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Trauma, Suicide, and Motivational Interviewing: A Handout for BYEP Mentors

Sunset

Trauma may be the most common underlying factor contributing to mental disorders. Unfortunately, trauma is often overlooked, partly because it can manifest itself in so many different ways. That said, here are some common definitions. Trauma always involves a stressful trigger that activates a trauma response. Because, like everything, trauma responses are brain-based and involve the body, symptoms affect the whole person.

Old, informal, and useful definitions include:

  • A stressor outside the realm of normal human experience (but sadly, trauma is all-too-common)
  • A betrayal . . . (e.g., something that should not happen)
  • Occurrence of an event that’s emotionally overwhelming

Below I’ve listed the essence of the DSM-5 definition for Post-Traumatic Stress Disorder (note that the whole idea of PTSD centers on the chronic or long-lasting effects of trauma).

Exposure to a traumatic stressor that involves direct personal experience, witnessing, or learning about events involving threatened death, serious injury, or a threat to your physical integrity. The trauma response includes:

  • Intrusion symptoms (recurring unwanted memories, nightmares, flashbacks, and triggered distress)
  • Avoidance of trauma-related thoughts or external cues
  • Negative cognitive alternations (e.g., memory gaps, no joy, etc.)
  • Arousal and reactivity (e.g., irritability, risky behaviors, hypervigilance, insomnia, startle response)

Trauma and trauma responses can be big, medium, and small. Big traumas meet the DSM-5 diagnostic criteria for PTSD or acute stress disorder. Small traumas are usually disturbing and disruptive, but the body and brain adjust to them within 2-3 days. Medium size traumas have lasting effects, but don’t meet formal diagnostic criterial, and are usually referred to as subclinical.

I like to think of Trauma with an uppercase T (like in the DSM) and all other traumas that are difficult, challenging, and require adjustment as traumas with a lowercase t.

What to Say

Sometimes trauma responses or symptoms are visible and obvious. If so, it’s good to say and do some of the following:

  • Listen and show compassion
  • Reassure participants that physical/psychological responses are normal, take up energy & need soothing
  • Note that very effective treatments are available (e.g., This American Life)
  • Brainstorm on what helps
  • Remember: A pill is not a skill
  • Link and universalize (“It’s normal to have pleasant and unpleasant reactions to things we talk about”)
  • Brainstorm on more and less healthy reactions (Using substances is a quick distraction, but not a fix)
  • Share hopeful stories (what skills can be developed?)
  • Self-disclosure can help. But be careful with self-disclosure and remember that it’s not about you

Trauma is a normal and natural human response. You may experience trauma just by listening to people talk about trauma, or you may have your own direct experiences. When in the business of helping others, be sure to take good care of yourself.

Three Suicide Myths

Myth #1: Suicidal thoughts are about death and dying.

Most people assume that suicidal thoughts are about death and dying. On the surface, it seems like a no-brainer: Someone has thoughts about death, therefore, the thoughts must be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Not true. Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.”

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

Believing in this myth can make surviving family members, friends, and helping professionals experience too much guilt and responsibility. In fact, even the most famous suicidologists say that it’s impossible to consistently and accurately predict suicide.

Tips for Talking about Suicide

We need to be able to talk directly about suicide with courage and calmness. But first, we should listen. Here’s what you should listen for in general

  • Emotional pain
  • A sense of feeling trapped or ashamed
  • Not believing that anything can possibly help to reduce the pain and misery

While listening, show acceptance, empathy, and compassion. Remember: suicidal thoughts are not signs of illness or moral failing; if you judge the person, it will make it harder for the person to be open. Also remember: when people talk with you about their suicidal thoughts, that’s a good thing, because you can’t help unless they’re comfortable enough with you to speak openly about their suicidal thoughts and feelings.

Traditional warning signs in particular

Although it’s good to know these warning signs, there’s not much research supporting the idea that anything predicts suicide.

  • Active suicidal thinking that includes planning and talk about wanting to die
  • Preparation and rehearsal behaviors (stockpiling pills, giving away belongings, etc.)
  • Hopelessness related to feeling that the excruciating distress will never end
  • Recklessness, impulsivity, dramatic mood changes
  • Anger, anxiety, and agitation
  • Feeling trapped
  • No reasons for living, no purpose in life, broken relationships
  • Increased alcohol or substance abuse
  • Immense shame or self-hatred

How should I ask about suicide?

The answer to this is always, “Ask directly.” But we can do even better than that. We need to de-shame suicidal thoughts and talk. Before asking, communicate that you know suicidal thoughts are a normal and natural response to emotional pain and disturbing situations. For example, you could ask it this way, “I know that it’s not unusual for people to think about suicide. Have you had any thoughts about suicide?”

What should I say if someone admits to thinking about suicide? You can say things like,

  • Thanks for telling me.
  • It sounds like things have been terribly hard.
  • Thanks for being so honest, that takes courage.
  • I know I can’t instantly make everything better, but I want you to live and I want to help.
  • How can I best support you right now?
  • What can we do together that would help?
  • When you want to give up, tell yourself to hold off for one more day, hour, minute—whatever you can.
  • Or . . . use your good listening skills and reflect back the feelings and thoughts that the person shared.

Resources for Help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

What is Motivational Interviewing?

Motivational interviewing (MI) is an evidence-based approach to treating substance problems, health concerns, and other mental health issues. MI is “person-centered” and based on the foundational principle that clients should be the ones who make the case for change in their lives. MI:

  • Focuses on the common problem of ambivalence about change.
  • Relies on four central listening skills (OARS): open questions, affirming, reflecting, and summarizing.
  • Helps clients transition from less healthy to more healthy behaviors

Four overlapping components combine to create the spirit of MI:

  • Collaboration (partnership; dancing, not wrestling)
  • Acceptance (UPR, accurate empathy, autonomy, affirmation)
  • Compassion (honoring the client’s best interest)
  • Evocation (tapping the client’s well of wisdom)

MI is a specific treatment approach that requires professional training. However, operating on a few basic MI principles can improve nearly anyone’s approach to helping others. For more information, see the book: Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY: Guilford Press.

This handout is from a mentor workshop for the Big Sky Youth Empowerment Program. These ideas are based on research and collected from professionals who have experience working with people who are feeling suicidal. These guidelines should not be considered medical advice and are no substitute for getting an appointment with a licensed health or mental health professional. See: johnsommersflanagan.com for more information.

The End of Suicide Prevention Week

Chair

The September 12 edition of the New York Times included an opinion piece titled “What Lies in Suicide’s Wake” by Peggy Wehmeyer. Ms. Wehmeyer previously worked as a correspondent on ABC’s “World News Tonight.” In the opinion piece, Ms. Wehmeyer shared experiences following her husband’s death by suicide in 2008.

Wehmeyer’s account of widowhood by suicide grabs you by the throat and brings you to your knees. If you’re a suicide survivor, read it with caution, because it will bring you anger, sadness, pain, and guilt.

Wehmeyer’s story also made me want to take action. I wanted to do to her what Robin Williams did to Matt Damon in his role of the therapist in Good Will Hunting. Williams looked at a file on Damon’s history of abuse, and then stood in front of him, saying,

“All this shit. This is not your fault. Look at me son. It’s not your fault.” Then Williams repeated “It’s not your fault” until Damon collapsed crying in his arms.

Some burdens are too big. I want to take Ms. Wehmeyer in my arms and tell her she’s taking on too much. Her former husband chose suicide. That’s a tragedy. But it’s not her fault.

After a suicide, shame and guilt spread like warm butter on hot toast, seeping into crevices, muscles, joints, and neurons. Guilt stabs you in the heart and then pummels your brain with the most obvious, most painful, most important, and most impossible question, “Why?”

Why . . . is a stupid, impenetrable, devious, and unhelpful question. But suicide survivors can’t stop themselves from painfully ruminating on, Why did this happen? If I were the god of suicide recovery, I’d cancel that question from the genetic blueprint. After a suicide, the question Why is pointless and unanswerable.

I’m a psychologist and a counselor. I’ve got plenty of friends in the mental health professions. Many of my friends, being of the post-modern or existential ilk, like to exclaim, usually with intellectual delight and breathless discovery, that “Humans are meaning makers!!” Well, duh.

Of course humans are meaning makers. Basically, that’s all we do. We make up shit all the time in an effort to explain our existence and our experiences. Let’s say your romantic partner breaks up with you, if you’re like most humans, you’ll wonder “Why?” And then you’ll painfully exfoliate your soul until you corner yourself with some irrational bullshit like, “I must be unlovable” or “I’m defective” or “I’m undesirable.” Or, if you’re inclined the other direction, you’ll quickly conclude, “He was an asshole” or “She’s defective” or “I hope my ex gets hit by a train.” And there are the new-age explainers who repeatedly wax philosophical, saying, “It wasn’t meant to be” or “The universe is telling me that it’s not my time for a romantic relationship.”

Asking why shit happens (and then answering yourself) is simply not helpful; it’s not helpful because you will, being human, come up with dozens of stupid, irrational, and unhelpful explanations for terrible things that happen. In the aftermath of suicide, if you’re like Ms. Wehmeyer, and many of us are, most of your stupid, irrational, and unhelpful explanations will involve blaming yourself. You’ll think things like, “I should have loved him better” or, you’ll embrace the ultimate piece of bullshit, that, somehow, as Ms. Wehmeyer wrote, “I missed those [suicide] signs until it was too late.”

No she didn’t. Wehmeyer didn’t miss the signs. And neither did you. Predicting suicide is impossible for even the best suicide researchers on the planet. Like Robin Williams said: It’s not your fault. You’re not the god of suicide prevention. Things happen. Shit happens. People kill themselves. Suicide started eons before you were born and it will continue for eons after.

Accepting tragedy sucks. It sucks more than nearly anything else we can think of. But tragedy strikes. And most of the time, tragedies are outside our control. Does that mean you should stop trying to prevent suicide and save lives? Of course not. Do what you can when you can. Does it mean you should stop blaming yourself for actions and choices that other people make and that are beyond your control? Hell yes!

In case you missed it, National Suicide Prevention Week is just ending. All week we’ve been encouraged to watch for warning signs, to follow up on our concerns by directly asking friends, family, and colleagues how they’re doing, and if they’ve been thinking about suicide. All this is great stuff. But, along with the many educational messages we’ve heard, somebody has to point out the cold, hard truth.

Sometimes you track the warning signs, you ask all the right questions, and you love people with all your heart, and they’ll still die by suicide. If that happens, it doesn’t mean you missed the signs or that you weren’t lovable enough. If suicide happens, you need to take care of yourself; you need to talk about your sadness, pain, and regrets. But you need to add one more thing. You need to listen to Robin Williams (who also died by suicide) and forgive yourself, because . . . All this shit. This is not your fault. . . . It’s not your fault.

****************************

Resources for help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

 

Want to Learn More about Suicide Interventions and Treatment Planning? Here’s a link to a brand new CE course

John and Max SeattleOver the past several months I’ve been busy writing a 2-part continuing education course on a strength-based approach to suicide assessment, interventions, and treatment planning. As you may recall, Part One of this course was published last May (see: http://www.continuingedcourses.net/active/courses/course114.php ).

Today, I’m announcing that Part Two, titled, Suicide Interventions and Treatment Planning for Clinicians: A Strength-Based Model, is now available. To check it out, go to: http://www.continuingedcourses.net/active/courses/course115.php

Just in case you’d rather watch a CE video on this topic, last year I also did a cool three-part (7.5 hours total) continuing education video on suicide assessment and treatment.with Victor Yalom and Psychotherapy.net. Here’s a link to that resource: Psychotherapy.net: https://www.psychotherapy.net/video/suicidal-clients-series

Happy Labor Day!

John SF

 

Separating the Psychological (Emotional) Pain from the Self: A Technique for Working with Suicidal Clients

Blogs I follow

I’m working on a Suicide Assessment and Treatment Planning manuscript and here’s a small piece of what I just wrote:

Rosenberg (1999; 2000) and others have described a helpful cognitive reframe intervention for use with clients who are suicidal. She wrote,

The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self (1999, p. 86).

Shneidman’s (1996) guidance on this was similar, but perhaps even more emphatic. He recommended that therapists partner with clients and with members of the client’s support system (e.g., family) to do whatever possible to reduce the psychological pain.

Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit (p. 139).

Suicidal clients need empathy for their emotional pain, but they also need to partner with therapists to fight against their pain. Framing the pain as separate from the self can help because therapists can be empathic, but simultaneously illuminate the possibility that the wish isn’t to eliminate the self, but instead, to eliminate the pain.

Rosenberg (1999) also recommended that therapists help clients reframe what’s usually meant by the phrase feeling suicidal. She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the therapist’s empathic message.

Here’s a case vignette to illustrate how therapists can work with clients to separate the emotional pain from the self and then partner with clients to reduce the pain. As always, this case vignette is a composite compiled from clinical work and simulations with various individuals.

Case Vignette. Kate is a 44-year-old cisgender married female with two children. She arrived for counseling in extreme emotional distress. She was also agitated, stating, “It just hurts so badly to be alive. It hurts so badly.”

Much of Kate’s emotional pain was centered around the recent death of her mother, whom Kate had cared for over the past seven years. Kate had an ambivalent relationship with her; her mother had been diagnosed as having schizophrenia and caring for her was extremely challenging. Kate’s acute emotional distress was accompanied by fears of turning out like her mother and thoughts of reunifying with her mother. She said, “I just need to be with her.”

To help Kate separate her intense emotional pain from the self, I began by noticing that there were two different parts of Kate, and that these two different parts had different ideas about how to move forward. Noticing and articulating different perspectives of the self is a common approach from a person-centered theoretical perspective. Because of Kate’s family history of schizophrenia, I wouldn’t use an expressive Gestalt technique to separate her different ego states, but it felt like reflecting her obvious ambivalence was a safe approach. Specifically, I said, “Sounds like a part of yourself thinks the solution is to die, and that your kids will be better off. But there’s another part of you that says, maybe the solution isn’t to die. Maybe I can come in here and talk. Maybe my kids actually would suffer if I died.”

Kate accepted that she was “of two minds” about how to go forward. Next, I tried to further clarify these parts of herself, emphasizing that I wanted to align with the “second” part of herself, so that we could work together on her emotional pain.

The one part of yourself thinks your only hope of dealing with the pain is to kill yourself. The other part thinks, maybe I can stay alive, work in counseling to get rid of the pain, and then my children wouldn’t suffer from my death. How about, for now, we work from that second perspective. We can be a team that works hard to decrease the emotional pain you’re feeling. It might not go away immediately, but if you stay alive and we work together, we can chip away at the pain and make it shrink.

You may notice the words I used were somewhat redundant. Using redundancy with clients who are feeling suicidal may be needed because the agitated, depressed state of mind makes cognitive focusing difficult. Sometimes, if you don’t repeat the therapeutic perspective and keep focused on it, the therapeutic perspective can slip away from your clients’ cognitive grasp.

Linehan often uses a more provocative way of talking about partnering with clients to diminish their pain. For example, she might say, “Getting through this is like going through Hell. But I know therapy can help and I want to work with you on this. But I have to tell you this, therapy will only work if you stay alive. Therapy doesn’t work on dead people. So I want you to stay alive and work with me at attacking your pain. Will you give me six months for us to go through hell together so we can get control of your pain?

Either way, the goal is to partner with clients to work on decreasing emotional or psychological pain. This approach combines empathic listening, with an emphasis on the therapeutic alliance. As therapist and client partner together, then cognitive-behavioral problem-solving can commence.

Suicide Myths — Part Two

From M 2019 Spring

This is part two of my “Four Suicide Myths” blog post. If you read part one, you probably noticed that it ended abruptly. Apparently, that’s how I do two-part blog posts. Thinking back, I should have added something like, “end of part one.” 

And so, as an introduction, here’s the beginning of part two . . .

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.” Additionally, the rates of suicidal thinking among high school and college students is so high (estimates of 20-40% annual incidence) that it’s more appropriate to label suicidal thoughts as common, rather than a sign of deviance or illness.

Edwin Shneidman—the American “Father” of suicidology—denied a relationship between suicide and so-called mental illness in the 1973 Encyclopedia Britannica, stating succinctly:

“Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although . . . it has often been so treated in Western and other cultures).”

A recent report from the U.S. Centers for Disease Control (CDC) supported Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder. Keep in mind that the CDC wasn’t focusing on people who think about or attempt suicide; their study focused only on individuals who died by suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), meet diagnostic criteria for a mental disorder.  As one of my mentors used to say, “Having the thought of suicide is not dangerous and is not the problem.”

Truth #2: Suicidal thoughts are not—in and of themselves—a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress.

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

In 1995, renowned suicidologist, Robert Litman wrote:

At present it is impossible to predict accurately any person’s suicide. Sophisticated statistical models . . . and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient commits suicide while nine other equally depressed and equally suicidal patients do not, I answer, “I don’t know.” (p. 135)

Litman’s comments remain true today. Part of the problem stems from the fact that suicide is what is referred to as a low base rate event. When something occurs at a low base rate, it becomes mathematically very difficult to predict. Suicide is a prime example of a low base rate event. According to the CDC, in 2017, only about 14 of every 100,000 citizens died by suicide.

Imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 14 of the 100,000 fans will die by suicide over the next 365 days.

A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that every one of the 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide) and ask them to leave the stadium. Now you’re down to identifying which 14 of 15,000 will die by suicide.

For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.

At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive psychological treatment for the remaining 7,500 people. However, many of the fans will refuse treatment, including some of whom will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.

To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 14 individuals who will die by suicide over the next year. All this points to the magnitude of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people some of the time.

Truth #4: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research doesn’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, odds are, in the vast majority of cases, you won’t be able to efficiently predict or prevent suicide attempts or suicide deaths.

Myth #4: Suicide prevention and intervention should focus on eliminating suicidal thoughts.

Logical analysis implies that if suicidal thoughts within an individual are eliminated, then suicide will be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy? The first reason is because most people who think about suicide never make a suicide attempt. But that’s only the tip of the iceberg.

After his son died by suicide, Rick Warren, a famous pastor and author, created a Youtube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads, “If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!”

Although over 1,000 viewers clicked on the “thumbs up” sign for the video, there were 535 comments; these comments mostly pushed back on Pastor Warren’s well-intended message. Examples included:

  • Are you kidding me??? You’ve clearly never been suicidal or really depressed.
  • To say “Suicide is a permanent solution to a temporary problem” is like saying: “You couldn’t possibly have suffered long enough, even if you’ve suffered your entire life from many, many issues.”
  • This is extremely disheartening. With all due respect. Pastor, you just don’t get it.

Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, most of us try to use rational persuasion to encourage individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called psychological reactance helps explain why rational persuasion—even when well-intended—rarely makes for an effective intervention.

While working with chronically suicidal patients for over two decades, Dr. Marsha Linehan of the University of Washington made an important discovery: when psychotherapists try to get their patients to stop thinking about suicide, the opposite usually happens—the patients become more suicidal.

Linehan’s discovery has played out in my clinical practice. Nearly every time I’ve actively pushed clients to stop thinking about suicide—using various psychological ploys and techniques—my efforts have backfired.

Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective.

Starting Over

Individuals who are suicidal are complex, unique, and in deep distress. Judging them as ill is unhelpful. Believing that we can successfully predict and prevent suicide borders on delusional. Direct persuasion usually backfires. Letting go of the four common suicide myths might make you feel nervous. At least they provided guidance for action, right? But just like having the female on top to prevent pregnancy, clinging to unhelpful myths won’t, in the end, be effective. How do we start over? Where do we go from here?

All solutions—or at least most of them—begin with a clear understanding of the problem. As someone who has worked directly with suicidal individuals for decades, there’s no better person to start us on the journey toward a deeper understanding of suicide than Dr. Marsha Linehan.

Dr. Linehan is the developer of dialectical behavior therapy (DBT for short). DBT is widely hailed as the most effective evidence-based approach for working with chronically suicidal patients. To help her students at the University of Washington better understand the dynamics of suicide, Dr. Linehan begins her teaching with this story:

The suicidal person [is] 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.

Efforts to understand someone else’s reality are destined to fall short. You can’t always get it right, but that’s okay, because empathy is more about being with and feeling with others, than it is about perfectly understanding them. Trying to understand the inner world of others is an act of courage and compassion. Thus, our next step is to suspend judgment and begin our descent into that small, dark room with no windows.

Four Suicide Myths (and Truths) — Part I

Let’s start with a myth and a truth.

Myth: Rita bought me a pair of “Joker” pants (as in Batman). I think wearing them will make me funnier.

Truth: Wearing them makes me look funny, but they don’t actually make me funnier.

Joker Pants

The word “myth” has two primary meanings.

A myth is a traditional or popular story or legend used to explain current cultural beliefs and practices. This definition emphasizes the positive guidance that myths sometimes provide. For example, the Greek myth of Narcissus warns that excessive preoccupation with one’s own beauty can become dangerous. Whether or not someone named Narcissus ever existed is irrelevant; the story tells us that too much self-love can lead to our own downfall.

The word myth is also used to describe an unfounded idea, or false notion. Typically, the false notion gets spread around and, over time, becomes a generally accepted, but inaccurate, popular belief. One contemporary example is the statement, “Lightning never strikes the same place twice.” In fact, lightning can and does strike the same place twice (or more). During an electrical storm, standing on a spot where lightning has already struck, isn’t a good safety strategy. . . and wearing “Joker” pants won’t necessarily make you funnier.

The statement “We only use 10% of our brains” is another common myth. Although it’s likely that most of us can and should more fully engage our brains, scientific researchers (along with the Mythbusters television show) have shown that much more than 10% of our brains are active most of the time—and probably even when we’re sleeping.

False myths stick around for much longer than they should, sometimes they stick around despite truckloads of contradictory evidence. As humans, we like easy explanations, especially if we find them personally meaningful or affirming. Never mind if they’re accurate or true.

Not long ago I was discussing sex education with a group of teenagers. Several of them reported—with great confidence—that if a woman is on top during intercourse she can’t get pregnant.

“How might that work?” I asked.

“Gravity,” the leader explained. The rest of group nodded in agreement. “Sperm can’t swim uphill.”

Immediately, I tried to dispute their gravitational theory of birth control. To me, their belief in a birth control myth would likely lead to unhappy outcomes. But the teenagers held their ground.

Historically, myths were passed from individuals to groups and other individuals via word of mouth. Later, print media was used to more efficiently communicate ideas, both factual and mythical. Today we have the internet and instant mythical messaging.

Unfortunately, some myths are used for political or financial gain. Other myths, like the gravitational theory of birth control, lead to unplanned and adverse outcomes. Today, primarily through the internet, people are pummeled with information, misinformation, and outright lies. Despite amazing scientific, psychological, and technical progress, sorting fact from fiction remains an enormous challenge.

Suicide myths weren’t and aren’t designed to intentionally mislead; mostly (although there are some exceptions) they’re not about pushing a political agenda or selling specific products. Instead, suicide myths are the product of dedicated, well-intended people whose passion for suicide prevention sometimes outpaces their knowledge of suicide-related facts.

In some cases, people believe so hard in certain suicide myths that they cling to and defend their myths, even when the myths have become dysfunctional and even in the face of substantial contrary logical and empirical evidence. Thinking back to the teenagers and their gravitational theory of birth control, I recall their response to my scientific rebuttal. One of them said, “Well. Maybe so, but that’s what I heard, and it still makes sense to me. Even if sperm can swim uphill, gravity must make it harder to get a woman pregnant if she’s on top.”

When suicide (or birth control) myths take on a life of their own despite contradictory evidence, it’s usually because the myths have deep emotional roots or because people have an incentive that motivates them to hang on to their mythical beliefs.

Depending on your perspective, experiences, and your knowledge base, it’s possible that my list of suicide myths will push your emotional buttons. Maybe you were taught that “suicide is 100% preventable.” Or maybe you believe that suicidal thoughts or impulses are inherently signs of deviance or a mental disturbance. If so, as I argue against these myths, you might find yourself resisting my perspective. That’s perfectly fine. The ideas that I’m labeling as unhelpful myths have been floating around in the suicide prevention world for a long time; there’s likely emotional and motivational reasons for that. Also, I don’t expect you to immediately agree with everything in this book. However, I hope you’ll give me a chance to make the case against these myths, mostly because I believe that hanging onto them is unhelpful to suicide assessment and prevention efforts.

In this chapter, I list the four myths and provide brief descriptions. Read them, see what you think, and notice your reactions. In the next 4 chapters, we’ll dive deeper into evidence against these myths, why they’re potentially destructive, and alternative ways to think about suicide and suicide prevention.

Myth #1: Suicidal thoughts are about death and dying.

Most people assume that suicidal thoughts are about death and dying. It seems like a no-brainer: Someone has thoughts about death, therefore, the thoughts must be about death.

But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.

Let’s look at a parallel example. Couples who come to counseling often have conflicts about money. One partner likes to spend and the other is serious about saving. From the surface, you might mistakenly assume that when couples have conflicts about money, the conflicts are about money—dollars, cents, spending, and saving. However, romantic relationships are complex, which is why money conflicts are usually about other issues, like love, power, and control. Nearly always there are dynamics bubbling under the surface that fuel couples’ conflicts over money.

Truth #1: Among suicidologists and psychotherapists, the consensus is clear: suicidal thoughts and impulses are less about death and more about a natural human response to intense emotional and psychological distress. I use the term, excruciating distress to describe the intense emotional misery that nearly always accompanies the suicidal state of mind.