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.

Book Review-Treating Suicidal Behavior: An Effective, Time-Limited Approach

What started here would eventually become brief cognitive-behavioral therapy for suicide prevention (BCBT-SP).  In Treating Suicidal Behavior: An Effective, Time-Limited Approach, David Rudd, Thomas Joiner, and Hasan Rajab review what works in therapy of suicidal patients – and the current state of the literature.  Craig Bryan and David Rudd would publish Brief Cognitive-Behavioral Therapy for Suicide Prevention.  Of course, Thomas Joiner would go on to write Why People Die by Suicide and Myths about Suicide – among other works.

Concern

The book opens with a state of the art in suicide prevention for 2001 – and finds that it’s hard to identify the mechanisms of action for several studies, minimal clinical relevance for more, and plenty of mixed and confusing results.  This is true of 2001 – and today.

One of the things that seemed to elevate itself above the noise wasn’t a program specifically, but rather it was a component that seemed to be found in many of the effective programs.  That is the feeling that someone else cared about the suicidal person.  Whether it was Jerome Motto’s work with caring contacts or intensive tracking, it seemed that when people showed concern for the suicidal person – or appeared to show concern – it formed a protective bubble against the kinds of crisis that might cause a person believe that they are better off dead.  Perhaps, when others care for you, there’s always hope.

Caring Contacts

Motto’s work on what would be called “caring contacts” was first published in 1976.  The 2001 research, which confirmed the efficacy of the approach of sending letters randomly to those who declined treatment, wasn’t available as Treating Suicidal Behavior was being published.  As a result, the response in the book to the idea of caring contacts was tentative but hopeful.

Since then, the idea of caring contacts has proven to be a very cost effective intervention – particularly for those that are unwilling to pursue direct treatment of the things that may have brought them to suicidal ideation or a suicide attempt in the first place.

Effect Sizes in Ideation, Attempts, and Deaths

One of the challenges in the space of suicide even today is that the rates of suicide – and even documented attempts – are so low as to make it difficult to assess the efficacy of a program.  As a result, many research studies fall back to assessing impact on suicidal ideation.  The problem with this is that the degree to which this will impact the key metric – deaths by suicide – isn’t easy to predict.  Kirkpatrick’s Four Levels of Training Evaluation provides a reasonable framework to understand how asking for self-reports of how people feel about their ideation can be problematic.

It’s more challenging from the point of view that there’s no way to tell someone to not think about something without first bringing that thing to mind.  White Bears and Other Unwanted Thoughts makes this point quite clearly.  You can’t not think about a white bear if I tell you to not think about it.  So, talking about suicide makes it harder to not think about it – but not necessarily to not act on it, as the correlation between suicidal thoughts and ideation to action is rather low.

No Research for Inpatient Hospitalization

When most people think about others who have suicidal ideation and might attempt, they rather instantly think that the person should be hospitalized into an inpatient program – or even involuntarily committed.  There are numerous problems with this thinking; before that, it’s important to note that there is no study that proves that inpatient hospitalization is an effective treatment method.  In fact, there are studies that show the highest risk of suicide is the six months following discharge from an inpatient program.

There’s some anecdotal evidence that patients will lie to providers to get released so they can live without the rules and supervision – at least some of them for the purpose of making a suicide attempt easier.  Of course, other, less sinister explanations of the lowered psychomotor retardation of depression as it ends is another plausible reason for the problem.  Either way, discharge from a hospital inpatient program can be hazardous – with no proven efficacy for doing it in the first place.

Cognitive Distortions

One can easily forgive Mastering Logical Fallacies because they’re easy to make.  They are themselves a form of cognitive distortion.  They could be considered other variations of the kind of thing that Kahneman described in Thinking, Fast and Slow where we know that our thinking is biased and there’s very little that can be done about it.

The kinds of cognitive distortions seen in patients with suicidal ideation is a bit stronger.  They’ll give up on problem solving sooner – particularly related to interpersonal situations – and they’ll visualize fewer positive options.  It’s like they’re picked up a set of horse blinders and can only see what’s directly in front of them – even if they’re pointed in the wrong direction.  Therefore one of the skills that every potential suicidal person needs is the capacity to detect when their options are being narrowed into a state of cognitive constriction.  (See The Suicidal Mind for more on cognitive constriction.)

The Path to Suicide Leads through Cognition

Richard Lazarus in Emotion & Adaptation and Lisa Feldman Barrett in How Emotions Are Made agree – how we feel is mitigated through the lens of our cognition or thoughts about something.  If we want to address suicide we cannot ignore that even our affective feelings about things are influenced by our cognition – just as our cognition is influenced by our feelings.  If we are able to view things as positive and not a thread, then our feelings will follow.  Conversely, if we’re feeling depressed and hopeless then we’re less likely to see options and more likely to remain stuck “in a funk” because the nature of the affect makes it difficult to access positive thoughts.

Components of Personality

Beck proposed four components of personality: Cognitive, Affective, Behavioral, and Motivational.  This framework is similar to the one used for the fluid vulnerability theory of suicide (see Brief Cognitive-Behavioral Therapy for Suicide Prevention), which is: cognitive, affective, behavioral, and physical.  Beck’s model respects the hidden influences that motivations have on us.  In The Hidden Persuaders, Vance Packard explains how hidden things motivate us.  Steven Reiss delves deeper into what motivates each of us in Who Am I? relying on factor analysis to reduce motivations into 16 key factors.  What most of us fail to realize is that we make decisions and then rationalize them in many – if not all – cases.  (See Noise.)

Legal Foreseeability

Many clinicians are concerned about the idea of being sued for malpractice when treating suicidal patients.  This concern shows up in the text as recommendations for detailed documentation during or following sessions and to document, immediately following notice of death, anything that may not have previously made it into the records.  There’s some practical guidance to respond with compassion to the family’s inquiries about the treatment that the deceased patient received.  All of this is good advice.  However, overall, the legal concept that is false is the idea that we can foresee a risk of death by suicide.

There’s a difference between doing best practices of screening and assessments and whether these best practices are effective or not.  Even the best clinicians can’t get above about 80% prediction in hindsight.  Shneidman was famously put up to this test, and his results, though good, were far from perfect.  The fundamental principle of foreseeability is flawed, because no one can predict with certainty those who will and will not die by suicide.  No tool, technique, or approach meets the standard for predictability required for admission as evidence in federal courts.  Federal court rules require that experts’ testimony must be based on scientifically reliable instruments.  This is conveniently side-stepped, because the issue is the failure to execute a test – a test that is not sufficiently reliable to be admissible in court.

I feel for those who have lost loved ones – whether the professional behaved at the level of professional practice or not.  However, fundamentally, the idea of legal proceedings based on the death fails to meet the basic legal premise of foreseeability.

It Gets Better in Time

So many things in life get better if you just hold on a bit longer.  The idea that things will – or can – get better is one of the challenges of cognitive constriction (see The Noonday Demon).  Depressed and suicidal people literally can’t believe that the situation will get better in time – and that time is likely not far away.  This is true of the emotions that people are feeling even if the underlying circumstances of their life may not change as quickly.  One suggestion for people who consistently find themselves back in this space is to create a mood graph that records how the person feels over time.

The tangible output of this exercise is a graph that shows that things do vary and to get better.  This is irrefutable evidence in the place of a perception that things will never get better.  If you’re unable to get a mood graph, sometimes recalling happier times can be effective – but be prepared: it will likely take multiple examples rather than just a single one.

When the Rules Change

Some people who are suicidal arrive there because their perception of the world has been so radically altered that they don’t know what the rules are any longer.  They had a world view that has been shattered and they quite literally don’t know how to predict the next moment.  This is possible anytime an underlying belief about the world is shattered due to an accident, betrayal, or loss.  If you believe the world is a generally beneficial place, and you suddenly discover a friend was murdered, you’ll have to change your belief system to match the observed outcome, and that’s uncomfortable.  As creatures that thrive on prediction (See Mindreading and The Blank Slate), we literally don’t know what to think when one of the major rules is changed.

It should be shared that this is one of the reasons why postvention is so important.  Often after the death by a loved one due to suicide, the fundamental rules of life are reorganized whether the loved one was a spouse (or romantic interest), a parent, a child, or a friend.  Helping the survivor understand how the world can function in a way that allows for suicide is a great way to care for them.

Testing the Belief System

Recognizing that all of us hold belief systems that drive our predictions of the world can be good when talking with people who are considering suicide.  It allows you to look for, and then ultimately test, the beliefs that the person has about themselves and the world.  Often in a depressed or suicidal space, people will view things more negatively than they should – and, as mentioned earlier, they may have a hard time believing things will get better.  These beliefs lead to automatic thoughts that, though brief, can shape emotions and moods.

Ultimately, what you may find is that, though challenging, it may be important to understand Treating Suicidal Behavior.