I’ve been trying to find a way to say this nicely. Finally, I discovered a recent article in the Journal of the American Medical Association (JAMA) that says what I want to say—at least in part—in a more professional tone. The article is “Implications of Zero Suicide for Suicide Prevention Research.” Spoiler alert, the authors, Dominic Sisti, Ph.D. and Stephen Joffe, M.D. end their article with the following sentence: “To demonstrate which interventions are effective for reducing the suicide epidemic, it is necessary to let go of the belief that every suicide is preventable.” For their whole article, go to: https://jamanetwork.com/journals/jama/fullarticle/2706416?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=102318
I have no doubt that my views are more extreme that Drs Sisti and Joffe. They’re medical researchers, publishing in JAMA. But I was heartened by their article; it helped me feel less alone in my dislike for the idea of Zero Suicide. They inspired me to share some of my thoughts and writing on the topic.
That said, now I’m sharing an unpublished rant about Zero Suicide. As you read this, keep in mind that I’m strongly in favor of suicide intervention and suicide prevention. I’ve even started a trade book proposal on the subject. But I’m not in favor of Zero Suicide. Here’s why:
Last month I entered into a Twitter debate about Zero Suicide. It started and ended like most Twitter debates. We disagreed in the beginning. Then, after several passionate exchanges, we disagreed even more in the end.
The issue was Zero Suicide. Zero Suicide is a national suicide prevention campaign, healthcare philosophy, and comfortable delusion. In case you haven’t yet heard of Zero Suicide, there’s a Zero Suicide Academy, Zero Suicide ToolKit, Zero Suicide Community, and several websites orienting people to the Zero Suicide Initiative. As a pragmatic mental health professional and sentient human being, I’m completely in favor of suicide prevention. I’m in favor of suicide prevention because many people who think about suicide are in great psychological pain, and if that pain can be addressed, then their suicide wishes often can abate. I also support much of what the various Zero Suicide Initiative involves. However, as a behavioral scientist and someone who has regular contact with other humans, I consider Zero Suicide to be a ridiculous philosophy and a DUMB goal.
Zero Suicide is a DUMB goal, principally because it’s the opposite of a SMART goal. You can find definitions of SMART goals all over the internet. SMART goals are commonly attributed to Peter Drucker—a renowned management consultant, Austrian immigrant, and author of 39 books. Drucker is commonly considered one of the most important thought leaders in business management. Using Drucker’s principles, back in 1981, George T. Doran published a paper in Management Review titled, There’s a S.M.A.R.T. way to write management’s goals and objectives. Although many variations exist, SMART goals are typically defined as:
S = Specific
M = Measurable
A = Achievable or Assignable
R = Relevant or Realistic
T = Time-bound
Drucker and Doran were writing from a business management perspective, but smart goals are also intrinsic to psychotherapy. I won’t be going into the details here, but William Glasser and Robert Wubbolding, two renowned reality therapists, describe important variations of smart goals in psychotherapy. Put simply, the philosophy of Glasser and Wubbolding is simply common sense: “A goal should be within your control.” Put differently, if individuals or agencies identify goals that are dependent on other people’s behavior, then frustration and other problems will inevitably ensue.
Online resources for Zero Suicide are impressive. The breadth and volume of information will provide healthcare professionals with an excellent foundation for working with suicidal patients. For the most part, I have few objections to the quality and quantity of their online suicide prevention resources. Having these resources for healthcare professionals and the general public is important and fantastic. With a foundation of knowledge and informed action, it’s possible to prevent some, but not all suicides.
Despite its impressive array of information, Zero Suicide also has several shortcomings. For example, nowhere on their 66 item Zero Suicide Workforce Survey do they ask a question about having or holding empathy or compassion for suicidal patients. Empathy and compassion needs continual re-emphasis in suicide prevention. Why? Because patients, clients, and citizens who are suicidal, are also often experiencing depressive symptoms. All helpers and healthcare professionals should understand that empathic responding is the foundation of suicide intervention and prevention. Even further, one common depressive symptom is irritability. If irritability is present (along with depression and suicidal thoughts, when healthcare workers or others try to intervene with suicidal people—or persuade them to get help—the following pattern might emerge.
Gloria: I’m concerned about you and how you’re doing. “Have you been thinking about suicide?”
Sean: Yes. I think about it all the time.
Gloria: I want to tell you that there are some excellent resources available for people who are feeling suicidal.
Sean: I know that.
Gloria: Can I get you connected with a counselor here in town?
Sean: Not interested.
Gloria: But I want to be of some help to you, in some way.
Sean: I don’t want your pitiful help. I’m depressed and I’ve been thinking about suicide. I’ve been to counselors. Nothing helps.
Gloria: How about friends? Do you have some friends who might help and support you?
Sean: None of my friends care anymore.
Gloria: How about family?
Sean: My family has disowned me and I’ve disowned them.
Gloria: How about a church or community center? Lots of people get support at those places.
Sean: I can’t hardly get myself out of the house, so those are stupid ideas.
Gloria: Have you tried medications?
Sean: Medications just make me feel worse.
Gloria: How about exercise?
At this point in the conversation Gloria probably feels frustrated. She’s trying to help, but she can feel Sean resisting her efforts. Gloria is problem-solving, but Sean is feeling hopeless and isn’t able to engage in the problem-solving process. Sean has been through all these ideas in his head and in his depressive state of mind, he’s already rejected all these ideas as completely ineffective.
Next up, Gloria might up the ante by trying to get Sean to engage in logical thinking. She might say something like, “Suicide is a permanent solution to a temporary problem.” Having heard this logical ploy several times, Sean will be ready, “I’ve been living in misery for years. You might see the world as all happy and shit with your fancy shoes and Polly-Anna glasses on, but what I’m experiencing doesn’t feel temporary. I hate my life and I want to die.”
Even if Gloria is more saint-like than most, it will be difficult for her to sustain a helpful attitude toward Sean. She might try encouraging him to go to the hospital, but many suicidal people abhor the idea of hospitalization. Eventually, as Sean continues to insist that he’s suicidal, she might call for a county mental health professional to conduct an evaluation. If so, Sean may lie to the evaluator and say that he’s not imminently suicidal or the evaluator may decide Sean isn’t suicidal. Or, in the best case scenario, Sean may be hospitalized, but he also is likely to become very pissed off at Gloria, because he views her as usurping his personal rights and freedoms. In nearly every case, people like Sean are not likely to pause and thank Gloria for her suicide prevention efforts.
I could go on, but I’d probably just head further down this dark road. Instead, I’ll try to end with a few hopeful comments.
Suicide prevention is important, but it’s part of a strange dialectic. Sometimes, if we try hard to connect with someone and save them, we are fabulously successful. However, other times we try to connect and the person rejects us and suicide becomes even more likely. What’s the difference? I don’t know the perfect answer, but I’m pretty sure it involves collaboration and not coercion. I wish I had thought this up myself, but it’s something that suicidologists, researchers, and philosophers have known for millennia. On top of being fantastically unrealistic, zero suicide also smacks of coercion.
One of the best and forward thinking suicide intervention researchers is Marsha Linehan. You may have heard of her because she’s a University of Washington professor and developer of Dialectical Behavior Therapy. I’ll end with a rather amazing piece that she wrote. Take some time to read it and try to absorb the message. I think her story is all about being empathic and collaborative. Let me know if you think so too. Here are Marsha Linehan’s words, from the Foreword of a book titled, “Building a Therapeutic Alliance with the Suicidal Patient.”
I always tell my students a story about what it is like to work with suicidal individuals. In the story, I describe the suicidal person as trapped in a small, dark room with no windows and high walls (in my mind always with stark white walls reaching very, very high). The room is excruciatingly painful. The person searches for a door out to a life worth living but, alas, cannot find it. Scratching and clawing on the walls does no good. Screaming and banging brings no help. Falling to the floor and trying to shut down and feel nothing gives no relief. Praying to God and all the saints one knows brings no salvation. The only door out the individual can find is the door to death. The task of the therapist in this situation, as I always tell my clients also, is to somehow find a way to get into the room with the person, to see the person’s world from his or her point of view; to get inside the person, so to speak, and then together search again for that door to life that the therapist knows must be there.