues by explaining that someone can’t just “stop breathing.”  While he expects that some who are good at meditation might be able to achieve this, the mechanics of brain function are dubious about this point.  We’re designed to resume breathing when oxygen saturation in the prefrontal cortex is lowered below the point of conscious thought.  However, there are other, more accessible, approaches to biological manipulation that can hasten death.

Mode of Death Certification

Historically, the stigma against reporting suicide as the mode of death has been reported to have depressed the actual numbers of suicide deaths.  While the laws that would penalize people’s families for the death by suicide are off the books, the stigma is still alive and well.  Above, I mentioned what I saw as a clear-cut suicide, but the mode of death was recorded as an accident.

Some of what lingers is the exclusion for suicide in life insurance payouts.  Nationally, Humphrey quotes that the exclusion can’t exist for more than two years, or more than a year in Colorado.  The dynamics are that the life insurance providers don’t want people buying a policy and then dying by suicide to leave money to others.  If someone dies by suicide in that window, their premiums are refunded.  Problems still exist to get proper recording on a death certificate.

The other point that Humphrey makes – which Postmortem contradicts – is that the family must consent to an autopsy.  The property rights of a person to their body terminate at death.  While family wishes are generally respected with regards to an autopsy, they are unlikely to prohibit an autopsy even if they object.  All that must exist is a suspicion of foul play – which is an incredibly low standard.

Keeping It Secret

Humphrey acknowledges that some will desire to obscure the mode of death (suicide) for reasons of their own.  His recommendation is that a suicide should not be covered up, but that silence and discretion can and possibly should be used.  The challenge here is that covering up any aspect of a death is risky.  Doing so risks discovery and the loss of credibility.  That can lead to problems that aren’t good for anyone.

There are, in most states, limitations about who can get death certificates and how much information they can get from them.  It’s reasonable to record the death as a suicide and have not very many people know that.  Few people see death certificates.  More frequently, people learn of a death through the obituary, in which anything the family desires can be written.  An associate of mine confided that her father’s death was suicide, but the obituary said, “hunting accident.”  She wondered who would believe that story when his death occurred in July (not any recognized hunting season).

While I discourage the decision for suicide in all circumstances, there is some perspective to be gained by considering the Final Exit.

[I’ve intentionally omitted the means and methods with their efficacies and problems from this review.  My point was to investigate the issues surrounding planned death, not to select a means – or encourage others to do so.]

Book Review-Postmortem: How Medical Examiners Explain Suspicious Deaths

It’s not a morbid curiosity (or maybe it is).  One of the key aspects of suicide work is the psychological autopsy or fatality review.  It’s an attempt to understand the intent of someone who died to determine whether their death was an accident – or if it was intentional.  If I was going to understand the psychological autopsy, I felt I needed to understand how the overall autopsy process worked, which led me to Postmortem: How Medical Examiners Explain Suspicious Deaths.

It starts with an understanding that, even though it’s performed postmortem (after death), it’s done for the living.  It helps us to better understand what happened and what things can cause death.  Autopsies are at the heart of much of our medical knowledge.  What’s curious is when the long-term or justice needs served by an autopsy come in conflict with the short-term, organ-donation, life-saving benefits.  The ethical dilemmas are large in a space where we’re seeking the truth by means of dissection.

Suspicion

Now, autopsies are done only when the death is suspicious, “suspicious” meaning the death occurred out of place or out of time.  Perhaps the person was found two states away from where they lived.  Maybe they died young without any known diseases.  Maybe the scene of their death just didn’t look or feel right.  (See Sources of Power about unconscious, tacit knowledge that can lead to “not right” without the ability to articulate why.)

Overall, roughly 75% of deaths occur in places where they’re expected.  Nursing homes and hospitals have staff that understand how to be culturally sensitive in response to a death.  While it is not the desired outcome, it is one that they’re all too familiar with.  Of the remaining 25%, most (20% of all deaths) are suspicious.  Those are the ones that consume the medical examiner’s attention.

Hope

The kind of hope that fills the medical examiner isn’t going to help the deceased.  If they discover an infection, it can be that it may help prevent its spread or aid in its identification.  They can save other lives by means of advancing medicine and public health initiatives.  However, a different situation reveals a homicide rather than a natural disease.

In the case of homicide, the medical examiner serves the public good by increasing the chances of finding and punishing the offender.  This frequently removes them from the general population, thus preventing another homicide.  Additionally, the belief that, if you murder another individual, you’ll be brought to justice deters the action.  (See Dreamland for the power of deterrent.)

Expert Testimony Standards

Ultimately, if a medical examiner determines that a person was murdered, they’ll be called to trial.  During the trial, the medical examiner will be called as an expert witness.  A series of court decisions collectively known as Daubert-Joiner-Kumho establish the criteria upon which a judge can disqualify a witness as an expert witness.  I cover the criteria in detail in my post for Science and Pseudoscience in Clinical Psychology, and in my review of The Cult of Personality Testing, I explain how Rorschach’s inkblots fail to meet this test.

It’s for these reasons that the approaches medical examiners use are exacting and why their documentation is rigorous.  They want to ensure that their testimony stands up to the judge’s criteria – and ultimately cross-examination.  The cross-examination represents a bigger problem, because no matter how high the standards are in a medical examiner’s office, there are always more things that can be done; it’s important to help the jury understand that the steps that aren’t done don’t add enough value.

NASHU Standard

For the most part, medical examiners use a standard for the manner of death.  NASHU stands for Natural, Accidental, Suicide, Homicide, or Undetermined.  Buried in this is the problem of inferring intent.  Did the person intend to run off the road into the abutment, or did they lose control of their vehicle?  One is an accident, and the other is a suicide.  Did the mechanic intentionally disable the brakes on the vehicle, or did they simply fail?  One is a homicide, and the other is an accident.

Hiding Intent

A bullet wound is relatively easy to document and implicates a gun as the method of death.  However, it says nothing for the manner of death – it says nothing for intent.  Was it an accidental discharge while cleaning the gun?  Was it an attempt to die by suicide?  Did someone else fire the gun?

Some medical examiners had previously only recorded the manner of death as a suicide if there was a suicide note.  However, this substantially undercounted the number of suicides, because the rate of suicide notes for death by suicide is quite low.  (See Clues to Suicide.)  In many cases, the person dying by suicide intentionally hid their intent – at least prior to their death – to prevent people from trying to stop them.

Similarly, murderers have substantial motivation to hide their behaviors, so the medical examiner might classify the death as natural or accidental – or at least undetermined.  So, while intent is difficult to discover, it’s the job of the medical examiner to use all the medical tools at their disposal to expose the method and manner of death.

Thanatography

A biography is the story of the living.  It’s the story of their life.  A thanatography is a story – or narrative – of the death.  If those around the deceased volunteer the social situation for the individual, it may include their losses and environmental problems, but frequently it does not.  Think about the impact on intent if the deceased recently lost a job or a love or had financial or legal problems.  It creates significant doubt that their death was either natural or accidental – though these same factors would tend to create poorer cognitive processing and therefore poorer decision-making, potentially leading to an accident.

Things We Do

Disturbing a dead body is taboo in Western societies, which is why there is a degree of concern about the autopsy process.  However, we accept it as a necessary process to protect the public interest.  We do many things in an attempt to save patients, which make the medical examiner’s job harder.  Life-saving attempts like CPR have successful recovery rates in the single digits and necessarily create their own traumas.  When it’s not successful, the medical examiner is forced to decide whether the injuries they see were causal to the death or were a part of the attempts to retain life.  (Most people don’t realize how much force must be used to do CPR correctly.)

Addiction over Intent

With addictive substances, like alcohol, the precipitating causes of death are presumed to be overdoses rather than suicide.  The presumption is that the factors that would lead to an accident are stronger than their agency to produce a suicide.  (See The Mind Club for more about agency.)  In cases of overdose, it’s rare that the evidence can outweigh the bias towards an accident.  Certainly, a suicide note is clear but, other, subtle signs of distress may justify the increased substance use as a way of numbing.

Medical examiners are used to this kind of precedence in general, with cardiac (heart) causes taking precedence over pneumology (lungs).  Immediate, lethal trauma has precedence over chronic disease.  In this way, there’s an order to the evaluation of criteria.

Validity of Precision

The documentation process can consume 75% of the work of the medical examiner because of its criticality to the potential legal needs – whether defending the office or prosecuting a murderer.  In this documentation, accuracy is privileged over precision.  Bands of gold on the left hand of the victim will be described as such even if it’s clear to everyone that it’s a wedding ring.  The first is an observation.  The second is a culturally-informed value judgement – and is thus less about truth and more about the beliefs of the examiner.

Witnesses

The history of law has a long relationship with witnesses both in recognizing their necessity and their lack of reliability.  In numerous places, the Christian Bible explains the need for two witnesses – including Deuteronomy 19:15.  The implication is false accusations, but there’s more than that.  Witnesses are notoriously unreliable owing to our belief that our memories – and theirs – are accurate representations, like a photograph or a video tape.  However, we know quite clearly that our memories are more reconstructions than they are recordings of the actual events.  (See White Bears and Other Unwanted Thoughts.)

It’s a difficult spot for prosecutors when the memories of the witnesses come in direct conflict with the pathological evidence that’s captured by the medical examiner.  Simple changes like believing a person was stabbed in their left or right side when the physical evidence shows the opposite can unwind the credibility of a witness’s testimony.

Getting Away with Murder

While precautions are taken to prevent someone from a murder going undetected, not everything in the autopsy process is biased towards detection.  Precautions like delaying examination for 24 hours and limiting the toxicology screenings to the things that make the most sense mean that some mechanisms for murder can slip past detection.  Some substances break down in the 24-hour period and aren’t detectable.  Others are sufficiently rare that they’re rarely tested for.

Medical examiners noted that the homicides they saw tended to be of the “heat of passion” kind.  These murders aren’t well planned out and are thus relatively easy to spot.  Of course, if someone had planned out a murder well, the medical examiners would reach the same conclusion – leaving the well-planned and executed to accidents, natural, or undetermined, because there were no traces of evidence left.  Either way, the chances of getting caught taking someone else’s life are sufficiently high as to be a deterrent.

Police Homicide

Invariably, there will be a requirement for a medical examiner to evaluate a death caused by a police officer.  Some cases will be where the suspect forced the officer into a decision to shoot.  It’s possible that some of these are best described as suicide by cop, where the victim wanted to die but couldn’t do it themselves, so they created a situation of threat that no officer could ignore.

Other cases are tragically where the officer used too much force for no valid reason.  The problem, for the medical examiner, is that the bias to not declare the officer – whom they’ve worked with for years – as the problem is large.  It’s a very high bar for a medical examiner to determine that the officer used a level of force that resulted in death because of the discomfort they’ll feel in doing so.

When Babies Die

In the second half of the nineteenth century, historians estimate that 15-to-30 percent of infants didn’t live to their first birthday.  It’s difficult to attach to a baby that you believe only has a 3:4 chance of living.  By attaching, you’re setting yourself up for a high degree of loss.  In today’s world, infant mortality is substantially lower.  That’s why, when a parent or caretaker doesn’t show sufficient concern for the death, they’re automatically considered as a suspect.  There’s a cultural norm to grieving even if it’s a unique experience.  Reactions outside the normal, expected band are suspicious.

Sudden infant death syndrome (SIDS) is a real problem that plagues infant mortality.  In 2002, about 8 percent of infant deaths were attributed to SIDS.  Some of those undoubtedly weren’t SIDS in the proper sense.  Some of them are situations where babies are suffocated – mostly accidentally.  One Ohio coroner observed wryly that “the only difference between SIDS and a suffocation is a confession.”  Co-sleeping relationships, while understandable, place the baby at risk.

The Cost of Life

Organ donation saves lives.  They’re frequently called “gifts of life;” however, they’re also big business.  Technically, the organs themselves are gifts, but recipients are still expected to pay for the services necessary to get them.  Sometimes, the needs of the medical examiner – including the 24-hour delay before examining a body and the potential desire to biopsy or cut open an organ to learn more – comes at odds with these life-saving goals.

There are no easy answers to what should take precedence – the harvesting of organs and both the lives saved and the economic engine it entails may be the right answer.  Conversely, the need to protect the public from murderers has some lifesaving value, too.  Which one should take precedence is a question that is becoming more legislated, with laws being written about who has precedence and when.  This is necessary, because in some cases, medical examiners have failed to yield their presumptive authority for the preservation of life through organ donation.

It’s an ethical dilemma of the highest order, as it means life and death for different people.  We’ll never know which decision was right, even Postmortem.