Kia ora.
I’m in New Zealand to present at their 50th Anniversary Jubilee Psychology Society Conference. . . which is way cool. Below are two resource links.
First, the Powerpoint Slides: NZ 2018 Suicide Workshop
Second, a link to my 2018 Journal of Health Service Psychology article on suicide assessment and intervention: Conversations About Suicide by JSF 2018
Have a fabulous week!
John
My mother always said, “Bad news comes in threes.” That concept, along with many of her other superstitions, never made much sense to me.
In truth, the bad news never stops. She knew that. I suppose that organizing bad news into groups of three offered hope that the suffering might soon end—at least until the next set of three bad things came round.
This week we’ve had bad news in waves, with three particular pieces distinctly linked to suicide. On Tuesday, there was fashion designer, Kate Spade. Yesterday, there was the release of a new CDC report on Suicide. And then this morning there was Anthony Bourdain.
When people like Kate Spade and Anthony Bourdain die by suicide, it’s hard not to be mystified. By all measures, both Spade and Bourdain were highly successful. They were passionate and fully alive. The dynamics that may have led them to choose death are opaque. We can’t see these dynamics. They’re not obvious.
Another thing that’s not easily seen or especially obvious is the fact that, along with Spade and Bourdain, 865 other Americans will die by suicide this week. Let that number sink in. Many of these other American suicides will be military veterans. These 865 Americans may choose suicide for reasons similar or different than Spade and Bourdain. We can’t know the deeply personal reasons why individuals choose suicide.
In honor of my mother’s desire to manage bad news in groups of three, I’ve got some other threes to share:
Three Things to Remember About Suicide
Three Evidence-Based Therapies
Here are links to the three top evidence-based therapies for suicide.
Dialectical Behavior Therapy (DBT): https://www.amazon.com/DBT%C2%AE-Skills-Training-Manual-Second/dp/1462516998/ref=sr_1_1?s=books&ie=UTF8&qid=1528498109&sr=1-1&keywords=linehan+suicide
Collaborative Assessment and Management of Suicide (CAMS): https://www.amazon.com/Managing-Suicidal-Risk-Second-Collaborative/dp/146252690X/ref=sr_1_1?s=books&ie=UTF8&qid=1528498077&sr=1-1&keywords=jobes
Cognitive Therapy for Suicide: https://www.amazon.com/Cognitive-Therapy-Suicidal-Patients-Applications/dp/1433804077/ref=sr_1_4?s=books&ie=UTF8&qid=1528497986&sr=1-4&keywords=cognitive+therapy+suicide
Three More Resources
The CDC Report, although depressing, includes excellent information. You can read it here: https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w You can also listen to or read an NPR interview with the report’s lead author, Deborah Stone, here: https://www.npr.org/sections/health-shots/2018/06/07/617897261/cdc-u-s-suicide-rates-have-climbed-dramatically
A while back I wrote an Op-Ed piece for the Missoulian newspaper. This Op-Ed emphasized core factors or dimensions that often drive suicidal behavior. Reading the article can give you a better understanding of suicide dynamics and could help you help others, but in no way will it make you capable of successfully preventing suicide amongst all of your family and friends. This article is available through the Missoulian: https://missoulian.com/news/opinion/columnists/suicide-prevention-ignore-the-math/article_ce3c7f1e-ab86-587e-9505-310cc00b3355.html
In January I had a suicide assessment and intervention article published in the Journal of Health Service Psychology. This article is a good resource for professionals who work with suicidal clients. It’s an easy read and might also be of interest to non-professionals seeking to understand more about how professionals work with suicidal people. Conversations About Suicide by JSF 2018
I wish you all a weekend of connection and healing.
The following material is adapted from an article in the Journal of Health Service Psychology. You can access the whole article here: Conversations About Suicide by JSF 2018
***************************
My favorite suicide assessment procedure is to ask about suicide in the context of a mood assessment (as in a mental status examination). This procedure utilizes a scaling question to explore patient mood and possible suicide ideation (Sommers-Flanagan & Shaw, 2017). As you read through these steps, think about how you might apply this procedure with a recent or current patient of yours.
This procedure is a general map that can be used more or less creatively. No doubt, when you start the process with an individual patient, there will be opportunities to stray from the procedure. For example, when exploring the low end of her mood, your patient may begin sharing a traumatic experience. If so, you are at a key choice point. Should you continue with the next step in the procedure or focus in more detail on the trauma? Either option may be appropriate and will depend on one or more of the following factors:
Numbers can be useful in rating patient mood, but because every patient is unique, the meaning of specific numbers will be subjectively variable. I have interviewed teenagers and young adults who emphasize their distress by saying something like, “I’m a negative three!” Despite the fact that having a negative three rating on the suicide scale indicates—in a quantitative sense—suicide certainty, these patients are typically making a point, and may or may not be an especially high suicide risk. In contrast, I have also worked with cases where adult patients burst into tears and admit to suicide ideation after giving themselves a current mood rating of 8 or 9. One patient who rated herself as “9” explained that she always thought of herself as being a 10. For her, anything outside of a perfect mood rating as terribly disturbing.
Several of my supervisees who work with teenagers have creatively transformed the scaling method to eliminate numbers. One supervisee engaged a patient in mood scaling using musical genres. After a collaborative conversation, they established that listening to opera 24/7 was equivalent to zero and imminent suicide, while listening to heavy metal was a solid 10. When working with a middle school boy, another former student used Yoga as zero and pizza as 10. The point of these examples is that practitioners can collaborate with patients to identify a method to discuss mood. Collaborative rating systems makes the method personally meaningful to the patient; it also involves interpersonal connection, implying that the assessment method has become simultaneously therapeutic.
The mood scaling procedure offers several advantages. First, it is a process that facilitates engagement, and engagement or interpersonal connection is central part of suicide interventions. Second, when patients bind their low and high moods to concrete external situations, you gain knowledge about the themes and triggers that lift and depress your patient’s mood. Third, as illustrated in the case where a client begins talking about trauma, the mood scaling procedure can be abandoned (temporarily or permanently) in favor of more salient therapeutic opportunities. Fourth, mood scaling flows smoothly into safety planning or other suicide interventions (e.g., “When you say that being a zero always involves you being alone, it tells me that one thing we should talk about now or later is how you can reach out to others, and we should talk about who you want to reach out to, during those times when you’re feeling like a zero. It also tells me that we should talk some more about other methods you can use to move from a zero to a one.”).
One final note: The mood scaling technique is an indirect method for assessing suicidality. As such, it is not a replacement for using a normative frame and asking directly. In fact, you should be thinking about if and when you will weave asking directly into your mood scaling process. For example, if your client says “I’m a 3” you might follow that with a normative-based direct question: “It’s not unusual for people who rate themselves as a three to sometimes have thoughts about suicide. Has that been the case for you?”
Back in March, 2012, I settled into a Starbucks in Vancouver, Washington to reflect on my experiences at the annual American Counseling Association conference in San Francisco. Memories of Dr. Irvin Yalom’s keynote bubbled up in my mind, so that’s what ended up in my fingers, on my screen, and in my blog.
Several days later, I got an email from a “Dr. Yalom.” Seeing the name, I immediately felt anxiety and anticipation. First thoughts, “I meant to be positive. I hope I didn’t write anything offensive?”
The email was from Dr. Victor Yalom. It was nice . . . and supportive . . . and positive . . . and a big relief.
Victor is the owner/publisher/president or grand sultan of psychotherapy.net. Psychotherapy.net is a publisher of psychotherapy training and continuing education materials, mostly videos. Over the past 6 years Victor and I have struck up a collegial friendship. He is the biggest fan and proponent of our Clinical Interviewing video series (which he sells through psychotherapy.net). After viewing the Clinical Interviewing video, he has repeatedly asked Rita and I about doing a video for psychotherapy.net. Unfortunately, the timing never worked out, until this past fall, when we agreed to collaborate on a six-hour suicide assessment and intervention training video.
As they say in the film industry, everything is in the can. We’re down to final editing and other details. We filmed in Missoula and Mill Valley. Rather than working directly with imminently suicidal clients, we got volunteers to channel previous or potential suicide-related experiences. All this is just my way of introducing this sneak peek into this upcoming video.
Of course, reading isn’t the same as watching, but the next 2,000 words can give you a glimpse of one of the cases featured on the video. The client is a young Native American man and veteran. Many cultural issues emerge during the session, along with suicide ideation. Here’s the clip, along with my side “commentary” in bold:
***********************
John: Cory, I know a little bit about you, but not very much. And so maybe the best place to start is for you to tell me some things about yourself, some things about how you’ve been feeling in your life, some things about the situations that you’ve been in, and maybe help me get a sense of how I might be of help.
Cory: Yeah, I come from a small reservation in Eastern Montana, and I was kind of – it was a comfortable life growing up. I didn’t know anything different. And I remember sitting there with my family watching the war and kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.
John: Yeah, what tribe?
Cory: I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.
John: Okay. Great, thank you. Sorry.
Cory: So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and feeling pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancée when I left. Life was great. Eventually time to come home and came home. And my family’s kind of in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.
John: Yeah.
Cory: So, kind of tore me up. My fiancée left me for one of my best friends, so that was the shock of my life.
John: Yeah. So, at least at this point I’m hearing that you were on kind of a high and feeling good at 17, get a big sendoff from your tribe, from your family, and you go, and you go to Iraq. And you get back, and things are a mess.
Cory: Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and prison and kind of whole world changed, I guess. Eventually, I didn’t – just came back and started drinking. Not sure who I was anymore. So, that was difficult, didn’t have very many people to turn to anymore. Never had a father growing up. My mom was always raising us with a couple jobs. And eventually her and her boyfriend got into drugs, so that’s kind of pretty difficult. And I didn’t know what to do anymore. And I was kind of feeling down and just kept drinking, and I kind of don’t know what to do anymore. For us it’s a honor to serve and kind of makes us who we are.
John: Yeah.
Cory: We view it as becoming a warrior man.
John: Yeah.
Cory: And I felt like I did that, and I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shame. A lot of shame comes from it. So, it’s kind of you just deal with it.
John: Yeah, yeah. Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.
Cory: Yeah, I mean, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.
John: You’re warriors. You’re strong.
Cory: Yeah.
John: And so you keep it all –
Cory: Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.
John: Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?
Cory: I guess I just – kind of just helped me feel nothing.
COMMENTARY: Cory has covered lots of ground quickly. He has articulated his collectivist identity. Knowing about his collectivist identity early in the session is a very good thing. He has also mentioned multiple stressors and losses; these stressors and losses are traditional risk factors and load onto the various risk dimensions. These include: coming back from war, being a veteran, loss and betrayal by his girlfriend, his grandmother’s death, the disarray of his tribal community from meth, and other issues. In addition, one immediate challenge that’s coming into my mind is how to address alcohol, because it’s a suicide desensitizer, but it’s also helping him “feel nothing” which is consistent with his cultural value of not expressing his feelings. At this point I’m choosing to build a relationship with Cory before jumping in and discussing alcohol directly.
John: Okay.
Cory: Just kind of, I guess, how I dealt with it because I couldn’t talk about stuff that happened over there, and I didn’t have no male role models in my life to kind of talk about culturally with or anything.
John: Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you if we –
Cory: Yeah, that’s fine.
John: Yeah, because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.
Cory: Uh-huh.
John: And getting rid of those emotions. And as you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought because it’s not unusual when people come back and life is disappointing and hard, and you’re drinking, and you’re managing those emotions, it’s just not unusual to have a thought about suicide or about killing yourself. And my guess is that would be in opposition to your culture, too, but I don’t know.
Cory: Yes and no. One way we look at is from we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka which is our God. So, when it’s our time, it’s kind of our choice.
John: Okay.
Cory: The sad thing about it is, I’m feeling down, and a lot of times like as I grew up I had – I was probably nine years old. My first friend committed suicide. And it brings the community together. We have big honoring, big feast for his family, for him, and just days of celebrating. It’s kind of like bring the family back together. I had another friend do it after that because he was – couldn’t graduate high school and didn’t have nobody there, and he wanted his family to come back together, so he committed suicide, just felt like it’s going to bring his family back together. And it did for a bit, but meth came in again, so it kind of tore it apart.
John: Uh-huh.
John: So, I’m hearing two suicides of people that you knew well around the time that you graduated high school?
Cory: Oh, one was when I was 9, and a good friend was 16. And by the time I was 18, I probably lost maybe 7 friends from drinking and driving, drugs, stabbings. So, I guess to us, I mean, death is death, so it wasn’t really a big deal, kind of a celebration and we’ll see them again.
John: Yeah. So, for each one the family celebrates, the community celebrates –
Cory: Uh-huh.
John: – the life. And sometimes it almost sounds like somebody might choose suicide as an effort, it sounds like, to pull the family together to get everybody closer.
Cory: Yeah, I guess, too, they know people will care. Pretty big sense of hopelessness there. Not many people know where to turn.
John: Yeah. Yeah, so that’s a lot of death that you saw even by the time you graduated high school. Have you had some thoughts of suicide yourself?
Cory: Originally when I first came back, I did. I just didn’t know what to do anymore. Then I came to college, thought I was going to – wanted to do something honorable again. Again, big celebration and sent us off to college. And I get here, and things are going well at first. Then just the culture differences, like nobody understood me, didn’t know what to do. I was doing all right in classes, but I just kind of couldn’t fit in, didn’t feel like anybody understood me. I mean, they’re all pretty nice guys and gals. I could tell they were trying to, but just something I knew they didn’t.
And then now things are getting bad again. I’m trying to sleep at night. Yeah, just every time I go to sleep, I remember one time in Iraq we were sitting there, and they decided – well, I guess Al-Qaeda, they blew a whole street, whole city block, and it just – I mean, every building came down. And we were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help as best we can, and same time people shooting at us and just didn’t know what to do.
My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we – not what we’re here for. Yeah, I just remember a mom with no leg carrying her helpless child just in her arms, and the child was dead. I mean, just every time I go to sleep, I just remember that kid helpless laying there. And so I’m not sleeping much, a lot of drinking still. I guess I don’t know what to do anymore.
COMMENTARY: It’s not unusual for suicidal clients to present with a vast array of psychological pain. That can be overwhelming to the client and to the therapist. Cory has shared several layers of unresolved grief, traumatic war memories. The number of people whom he has known who have died by suicide is immense. Additionally, because of his cultural norms of stoicism, I’m wanting to address these parts of his experience, while not activating intense emotions. my strategy has been and will be to use reflection of content, to avoid reflecting back strong emotions like sadness or anger, to keep his collectivist perspective in mind, and to take notes in a way so that he and I can take a more intellectual and problem-solving approach to working with him on his experiences.
*******************
If you made it this far, a big congratulations. Acquiring skills to work effectively with clients who are suicidal is challenging, but dealing with the emotions that come up is probably even more difficult. The purpose of this training video (when it becomes available) is to help practitioners obtain knowledge, learn skills, and refine their awareness of the inner and interpersonal dynamics associated with suicide assessment and intervention. When I have more information on the video’s availability, I’ll let you know.
Tomorrow I’m doing a day-long workshop on suicide assessment and intervention at the University of Montana. The powerpoints are here: UM 2018 Suicide Workshop REV
This might be the last call for you to sign up for the upcoming suicide workshop in Missoula. To help you lean toward attending, I’m doing something against my own advice. Below I’m listing the extremely exciting workshop Learning Objectives. Why is that against my own advice? Because usually I think Learning Objectives are obnoxiously boring. However, because I’m so into this topic, the LOs seem fascinating to me. . . this is just more evidence that I’ve lost my perspective and judgment. Anyhow, here they are:
2. Expand and Practice Suicide Assessment and Intervention Skills
3. Develop Your Self-Awareness and Refine Your Attitude Toward Suicide
Check out the registration form here:
Suicide and MSE Registration Form 2018
Or, call 406-243-5252 to find out what you need to do to register for the Friday, April 6 workshop.
Hey Blog Readers.
For those of you who might be interested, I just published a new article on suicide assessment and interventions in the Journal of Health Service Psychology. The article title is, “Conversations about suicide: Strategies for detecting and assessing suicide risk.” The article is designed to help practitioners who work or may find themselves working with suicidal clients.
Here’s a link to the article: Conversations About Suicide by JSF 2018
Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.
Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.
Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.
Here are the eight dimensions.
Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)
Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.
Problem-Solving Impairment (Shneidman’s Mental Constriction)
Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).
Agitation or Arousal (Shneidman’s Perturbation)
Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).
Thwarted Belongingness and Perceived Burdensomeness
Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.
Hopelessness
Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.
Suicide Desensitization
Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.
Suicide Plan or Intent
In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.
Lethal Means
Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).
I spent my K-12 life at VSD #37. Today I’m back, doing a “Tough Kids” and suicide prevention workshop at Skyview H.S. Should be fun. Here are the handouts.
From 13 Reasons Why, to Chris Cornell’s recent death, issues pertaining to suicide have been in our face this month. This is no surprise. May (late spring in the Northern hemisphere) is nearly always the month with the highest suicide rates.
That’s why right now is an excellent time for some straight talk about suicide.
Suicide is an emotionally triggering topic that’s notoriously difficult to talk or write about. Most of us know people who have been suicidal. Some of us know people who have died by suicide. Still others who read this may be having suicidal thoughts in this moment, or may have made suicide attempts in the past. Talking and writing about suicide is unpleasant, but necessary.
Because suicide is difficult to talk about, myths and misconceptions flourish. Not talking (or writing) about suicide also makes it harder to keep tabs on the latest research. Sometimes, leading professional journals neglect publishing new articles on suicide for a decade or more. This brings me to my purpose. To bust a few stubborn suicide-related myths and provide a glimpse at recent research on suicide prevention.
Let’s begin with now.
It’s a beautiful green spring in Montana with brilliant white snow in the mountains. Despite this beauty and brilliance, suicide rates rise in the spring and early summer and drop in fall and winter. Most people think the opposite is true, but every year, late spring and early summer bring the highest rates. Why? There are theories, but unfortunately, “we don’t know” is the answer to this and many questions related to suicide. I’m starting with this misconception to illustrate how easy it is to get the even the simplest facts related to suicide completely wrong.
One of the most insidious and unhealthy myths about suicide is the promotion of the idea that suicidal thoughts and impulses represent deviance or indicate the presence of a mental disorder. Once again, although many think it so, this idea is also untrue. Suicidal thoughts are a normal and natural response to psychological distress and misery. Social disconnection (relationship break-ups, death of a loved one, or other relationship problems) also can trigger suicidal thoughts in so-called “normal” people.
Our entire culture needs to stop classifying suicidal thoughts as automatic deviance. At one point or another, most people contemplate suicide, at least briefly. That fact pretty much blows the whole idea of suicidal thoughts as deviance right out of the metaphorical water.
Suicidal thoughts can be associated with specific mental disorders, but they are not, in and of themselves, signs of a mental disorder. In a recent large scale study, it was reported that mental disorders and suicidal thoughts weren’t useful in determining which individuals would eventually make suicide attempts.
Believing that suicidal thoughts represent a mental disorder isn’t just untrue, it’s also unhelpful. People who are suicidal, don’t need the public or professionals to make them feel worse by implying that their suicidal thoughts represent some form of illness.
Another surprising research finding is that, in general, suicide warning signs and suicide risk factors are unhelpful. This is true despite the fact that following a death by suicide, one of the first messages you’ll hear in the media is how important it is to watch for specific suicide warning signs. Unfortunately, like many things related to suicide, this is both good and bad advice. It’s good advice in that it’s always important to notice when friends, family, coworkers, and strangers are in distress and to do what we can to be comforting. But it’s also bad advice. Pointing the public or professionals toward warning signs implies that scientifically-based warning signs exist. They don’t.
There’s no science that supports the usefulness of warning signs or risk factors. This may seem discouraging, but it shouldn’t, because it leads to ONE BIG EXCELLENT CONCLUSION. That is, we should all try to offer support, empathy, and compassion to everyone. The take-home message is, don’t wait to encounter a suicidal person to unleash your kind and compassionate side. You should be leading with that. All. The. Time.
Chew on this idea for a moment. We’re stuck. If we’re interested in suicide prevention (or in having healthy relationships), our best default response is to treat everyone with kindness, respect, and empathy. I understand that’s impossible and I understand that you may think there are some exceptions to universal compassion. But we should try to lead with kindness, respect, and empathy anyway.
A good thing about having a general philosophy of kindness and compassion is that it helps suicidal people trust you. It will be harder for them to conclude, “This person is just being nice because I’m suicidal.” Instead, you’ll be treating everyone with kindness and empathy simply because that’s the sort of world you’re creating around you.
Another common suicide myth is that asking about suicide might somehow put the idea of suicide into someone’s head. Not true. Most people who are suicidal feel relieved and appreciative if you ask them about it in a nonjudgmental way. And, if you ask someone and they aren’t suicidal, well, the point is that people are highly resilient. They’re not so fragile that posing a short inquiry about suicide suddenly becomes life threatening. The other point is that you should ask with kindness and compassion. Even better, you should normalize the question by saying something like, “It’s not unusual for someone in your situation to have thoughts about suicide. I’m wondering if you’ve been having suicidal thoughts?” Making a statement that normalizes (rather than pathologizes) suicidal thoughts can make it easier to for people to talk more openly . . . and when people who are suicidal are talking openly, it will be easier for you to be helpful.
As if it weren’t already hard enough, another thing that’s especially complex is that when people are contemplating suicide, they often have strong negative reactions to infringements on their personal freedoms. This is partly why telling someone, you shouldn’t or can’t choose suicide, is a bad idea. Well-meaning helpers who push people too hard away from suicidal thoughts and toward embracing life can come across as “not understanding.” This could trigger an oppositional response. The person you want to help might either stop talking about it (but keep thinking about it) or feel an urge to oppose all suicide prevention or intervention efforts.
It’s not unusual for suicidal people to feel interpersonally isolated, disconnected, or as if they’re a burden to family, friends, and society. This makes connecting with them all the more important. It’s unfortunate, but people experiencing depression can be rather irritable or unappreciative of your efforts to listen and help. When you express concern, they might say something nasty in response. If so, let go of your needs for feeling appreciated; listen and be supportive anyway.
People who are suicidal can have difficulty problem-solving in a way that reflects hopefulness. Who wouldn’t have trouble being optimistic after experiencing repeated misery? This is why it’s important to problem-solve WITH people who are suicidal. Don’t usurp their control; lend another perspective. Part of this perspective might be the simple message that suicide is always an alternative, but that it’s important to wait and try as many other alternatives as possible.
Often, the response to your problem-solving efforts will be something like, “I’ve tried everything and nothing helps.” Again, we need to understand that when someone is suicidal, this is how it feels! At this point, acknowledge that right now it feels like nothing could possibly help. But at the same time, it’s okay to say things like, “I want you to live.”
If you’re problem-solving with someone who is suicidal, it’s also important to be persistent. Try saying something like, “Let’s make a list of everything you’ve tried, starting with whatever was the worst and most unhelpful idea ever.” Starting with what was unhelpful can resonate with the person’s pessimistic mood and help you identify something that’s at least not the worst option on the planet.
Chris Cornell’s recent death by suicide is a reminder of how specific medications can sometimes increase an individual’s agitation and/or suicidal thoughts. He was taking Ativan (Lorazepam). Ativan is a benzodiazepine (like Xanax and Valium). IMHO (and the science supports this), benzos are very bad medications to use for anything other than very short-term treatment. The bottom line is that sometimes (not always) psychiatric medications are not a part of the suicide solution and can become part of the suicide problem.
Among other things, Thirteen Reasons Why is a reminder of how easy it is for people to feel tremendously guilty when someone dies by suicide. Twenty-six years later, I still feel guilt over the death of a boy with whom I was working. Was it my fault? Absolutely not. Do I still feel bad? Absolutely yes.
Death by suicide is a tragedy. I’m tempted to say that it’s always a tragedy, but I recognize that when it comes to humans and humanity, using the terms always and never is dicey.
Some individuals are living with what they experience as intolerable physical, psychological, or emotional suffering. For their loved ones it’s likely still a tragedy when they die by suicide, but is it a tragedy for them? It’s hard to rule out the possibility that death by suicide may represent solace for them.
Suicide is a very personal option on the palette of human choice. For example, I want people to live. I want to help them reduce their psychological pain, make positive relationship connections, and re-engage in activities they find meaningful. But even so, sometimes suicide happens anyway. This is deeply painful and the guilt can be enormous. If someone close to you dies by suicide or you’re feeling affected by any suicide-related event, please find someone to talk with. One of my former clients once said, “The mind is a terrible place . . . to go alone.” Find someone you can trust and share any dark thoughts you might be having. Deal with it. Don’t let your guilt and angst simmer.
To summarize, suicide rates are highest right now. Does that mean we can relax later? Of course not. Suicide risk factors and warning signs are mostly useless and so we should treat people with respect and compassion all the time. When needed, we should ask the suicide question directly and with a spirit of non-judgmental normality. When possible, we should help people with suicidal thoughts identify options that might move them toward feeling better, while acknowledging that suicide is an option. We need to remember that sometimes medications can make suicidality worse. Perfect prevention is impossible. Suicide may happen despite our best efforts. Dealing with guilt over a suicide takes time and requires support.
No one will be completely happy with the ideas I’ve written here. That’s good. Individual reactions to suicide issues are unique. If you want to argue with or improve on these ideas, feel free to engage in the conversation. Using an attitude of kindness and respect, let’s keep talking about suicide. Right now, that’s the best solution we have to our suicide problem. In fact, it may be the best solution we’ll ever have.
To check out my recent professional journal article in Professional Psychology, click here: SF and Shaw Suicide 2017
John Sommers-Flanagan 