Fighting to understand suicide

The tragic deaths of celebrities like Kate Spade and Anthony Bourdain pique our interest, but the truth is suicide is still shrouded in stigma even as rates increase. But the writers and people profiled in our Surviving Suicide project today want to break that stigma, and talk openly about this issue that touches so many families.

When someone we love dies by suicide, we want to know why. And yet it's a question that's often impossible to answer. Laura Trujillo wanted desperately to understand her mother's suicide at the Grand Canyon. She wrote a powerful essay for USA TODAY on how she learned to live without her mom – and without answers.

Laura’s mom was one of a growing number of Americans who die by suicide, the No. 10 killer in the U.S. Yet federal research funding for suicide lags behind that of all other leading causes of death – and even non-fatal issues like sleep or indoor air pollution. Some other major takeaways from the Surviving Suicide project:

Public perception is getting better, but people are still afraid to talk about it. That can make it difficult for people who are experiencing suicidal thoughts to reach out for help, or for people who've lost someone to suicide to get the support they need. Hope is out there. Millions of people every year think about suicide, but never attempt. Nine out of 10 people who attempt will not go on to die by suicide later. There are ways to cope with suicidal thoughts or a suicidal crisis. Not every story we read about suicide has to end in tragedy (National Suicide Prevention Lifeline: 1-800-273-8255 or the Crisis Text Line: Text "SOS" to 741741).

Why are men more likely than women to take their own lives?

Efforts to prevent suicide, such as those championed by Nick Clegg, must take into account some apparently paradoxical differences between men and women

This week saw the deputy prime minister, Nick Clegg, appeal for the widespread adoption of a “zero suicide” campaign in the NHS. This is admirable, but a concerted effort to prevent people from taking their own lives would be more effective if we understood why suicide is a particularly male problem. It’s known as the “gender paradox of suicidal behaviour”.

Research suggests that women are especially prone to psychological problems such as depression, which almost always precede suicide. In western societies, overall rates of mental health disorders tend to be around 20-40% higher for women than for men.

Given the unequal burden of distress implied by these figures, it is hardly surprising that women are more likely to experience suicidal thoughts. The Adult Psychiatric Morbidity in England 2007 survey found that 19% of women had considered taking their own life. For men the figure was 14%. And women aren’t simply more likely to think about suicide – they are also more likely to act on the idea. The survey found that 7% of women and 4% of men had attempted suicide at some point in their lives.

But of the 5,981 deaths by suicide in the UK in 2012, more than three quarters (4,590) were males. In the US, of the 38,000 people who took their own lives in 2010, 79% were men.

(These are startling figures in their own right, but it is also worth remembering just how devastating the effects of a death by suicide can be for loved ones left behind. Studies have shown, for example, an increased risk of subsequent suicide in partners, increased likelihood of admission to psychiatric care for parents, increased risk of suicide in mothers bereaved by an adult child’s suicide, and increased risk of depression in offspring bereaved by the suicide of a parent.)

So if women are more likely to suffer from psychological problems, to experience suicidal thoughts and attempt suicide, how do we explain why men are more likely to die by suicide?

It’s principally a question of method. Women who attempt suicide tend to use nonviolent means, such as overdosing. Men often use firearms or hanging, which are more likely to result in death.

In the UK, for instance, 58% of male suicides involved hanging, strangulation or suffocation. For females, the figure was 36%. Poisoning (which includes overdoses) was used by 43% of female suicides, compared with 20% of males. A similar pattern has been identified in the US, where 56% of male suicides involved firearms, with poisoning the most common method for females (37.4%).

Less is known about the choice of methods in attempted suicides that don’t lead to a fatality. A European study of over 15,000 people receiving treatment after an attempt did find that men were more likely than women to have used violent methods, but the difference was less pronounced.

Why do methods of suicide differ by gender? One theory is that men are more intent on dying. Whether this is true remains to be proven, but there is some evidence to back up the idea. For example, one study of 4,415 patients admitted to hospital in Oxford following an episode of self-harm found that men reported significantly higher levels of suicidal intent than women.

Another hypothesis focuses on impulsivity – the tendency to act without properly thinking through the consequences. Men are, on the whole, more likely to be impulsive than women. Perhaps this leaves them vulnerable to rash, spur-of-the-moment suicidal behaviour.

Not all suicides are impulsive, of course, and even for those that are, the evidence is mixed: some studies have reported that men are more susceptible to impulsive suicidal acts; others have found no such thing. What we do know is that alcohol increases impulsivity, and that there’s a clear link between alcohol use and suicide. Studies have found that men are more likely than women to have drunk alcohol in the hours before a suicide attempt, and that alcohol problems are more common in men who die by suicide than in women.

The third theory is that, even in their choice of suicide method, males and females act out culturally prescribed gender roles. Thus women will opt for methods that preserve their appearance, and avoid those that cause facial disfigurement. Again, the evidence is patchy. But a study of 621 completed suicides in Ohio found that, though firearms were the most common method used by both sexes, women were less likely to shoot themselves in the head.

Clearly much work needs to be done before we arrive at a reliable picture of what’s going on here. But it is striking that suicide, like mental health in general, is a gendered issue – it sometimes affects men and women in radically different ways. That’s a lesson we need to take on board in research, clinical care and prevention efforts alike.

Suicide, Guns, and Public Health

Most efforts to prevent suicide focus on why people take their lives. But as we understand more about who attempts suicide and when and where and why, it becomes increasingly clear that how a person attempts–the means they use–plays a key role in whether they live or die.

“Means reduction” (reducing a suicidal person’s access to highly lethal means) is an important part of a comprehensive approach to suicide prevention. It is based on the following understandings (click on each to learn more):

Firearm access can be a politically-charged topic. We welcome both gun owners and non-gun owners to this website. It is designed to introduce a non-controversial, “lethal means counseling” approach to reducing a suicidal person’s access to firearms and other lethal means.

Families and friends who are concerned about someone can also help. Read more about ways to bring up storing guns off-site.

Clinicians concerned about a patient should also consider addressing firearm safety with the patient, or with their family.

Our Mission

The mission of the Means Matter Campaign is to increase the proportion of suicide prevention groups who promote activities that reduce a suicidal person’s access to lethal means of suicide and who develop active partnerships with gun owner groups to prevent suicide.

Who We Are

The Harvard Injury Control Research Center is dedicated to reducing injury through training, research,intervention, evaluation, and dissemination. The Center has published hundreds of studies on injury topics ranging from motor vehicle crashes to alcohol use to youth violence and suicide. The Center is part of the Harvard School of Public Health.

How and Why the 5 Steps Can Help

The five action steps for communicating with someone who may be suicidal are supported by evidence in the field of suicide prevention.


How – Asking the question “Are you thinking about suicide?” communicates that you’re open to speaking about suicide in a non-judgmental and supportive way. Asking in this direct, unbiased manner, can open the door for effective dialogue about their emotional pain and can allow everyone involved to see what next steps need to be taken. Other questions you can ask include, “How do you hurt?” and “How can I help?” Do not ever promise to keep their thoughts of suicide a secret.

The flip side of the “Ask” step is to “Listen.” Make sure you take their answers seriously and not to ignore them, especially if they indicate they are experiencing thoughts of suicide. Listening to their reasons for being in such emotional pain, as well as listening for any potential reasons they want to continue to stay alive, are both incredibly important when they are telling you what’s going on. Help them focus on their reasons for living and avoid trying to impose your reasons for them to stay alive.

Why – Studies show that asking at-risk individuals if they are suicidal does not increase suicides or suicidal thoughts. In fact, studies suggest the opposite: findings suggest acknowledging and talking about suicide may in fact reduce rather than increase suicidal ideation.


How – First of all, it’s good for everyone to be on the same page. After the “Ask” step, and you’ve determined suicide is indeed being talked about, it’s important to find out a few things to establish immediate safety. Have they already done anything to try to kill themselves before talking with you? Does the person experiencing thoughts of suicide know how they would kill themselves? Do they have a specific, detailed plan? What’s the timing for their plan? What sort of access to do they have to their planned method?

Why – Knowing the answers to each of these questions can tell us a lot about the imminence and severity of danger the person is in. For instance, the more steps and pieces of a plan that are in place, the higher their severity of risk and their capability to enact their plan might be. Or if they have immediate access to a firearm and are very serious about attempting suicide, then extra steps (like calling the authorities or driving them to an emergency department) might be necessary. The Lifeline can always act as a resource during these moments as well if you aren’t entirely sure what to do next.

The Harvard T.H. Chan School of Public Health notes that reducing a suicidal person’s access to highly lethal means (or chosen method for a suicide attempt) is an important part of suicide prevention. A number of studies have indicated that when lethal means are made less available or less deadly, suicide rates by that method decline, and frequently suicide rates overall decline. Research also shows that “method substitution” or choosing an alternate method when the original method is restricted, frequently does not happen. The myth “If someone really wants to kill themselves, they’ll find a way to do it” often does not hold true if appropriate safety measures are put into place. The Keep Them Safe step is really about showing support for someone during the times when they have thoughts of suicide by putting time and distance between the person and their chosen method, especially methods that have shown higher lethality (like firearms and medications).


How – This could mean being physically present for someone, speaking with them on the phone when you can, or any other way that shows support for the person at risk. An important aspect of this step is to make sure you follow through with the ways in which you say you’ll be able to support the person – do not commit to anything you are not willing or able to accomplish. If you are unable to be physically present with someone with thoughts of suicide, talk with them to develop some ideas for others who might be able to help as well (again, only others who are willing, able, and appropriate to be there). Listening is again very important during this step – find out what and who they believe will be the most effective sources of help.

Why – Being there for someone with thoughts of suicide is life-saving. Increasing someone’s connectedness to others and limiting their isolation (both in the short and long-term) has shown to be a protective factor against suicide. Thomas Joiner’s Interpersonal-Psychological Theory of Suicide highlights connectedness as one of its main components – specifically, a low sense of belonging. When someone experiences this state, paired with perceived burdonsomeness (arguably tied to “connectedness” through isolating behaviors and lack of a sense of purpose) and acquired capability (a lowered fear of death and habituated experiences of violence), their risk can become severely elevated.

In the Three-Step Theory (or more commonly known as the Ideation-to-Action Framework), David Klonsky and Alexis May also theorize that “connectedness” is a key protective factor, not only against suicide as a whole, but in terms of the escalation of thoughts of suicide to action. Their research has also shown connectedness acts as a buffer against hopelessness and psychological pain.

By “being there,” we have a chance to alleviate or eliminate some of these significant factors.


How – Helping someone with thoughts of suicide connect with ongoing supports (like the Lifeline, 800-273-8255) can help them establish a safety net for those moments they find themselves in a crisis. Additional components of a safety net might be connecting them with supports and resources in their communities. Explore some of these possible supports with them – are they currently seeing a mental health professional? Have they in the past? Is this an option for them currently? Are there other mental health resources in the community that can effectively help?

One way to start helping them find ways to connect is to work with them to develop a safety plan. This can include ways for them identify if they start to experience significant, severe thoughts of suicide along with what to do in those crisis moments. A safety plan can also include a list of individuals to contact when a crisis occurs. The My3 app is a safety planning and crisis intervention app that can help develop these supports and is stored conveniently on your smartphone for quick access.

Why – Impact of Applied Suicide Intervention Skills Training on the National Suicide Prevention Lifeline found that individuals that called the National Suicide Prevention Lifeline were significantly more likely to feel less depressed, less suicidal, less overwhelmed, and more hopeful by the end of calls handled by Applied Suicide Intervention Skills Training-trained counselors. These improvements were linked to ASIST-related counselor interventions, including listening without judgment, exploring reasons for living and creating a network of support.


How – After your initial contact with a person experiencing thoughts of suicide, and after you’ve connected them with the immediate support systems they need, make sure to follow-up with them to see how they’re doing. Leave a message, send a text, or give them a call. The follow-up step is a great time to check in with them to see if there is more you are capable of helping with or if there are things you’ve said you would do and haven’t yet had the chance to get done for the person.

Why – This type of contact can continue to increase their feelings of connectedness and share your ongoing support. There is evidence that even a simple form of reaching out, like sending a caring postcard, can potentially reduce their risk for suicide.

Studies have shown a reduction in the number of deaths by suicide when following up was involved with high risk populations after they were discharge from acute care services. Studies have also shown that brief, low cost intervention and supportive, ongoing contact may be an important part of suicide prevention. Please visit our Follow-Up Matters page for more.

Legislative Action

As Suicide Problem Grows in Oregon, Legislators Debate Solutions - Apr 28 2017

The Senate passed a bill giving law enforcement more tools when encountering suicidal people, while the House closed gaps for mental health patients discharged from emergency rooms. But a bill to assist gun shop owners was spiked.

The Oregon House and Senate passed complementary bills addressing suicide prevention on Wednesday, but a separate bill to provide gun shop owners with materials and training to prevent firearm deaths was spiked without a vote.

House Bill 2526, which will not advance, directed the Department of Justice to assist gun shop owners with identifying potential suicide victims and to provide them with literature to hand to customers about the risk. The original bill required gun shop owners to disseminate the materials to gun purchasers, while an amendment from Rep. Knute Buehler, R-Bend, would have made the program optional.

The gun shop bill was introduced by Buehler and represented a rare bipartisan opportunity to deal with the public health problem presented by firearms in Oregon and the United States. Just under half of the 43,000 suicides in the country in 2014 were committed with the aide of a gun.

“If someone buys a handgun, they’re over 50 times more likely to kill themselves in the next week,” Buehler told The Lund Report. He said his legislation was modeled on laws that had passed in about half the states; it had the support of some gun rights groups while still being opposed by others.

He said gun-control advocates had been supportive, but HB 2526 did not make it out of the House Judiciary Committee by the deadline this month, nor was it passed on to the House Rules Committee to keep it alive.

The office of House Speaker Tina Kotek, D-Portland, did not respond to questions about why the bill was spiked, but Buehler said partisan politics may have gotten in the way. Buehler is seen as a potential challenger to Gov. Kate Brown next year and some Democrats are not enthusiastic to support his initiatives. However, he said that Sen. Elizabeth Steiner Hayward, D-Beaverton, a co-sponsor of HB 2526, planned to reintroduce it this session as one of her priority bills.

The House did pass House Bill 3090, a bill from Rep. Alissa Keny-Guyer, D-Portland, which requires hospital emergency departments to adopt discharge procedures for patients in a mental health crisis, helping to coordinate care from acute care to outpatient treatment.

“Suicide is the second-leading cause of death for youth 10 to 24,” said Keny-Guyer, who added that suicide rates have been on the rise in the state since 2000, even as they have dropped elsewhere.

HB 3090 is an extension of the 2015 Susanna Gabay Law, which required hospitals to develop such plans for psychiatric patients, something that failed to happen for Gabay, who committed suicide. But the 2015 law only applies to admitted patients, not people who come to the ER but are never formally admitted to the hospital. HB 3090 closes that gap, which Keny-Guyer said was especially crucial in rural hospitals without psychiatric wards.

The House also passed a separate Keny-Guyer bill, House Bill 3091, which requires health insurers and Medicaid plans to cover a behavioral health assessment and any recommendations.

The Senate passed Senate Bill 833, which directs law enforcement agencies to encourage officers responding to behavioral health incidents to offer to telephone the suicide hotline for the person in distress.

“Our mental health system is in a crisis,” said Sen. Sara Gelser, D-Corvallis, the chief sponsor of SB 833, which was also sponsored by Buehler and Keny-Guyer. “There’s a reason why Oregon’s suicide is growing while other states are declining.”

SB 833 sparked a volley of comments from senators concerned about the issue. “This is a clarion call for qualified suicide prevention specialists,” said Sen. Betsy Johnson, D-Scappoose. “We need to keep our commitment to Lines for Life.”

Sen. Brian Boquist, R-McMinnville, whose son took his own life, complained that the Oregon Health Authority had done a poor job of enacting previous suicide prevention laws, singling out one that was intended to provide law enforcement officers with hands-on training to prevent suicides but instead was turned into a PowerPoint slide presentation.

Oregon had the 14th-highest youth suicide rate in 2012 and 2013, according the Centers for Disease Control -- 166 deaths, or about 11 deaths for every 100,000 people. It’s a problem that’s especially high in the American West -- all but two states in the top 15 are west of the Mississippi River, while only two western states -- Texas and California -- are in the bottom 15.

Alaska leads the nation with 25 suicide deaths per 100,000 people while Rhode Island had 3 youth suicide deaths per 100,000 people in 2012 and 2013.

The reasons for the higher suicide rate in the West are unclear, but two factors appear to be a greater proliferation of firearms and an isolating, individualistic culture, according the state Youth Suicide Intervention and Prevention Plan. Native Americans, who have larger populations in the West, are also at a much higher risk than other races.

Male youth are four times as likely to kill themselves as female youth, and male returning military veterans are four times as likely to commit suicide than other men.

The recently released plan calls for integration of existing suicide prevention programs, supporting school intervention and providing additional training to community first-responders and clinical service providers.

Reach Chris Gray at


People are afraid to talk about mental health at work, but here's how to do it.

It’s “best to focus on the impact it’s having on your work,” Dr. David Ballard tells Moneyish

Sometimes it’s way more than a case of the Mondays.

A new survey on mental health suggests that people don’t think their colleagues would be receptive to any mention of mental health issues at work.

Researchers found that 85% of workers thought there was still a stigma attached to stress and mental health issues in the workplace, according to a study of UK workers by the London-based Chartered Institute of Personnel and Development course providers.

The survey polled 1,000 working adults, 26% of whom had taken a day off work because of a mental health problem but had lied about why they were out of the office. More than half (58%) revealed they weren’t comfortable telling their boss if they were diagnosed with a mental health issue, and just 20% believed their manager would be supportive of workers battling mental disorders, as they feared their employers wouldn’t take them seriously.

Americans’ mental health struggles on the job are well documented, too: 18% percent of workers in a 2017 American Psychological Association survey said mental health issues had made work challenges harder to handle in the past month, 15% said those issues had kept them from achieving work goals, and more than a third suffered from chronic job stress.

The APA’s 2015 survey also found 4% of American workers were experiencing severe elevations in depression and anxiety-related symptoms, while another 24% reported mild to moderate elevations. Despite those numbers, only 48% in 2017 said their employer provided the necessary resources for workers’ mental health needs.

But how are you supposed to talk to a boss about mental health? We asked experts to weigh in.

First, decide if you need to tell him or her, said David Ballard, assistant executive director of the APA’s Center for Organizational Excellence. “As much as it shouldn’t matter and people should be able to go and talk about these things openly, that’s not the case in every workplace,” he told Moneyish. Your dynamic with the boss and company culture will factor into the decision, Ballard said — not to mention a good portion of stress-related issues likely won’t warrant a talk with your supervisor, added Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention.

You may go straight to tapping into your mental health benefits, asking about your employee assistance program and seeing if HR can connect you with more resources, Ballard said. Practice self-care like sleep, exercise, diet and spending time with family and friends.

If you feel totally unable to talk to a supervisor, visit the Job Accommodation Network (JAN), a site run by the Department of Labor’s Office of Disability Employment Policy, for a free, confidential consultation on workplace accommodations. “Arm yourself with your rights … if you think it’s going to come to that,” Theresa Nguyen, vice president of policy and programs at Mental Health America, told Moneyish.

But if the talk seems like a good idea, or you feel your mental health condition is affecting your productivity or professionalism, it’s “best to focus on the impact it’s having on your work,” Ballard said. “Your boss is not your therapist, but they can be someone who can provide support so that you can continue to do your job well,” he added.

Think of the issue in terms of physical health. “And how would you approach it in that case?” Moutier told Moneyish. “You’re going to treat it as, ‘I’d like to speak with you about this health issue going on in my life, because I’ve wondered if it could be impacting my work.’” But not all bosses are “progressive and educated” on mental health issues, she acknowledged. “So by no means would we advocate for people to jeopardize their reputation or their supervisor’s view of them,” she said.

Decide how much you want to disclose. “It would be reasonable to just leave it in the category of ‘a health issue I’m dealing with and addressing … that applies to whether it’s hypertension, diabetes or depression. You’re not obliged to name your condition to your supervisor,” Moutier said. “(Employees) can be guided by their instincts in terms of whether or not it feels safe or comfortable to disclose whatever level of detail that they’re thinking of sharing.”

Know what to expect. Discuss the timeframe of your issue — chronic or temporary? A week, a month or six months? — and whether any specific informal accommodations might be helpful. “The person could just be given some more flexibility with the deadlines on their projects,” Moutier said. “They may be, of course, allowed to take certain days off to attend to their health needs for medical appointments or other ways that the person is going to address their health.”

If you’re too anxious to have the talk in the first place, review your main talking points when you’re feeling less overwhelmed and try doing it before things reach a “crisis point,” Ballard said. You could also draft an email or letter to your boss during a lower-anxiety time, suggested Nguyen — taking your time “in a place where you feel like you have more clarity of mind and more control.”

Realize your boss might be more receptive than you think. About 43.4 million people 18 and up — or 17.9% of U.S. adults — were struggling with mental illness within the past year, per the 2015 National Survey on Drug Use and Health. And 89% of U.S. adults view mental and physical health as equally important for overall health, according to a Harris Poll co-sponsored by AFSP. “It’s very possible that your supervisor has faced their own challenges … and will be quite knowledgeable and supportive,” Moutier said.

Employers need to play their part, too, said Nguyen. “If everybody from upper management to bottom management engages in a practice where they’re openly talking about their mental health problems, then it sends a message to the entire community (that) it’s OK to talk about these issues,” she told Moneyish. “The goal is to allow people to feel like they can talk about this earlier instead of waiting ’til it’s a problem.”

“An important point to hammer home is that treatment works,” Ballard added. “And not to let fear about stigma, or being viewed negatively in the workplace, get in the way of getting the help you need.”

How to create a more supportive workplace

On mental health issues, anxiety and stress: how to create a more supportive workplace

This year’s World Mental Health Day theme is mental health in the workplace. In light of this, we wanted to conduct some research of our own into workplace attitudes towards these issues. Our main aim was to gauge how workers feel about their working environment, and whether they are confident about receiving the support they need if they experience an issue.

Our findings were a little disappointing, and certainly highlight a need for changes in the way our nation’s workplaces deal with issues such as stress, anxiety and mental illness. Our findings also highlight an issue with perception – something this article will try to tackle.

Identifying a problem

One of the most shocking findings was that 85% of UK workers thought there was a stigma attached to mental health issues in the workplace. This illustrates how hard it is for workers to open up about potential mental health issues. Those suffering are likely to feel isolated and dejected, so to feel as if seeking help may only marginalise them further is a truly desperate situation.

This stigma may explain our finding that 58% of workers wouldn’t be comfortable telling their manager if they were suffering from a mental health issue. This means that over half of the country would suffer in silence should they face one of the toughest challenges.

Another reason that managers may be being kept at arm’s length with these issues is that just 20% of workers thought their manager was fully equipped to support mental health issues in the workplace.

When we asked Tom Oxley – lead consultant and relationship director at Bamboo Mental Health – about the problem facing some workplaces today, he said: “Despite wonderful awareness campaigns, stigma is alive and well when it comes to mental health at work. Stigma comes from within individuals, or it can be nurtured by some organisations. Make no mistake; subject knowledge has improved but there’s a chasm between awareness and action for many employers.

“Six out of ten [of those currently suffering] aren’t saying anything to their manager. That means they’re working unwell and not getting support. That means the team performance may be impaired.

Identifying a solution

So, what can managers and workplaces do to mitigate this issue and create a more open and supportive atmosphere? And how can they make seeking support seem like an attractive, positive move instead of a potentially destructive action?

With the help of some of our tutors and Tom Oxley from Bamboo Mental Health, we’ve assembled a few tips to help move towards a more openly supportive workplace culture.

1. “Managers need to build the trust and rapport between themselves and their team.”

Without trust, and without the social bond that makes trust possible, it can be hard to share weekend plans with managers, let alone serious health issues. Whilst a manager’s role is to ensure the delivery of a process, service or similar, it is also their responsibility to motivate and inspire staff. Getting the most from staff members isn’t simply about working them hard.

2. “Managers need training to rehearse what to say, when to step in, and how to support individuals.”

Appropriate training and feeling equipped to deal with serious health issues can be a daunting prospect even for seasoned managers. Specialised training is available and is a valuable tool in the manager’s repertoire, not only for helping to mitigate issues but also for noticing them, and approaching them with tact.

3. “Managers need to be trained and supported by HR and leadership teams.”

As above, training needs to be made available for managers. HR and leadership teams need to take the initiative and responsibility to implement this, however.

4. “Managers need to be human in their response to the subject.”

This ensures that the worker is allowed to feel human despite their issue. Many sufferers of stress, anxiety or mental health issues feel that they are in some way flawed or different to the rest of society, so it’s imperative they are helped to feel normal, and that it is ‘okay to not be okay’. Expanding the point, Tom Oxley said “managers with personal or lived experience of mental ill health tend to be better equipped with the language around mental health”.

5. “Managers need to be empowered to make adjustments.”

Helping the employee deal with their workload and focus on getting better can have a great effect on making them feel supported and relieving pressure. Setting more appropriate working hours and targets is a great place to start. However, genuinely being able to make these adjustments is crucial – particularly without drawing too much attention or encountering red tape.

Looking forward

This year’s World Mental Health Day is set to cast mental health in the workplace into sharp focus. Hopefully, with this comes serious change. We believe that the majority of workplaces across the nation are becoming more accepting, supportive places to work but that, whilst they have come a long way, there’s still work to be done.

Not only do our courses provide an incredible toolset for HR and leadership teams to be able to deal with such sensitive issues, they also make it easy to pass these skills down the line in an organisation, so that all levels can feed into a more supportive working culture.

Helpful links:

UK charity Mind:

World Health Organisation:

Mental Health Foundation:

Suicide can be prevented

It's World Suicide Prevention Day and that should be of particular interest in the United States, where suicide rates are up across demographic groups — even, tragically, among children. But you could save a life, experts say, by following five steps , starting with reaching out someone who's struggling. If you're having suicidal thoughts (or want advice on how to help someone who is) here's what you can expect when you call the National Suicide Prevention Lifeline. USA TODAY's new Facebook group I Survived It is open to suicide survivors, suicide loss survivors (friends and family affected), as well as survivors of other issues.

Suicide Lifeline: If you or someone you know may be struggling with suicidal thoughts you can call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255) or text "SOS" to the Crisis Text Line 741741 any time of day or night.

For people who identify as LGBTQ, if you or someone you know is feeling hopeless or suicidal, you can also contact The Trevor Project's TrevorLifeline 24/7/365 at 1-866-488-7386.

The Military Crisis Line, online chat, and text-messaging service are free to all service members, including members of the National Guard and Reserve, and veterans, even if you are not registered with the U.S. Department of Veterans Affairs (VA) or enrolled in VA health care. Call 1-800-273-8255 and press 1.

Check these out:

To connect with suicide survivors and others, join USA TODAY's Facebook group I Survived It

What actually happens when you call the suicide hotline

If you're thinking about suicide, I was there

The teen suicide rate has more than doubled: What you can do for your child

Calls to suicide crisis centers doubled since 2014

Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?


There is a commonly held perception in psychology that enquiring about suicidality, either in research or clinical settings, can increase suicidal tendencies. While the potential vulnerability of participants involved in psychological research must be addressed, apprehensions about conducting studies of suicidality create a Catch-22 situation for researchers. Ethics committees require evidence that proposed studies will not cause distress or suicidal ideation, yet a lack of published research can mean allaying these fears is difficult. Concerns also exist in psychiatric settings where risk assessments are important for ensuring patient safety. But are these concerns based on evidence? We conducted a review of the published literature examining whether enquiring about suicide induces suicidal ideation in adults and adolescents, and general and at-risk populations. None found a statistically significant increase in suicidal ideation among participants asked about suicidal thoughts. Our findings suggest acknowledging and talking about suicide may in fact reduce, rather than increase suicidal ideation, and may lead to improvements in mental health in treatment-seeking populations. Recurring ethical concerns about asking about suicidality could be relaxed to encourage and improve research into suicidal ideation and related behaviours without negatively affecting the well-being of participants.

Comment in

Letter to the editor: Suicidal ideation and research ethics committees. [Psychol Med. 2015]

Letter to the editor: Suicidal ideation and research ethics committees: a reply. [Psychol Med. 2015]

Comment on

The ethics of doing nothing. Suicide-bereavement and research: ethical and methodological considerations. [Psychol Med. 2014]

PMID: 24998511 DOI: 10.1017/S0033291714001299

A Historical Perspective on Suicide

When I first read this quote, my initial impression was that it came from Freud. If pressed, I would have guessed from his late-life despairing opus, Civilization and Its Discontents.2 But I was wrong. These were among the last words written by Walter Benjamin, months before his suicide in 1940. In fact, these words are engraved on his tombstone. Even more oddly, and perhaps profoundly befitting his somewhat scattered career, this German-Jewish atheist who died by suicide was allowed burial in consecrated Catholic soil in Spain.

Walter Benjamin was one of the founding fathers of the so-called Frankfurt School of Philosophy in the 1920s and 1930s, which included Theodor Adorno, Max Horkheimer, Erich Fromm, Hannah Arendt, and Herbert Marcuse. The members were German neo-Marxists and psychoanalytically influenced scholars who were openly critical of the German people who allowed the National Socialists to come into power. The group introduced the concept of applying multidisciplinary study and dialectical methods to the bigger questions of history, psychology, economics, philosophy, and art—even to medicine, long before there was any discussion of a “bio-psycho-social” approach. For better or for worse, they developed the increasingly ill-defined “critical theory” that has so pervasively, even fetishistically, enthralled the academic towers in America since the 1960s.

Of all the group, Benjamin, primarily an historian and art critic, struggled most with mood lability. He wrote several suicide notes throughout the course of his brief lifetime, typically addressed to his current female partner, before finally composing his last one—addressed to no one in particular, on the night of September 26th, 1940. He gave the note to one of his fellow German-Jewish refugees, Henny Garland, who took it and did nothing to stop him from overdosing on morphine. She destroyed the note and convinced the authorities that Benjamin’s death was the result of heart failure, concerned that if the authorities discovered Benjamin’s death was a suicide it would weaken the entire group’s chances of obtaining exit visas.

The standard historical interpretation of Benjamin’s death is one of tragic pseudo-irony. Benjamin, with the help of his expatriated colleagues, Adorno and Horkheimer, had undertaken a desperate flight from Marseilles to Port Bou in Spain with several other refugees. Benjamin carried a single attaché case reportedly containing an unknown manuscript, and “enough morphine to kill a horse.” He had already abandoned his brother and sister to their own devices (as German-Jewish exiles with no citizenship; as did Gurland, who abandoned her prisoner-of-war second husband, only to marry Fromm 4 years later, and to commit suicide herself in 1952). Once in Port Bou, the group was told that Spain was no longer issuing exit visas to undocumented French refugees, and this was the pretext for Benjamin’s suicide. The next day, this decision was reversed, and the group was allowed to leave for neutral Portugal, and eventually for New York.

Walter Benjamin’s suicide is especially interesting as a bridge from the Freudian psychosocial era of hysteria-neuroses to the current era of the borderline-narcissist. Psychoanalysis was foundational to the Frankfurt School, and philosophically they were really a marriage of Marx and Freud. All the founding members were sons of wealthy Jewish businessmen who turned their backs on the capitalism of their fathers (often able to do so, ironically, with the financial support of their fathers), but who frequently, especially Benjamin, wrote nostalgically, almost longingly, of their childhoods.

Benjamin especially refused to grow up. His entire historical worldview in fact was that we all march through history backward, that we all greet the imminent future with our backs turned. In other words, the future is a constant reappraisal of the past, a constant atonement, a series of ruminations and regrets, a wistful clinging to prior accomplishments.

The biggest target of Benjamin and his colleagues, and the root of their almost paradoxical nostalgia, was the so-called “culture industry,” the manufacture less of products than of wants and desires by, as they saw it, vast capitalistic machines. They frequently compared Hollywood to the Nazi propaganda machine, and they harbored little doubt that Hitler and his lieutenants’ primary motivation was less ideological than financial. (America was under the sway of “monopoly capitalism”; Germany and the Soviet Union under “totalitarian capitalism.”) They feared less that the Nazis would militarily conquer the world than that the rest of the world would link arms in capitalistic solidarity with the Nazis.

In this context Walter Benjamin became the 20th-century iteration of the “wandering Jew.” While his colleagues settled in Frankfurt, at least until it became too dangerous, he remained restless, taking up residence variously along the Mediterranean and in Germany and Paris, intermittently moving back home with his parents. He was married, but he had frequent affairs, often quite intense relationships that left him temporarily suicidal. He seemed to care little for his only son.

What is especially significant here is Benjamin’s comparison of the what he calls “destructive character,” what we might more euphemistically call the “cluster B personality,” with the “consciousness of historical man.” In his 1931 essay, The Destructive Character, he sums it up in this way: “The destructive character lives from the feeling not that life is worth living, but that suicide is not worth the trouble.”3

This reads like a blithe shrugging off of the slightly later Algerian-French existentialist philosopher Albert Camus’ famous admonition that whether to commit or not commit suicide is the only legitimate philosophical question remaining.

So why go on?

This is where the German critical theorists and French existentialists agreed. Because there is always work to be done.

Arthur Schopenhauer, perhaps the most miserable 19th-century philosopher who ever lived, in his cheerily titled On the Suffering of the World,4 ironically provided what may be the best admonition against suicide, and the one repeatedly resorted to by the critical theorists and existentialists: “The only cogent argument against suicide is that it is opposed to the achievement of the highest moral goal, inasmuch as it substitutes for a true redemption of this world of misery a merely apparent one.”

In other words, suicide is inauthentic. The redemption sought through suicide is illusory. As Benjamin himself put it, “The destructive character sees nothing permanent. But for this very reason he sees ways everywhere. Where others encounter walls or mountains, there, too, he sees a way. . . . Because he sees ways everywhere, he always stands at a crossroads. . . . What exists he reduces to rubble—not for the sake of rubble, but for that of the way leading through it.”3 Jean-Paul Sartre qualified this years later by specifying that suicide is essentially “out of bounds.” It is the one “way” out that, by its very inauthenticity, remains inaccessible.5

Benjamin’s essay was 10 to 11 years before Camus’ seminal work, The Myth of Sisyphus,6 in which he elaborates upon the “absurdity” of existence, the inescapable contradiction between the human faculty of reason and an unreasonable world. He bemoans the inevitable “philosophical suicide” that results from any attempt to provide an overarching metaphysical structure to existence: all conclusions invariably contradict their (absurd) premises. His conclusion? We must continue on. We must find our path. Sisyphus was damned to a hell on a treadmill. But even he eventually acknowledges the truth of his absurd situation, of his own personal tragedy, and there is meaning in that.

That is, even in the midst of hell, there is still, or even especially, work to be done.


1. Benjamin W. Theses on the Philosophy of History. Accessed June 18, 2018.

2. Freud S. Civilization and Its Discontents. Seaside, OR: Rough Draft Printing; 1913.

3. Benjamin W. The Destructive Character. Accessed June 19, 2018.

4. Schopenhauer A. On the Suffering of the World. London/New York: Penguin; 2004.

5. Sartre J-P. Literary and Philosophical Essays. New York: Collier; 1955.

6. Camus A. The Myth of Sisyphus. Trans. Justin O’Brien. New York: Vintage; 1983.

The 3-Day Rule and Suicide

Many people who attempt suicide do so impulsively. Extremely impulsively.

One study of people who attempted suicide found that 48% thought of suicide for fewer than 10 minutes before making the suicide attempt.

The haste with which many people die by suicide is staggering. Had they waited a little longer, then the intense impulse to act on suicidal thoughts might have passed.

This brings me to the 3-day rule. I’ve heard about this rule anecdotally and read about it here and there on blogs and other websites. One site in particular sums it up quite well:

“For me I have a 3 day rule. With most big decisions that will affect my life, I give myself 3 days. If I still think it is the best choice for me after 3 days, then I go with it. Yes even with suicide…

“If even for one moment you feel a smidge of joy or like life is actually worth living, you have to start the 3 days again. Again time many times brings clarity.”

The author, Ali McCollum, also states, “Spoiler… death by my own hand has yet to feel like the right choice for 3 straight days.”

Keep On Keeping On

The old adage “one day at a time” holds true here. With suicidal thoughts, however, the mantra may be “one hour at a time,” or “one minute at a time.”

Even “one moment at a time” can be difficult.

If you hold off for three days, chances are you will not feel 100% intent on dying that entire time. And maybe you will even feel hope, or pleasure, or some other reason to live.

If your suicidal thoughts are so intense that even waiting 3 days seems impossible, please get help immediately. Call 911 (or, if you are outside the U.S., whatever the emergency number is in your country). Or go to an emergency room. Or call someone who will help you stay safe.

Really? Suicidal Thoughts Stop After 3 Days?

Keep in mind that I’m not talking about all suicidal thoughts. It would be foolish to say that suicidal thoughts tend to pass in 3 days. Some people think of suicide for weeks and months, even years.

What I m referring to is the profound intent to act on suicidal thoughts. If someone is on the verge of suicide, those 3 days can mean the difference between life and death.

Suicidal thoughts might persist, but the impulse to act on them can change many times over three days.

To quote the late psychologist Edwin Shneidman, one of the pioneers in suicidology:

“The acute suicidal crisis (or period of high and dangerous lethality) is an interval of relatively short duration – to be counted, typically, in hours or days, not usually in months or years. An individual is at a peak of self-destructiveness for a brief time and is either helped, cools off, or is dead.”

Naturally, my hope is that you are helped or cool off.

What If 3 Days Go By and Suicide Still Beckons?

Time does not heal all wounds, especially not quickly. The 3-day rule aside, I do not mean to imply that you should end your life if you still feel acutely suicidal after three days.

In some ways, 3 days is a long time. A lot can happen. Feelings can change. Perspective can change.

Getting a good night’s sleep during those 3 days, or talking with a friend or suicide hotline, or simply surfing the waves of moods, can weaken the suicidal impulse.

In other ways, 3 days is hardly a blip on the radar screen of an entire life. If after 3 days you still are intent on dying, please get help.

Reach out to others, whether someone you know or a stranger at hotline or online. For a list of places where you can get help anonymously, you can start here.

What Next?

Even if you follow the 3-day rule and no longer feel adamantly that suicide is your only option, the suicidal thoughts might still persist or revisit.

Ultimately, to survive suicide’s assault, more is needed than waiting.

You might need to uncover reasons for living. Tapping into hope and rediscovering pleasure can also help.

More than anything, talking back to suicidal thoughts and learning to cope with them can fortify you in your fight against suicidal forces.

A Good Starting Place

The 3-day rule is a good place to start. Not only can it save your life, it can also show you with amazing clarity that suicidal thoughts can waver in their intensity.

Those 3 days can demonstrate that at least the strength of suicidal thoughts, if not suicidal thoughts themselves, can be temporary.

Suicidal thoughts can change, as can you, your mood, and your life.

Don't know what to say?

Try one of these opening lines to get the conversation rolling:

"I've noticed you've been down lately. What's going on?"
"Hey, we haven't talked for a while. How are you?"
"Are you OK? You don't seem like yourself lately."
"I know you're going through some stuff: I'm here for you."
"No matter what you're going through, I've got you're back."
"This is awkward, but I'd like to know if you're really all right."
"I haven't heard you laugh in a while. Is everything OK?"
"I'm worried about you and would like to know what's up so I can help."
"Is there anything you want to talk about?"
"Hey, you seemed frustrated today. I'm here for you. Want a hug? Or a chat?"
"Hey, where have you been? Missed you at practice."
"You ok? I noticed you've missed school a few times."
"I feel like something's up. Can you share with me?"
"Your face is telling me you could use a good talk."
"You know you can tell me anything. I won't judge."
"Seems like something's up. Do you wanna talk about what's going on?"
"Listen, you're my friend, and I just want to know how you're feeling."
"Whenever you're ready to talk, I'm ready to listen."
"I know life can be overwhelming sometimes. So, if you want to talk, I'm here."
"Is there anything you want to get off your chest?"
"Maybe it's me but I was wondering if you were all right."

No need to be an expert. Just be a friend. These tips should make starting a conversation about mental health a lot less awkward:

Keep it casual. Relax: think of it as a chill chat, not a therapy session.

You seized the awkward. What now? Keep checking in, and if you want to do more, there's a bunch of other ways to help your friend: Don't give up. Maybe the first attempt didn't go so well or maybe they just weren't ready to talk. Show your friend that you're there for them. Stay available and keep checking in.

In an emergency. If you or your friend needs urgent help, call 911 right away. Or even take your friend to the emergency room for assistance. If you feel it's safe, stay with your friend or find someone to stay with them until help arrive.

In a Crisis. Get immediate free support 24/7 by calling 800-273-8225 or text SOS to 741741. They won't judge, and everything you tell them is confidential, unless it's essential to contact emergency services to keep you or your friend safe.

How To Talk About Your Mental Health When No One Wants To Listen

According to the American Psychiatric Association, people from racial and ethnic minority groups are less likely to receive mental health care than the rest of the U.S. population.

Communities of color often lack adequate access to medical treatment for mental illnesses. They also face challenges like higher levels of stigma, misinformation and language barriers.

“While an individual may have their own [mixed feelings] toward how they think about mental health, it is then intertwined within the views that were being expressed within their household, school, work and so on,” said Shari Fedra, a licensed clinical social worker based in Brooklyn, New York.

But those barriers can be broken down. HuffPost asked several psychologists and mental health care providers who primarily treat patients of color how to have an effective and serious conversation about mental health and why it’s so hard to talk about in the first place. Here’s their advice:

Seeking professional help is OK ? even if it doesn’t seem like it.

June Cao, a New York-based clinical psychologist who specializes in working with Asian-Americans, said that one of her clients shared that silence was the default mode of communication between her family members.

“Her parents told her over and over that she just needed to endure and tough through, then her depression would be gone,” Cao said.

Cao’s patient is part of a larger trend: Asian-Americans are three times less likely to seek mental health services than whites, according to the American Psychological Association.

Karen Caraballo, a clinical psychologist working with Latino families in Brooklyn, said that because of the significant value placed on family, many members of the Latino community do not seek outside help for mental health problems.

“Latinos are expected to rely on [immediate] family, extended family, church, el curandero and friends,” Caraballo said. (A curandero is a spiritual guide within a community that people go to when they are sick.) “We are expected to keep our problems within our inner circle.”

Knowing when to see a medical professional for your mental health is important because the longer you go untreated, the more potential consequences could arise, including the worsening of your symptoms.

“The pressure to hide your problems could make you more fearful of your mental illness and cause you to isolate yourself,” Cao said. “Transparency and awareness is probably the most successful way to overcome this fear.”

Assert the importance of conversation.

When dealing with friends or family members who aren’t as open to talking about your experiences or getting professional help, Cao suggested that you should genuinely and assertively request a conversation by using phrases like “I need to speak with you,” “I need your help,” or “Please listen to me before you say anything.”

B. Nilaja Green, a licensed clinical psychologist based in Atlanta, said that you should find a time to speak to your loved ones when they are calm and you can have their full attention.

“Be as transparent with them as possible about what you’re experiencing, how these experiences are impacting you, and why you believe the experiences are serious enough to warrant outside intervention,” Green said.

Use language that your loved one can understand.

When discussing a topic as sensitive as mental health, you want to make sure that you communicate in a way that makes sense for both the person you’re talking to and yourself.

Cao recommended doing this by avoiding general and weighted vocabulary such as “mental disorder” or “abnormal,” as this may reintroduce the feeling of shame associated with these terms. Instead, try starting the conversation by talking about any physical symptoms you may be feeling, such as a loss in appetite or insomnia that will help break the ice.

“You may find it easier to communicate about physical symptoms first, like insomnia and appetite changes, because there is no stigma or shame attached,” Cao said.

It’s also important that you communicate in a tone that makes you sound open to receiving feedback if that is your goal of the conversation.

“We often notice another person’s resistance without being mindful of our own resistances,” Fedra said. “Create an open [atmosphere] within your communication style by being mindful of your words, tone and feelings.”

Religion and mental health support aren’t mutually exclusive.

One of the main reasons mental health usually isn’t openly talked about within the black community is because of the reliance on religious beliefs to solve or fix mental health issues without considering additional supportive resources, Green said.

According to the National Alliance on Mental Illness, only about 25 percent of African Americans seek mental health care, compared to 40 percent of whites.

“I have heard clients share that family members and friends have either undermined them going to treatment and/or referred them back to the church as their most appropriate source for healing and help,” Green explained.

If religion is a major part of your family’s lifestyle, Green said that you could inform your loved ones that there are resources that cater to families with religious backgrounds.

“There are counselors and therapists of varying religious backgrounds who integrate their faith into the work,” Green said. “Even if you do not want to go to a therapist who identifies themselves in a particular way, most therapists have training that allows them to appreciate and respect the religious beliefs of their clients.”

Take advantage of outside resources.

If you are absolutely unable to talk to relatives or friends about the state of your mental health, there are several other options to choose from.

“Seek professional help from a psychologist, psychotherapist, mental health counselors who speak your language and understand your cultural background,” Cao recommended.

If you believe you’ll have trouble paying for treatment, Cao said you can seek help from hospitals and clinics that offer appointments on a sliding scale adjusted for income. There are also online options and free alternatives that can still be helpful, like support groups. The Anxiety and Depression Association of America created a list of support groups throughout the U.S. that you can filter by group name or support topic.

Bottom line: Own your experiences and know that a living with a mental health condition doesn’t make you “weak.” The more you talk about it, the more people will start to pay attention. Experts agree that open communication can play a vital role in eliminating the shame and stigma surrounding mental health.

“Simply talking about your situation and illness to someone understanding may reduce some of the stress you have,” Cao said. “It can also help your loved ones to understand you better and relieve their concerns about you."

Method Choice and Intent

It is intuitive to think that those who attempt suicide and live were less intent on dying than those who died by suicide. While seriousness of intent plays a role in severity of attempt and choice of suicide method (means), the relationship is not a straight-forward one. Many studies (some described below) find little relationship between intent and medical severity or between intent and choice of method. Other studies, however, do find a relationship (e.g., Townsend 2001, Hamdi 1991, Harriss 2005). One reason for the mixed results is that other factors also play a role, such as the availability and acceptability of methods and attempters’ knowledge of the likely lethality of a given method. Many people who attempt suicide have inflated expectations about the lethality of common methods like poisoning and cutting.

Thirty patients who attempted suicide with motor vehicle exhaust were interviewed (Skopek 1998). Reasons given for choosing the method included availability, painlessness, and lethality. Suicide intent scores were not high, which was inconsistent with most patients being aware that the method was highly lethal. Relationship problems were the most frequent precipitating circumstance. Most attempters regretted the attempt. Survival was due largely to failure of the method or unexpected discovery rather than to patient factors.

Sixty patients presenting to a large urban medical center for a suicide attempt completed questionnaires measuring the seriousness of their suicidal intent and other factors (Plutchik 1988). No relationship was found between level of intent and medical seriousness of the attempt.

Among 268 self-poisoning patients in rural Sri Lanka, 85% cited easy availability as the basis for their choice of poison (Eddelston 2006). Patients had little knowledge about the lethality of the poison they chose. There was no evidence that attempters who used highly toxic poisons were more serious or deliberative in their attempt than those using less toxic poisons.

Patients’ expectation of the lethality of their attempt (as measured by the Beck Suicidal Intent Scale item 11) was not associated with observed medical severity in a sample of 173 attempters treated in an urban emergency department (Brown 2004). Only 38% of the patients were accurate in their expectations regarding severity; 32% were inaccurate, and 29% did not know whether what they did was likely to be lethal.

A study of 33 people (mostly young men) who attempted suicide with a firearm and lived found that all used firearms obtained in their homes (Peterson 1985). When asked why a firearm was used, the answer given most often was, “Availability.”

A Houston study compared nearly-lethal suicide attempts with less-lethal attempts and found that expectation of dying, planning, impulsivity, and taking precautions against discovery were not associated with the medical severity of the attempt (Swahn 2001).

Intent is a complex matter and falls along a continuum. While some attempters are probably at the low end of the spectrum with very little intent to die, and others are at the high end, many fall into an ambivalent middle ground. Still others have high intent but only during very brief episodes. It is these latter two groups for whom reducing easy access to highly lethal methods of suicide is likely to be most effective in saving lives.

Brown GK, Henriques GR, Sosdjan D, and Beck AT. Suicide intent and accurate expectations of lethality: predictors of medical lethality of suicide attempts. Journal of Consulting and Clinical Psychology. 2004;72(6):1170-74.

Eddleston M, Karunaratne A, Weerakoon M, Kumarasinghe S, Rajapakshe M, Sheriff MH, Buckley NA, Gunnell D.Choice of poison for intentional self-poisoning in rural Sri Lanka.Clin Toxicol (Phila). 2006;44(3):283-6.

Hamdi E, Amin Y, and Mattar T. Clinical correlates of intent in attempted suicide. Acta Psychiatr Scand. 1991;83(5):406-11.

Harriss L, Hawton K, Zahl D. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Brit J Psych. 2005;186:60-66.

Peterson L, Peterson M, O’Shanick G, and Swann A. Self-inflicted gunshot wounds: Lethality of method versus intent. American Journal of Psychiatry. 1985;142:228-231.

Plutchik R, van Praag HM, Picard S, Conte HR, and Korn M. Is there a relation between the seriousness of suicidal intent and the lethality of the suicide attempt? Psychiatry Resesarch. 1988; 27:71-79.

Skopek MA and Perkins R. Deliberate exposure to motor vehicle exhaust gas: the psychosocial profile of attempted suicide. Australian and New Zealand Journal of Psychiatry. 1998;32(6):830-38.

Swahn MH and Potter LB. Factors associated with the medical severity of suicide attempts in youths and young adults. Suicide and Life-Threatening Behavior. 2001;32:21-29.

Townsend E, Hawton K, Harriss L, Bale E, Bond A. Substances used in deliberate self-poisoning 1985-1997: trends and associations with age, gender, repetition and suicide intent. Soc Psychiatr Epidemiol. 2001;36(5):228-34.
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'Like a busy emergency room': Calls to suicide crisis centers have doubled since 2014

The National Suicide Prevention Lifeline saw calls double from 2014 to 2017, an increase in volume that coincides with rising suicide rates across the United States.

The helpline answered over 2 million calls in 2017, up from approximately 1 million calls in 2014. In 2015 and 2016, the helpline answered over 1.5 million calls each year.

The helpline consists of a nationwide network of over 150 local crisis centers, as well as national backup centers to assist local lines.

But an uptick in calls may not only be attributable to rising suicide rates in the U.S. Increased public attention about helpline services has also led to greater call volumes, said Frances Gonzalez, director of communications for the national helpline.

"Due to media events and increased public awareness of suicide prevention and the Lifeline’s services, more people aware of this resource and are getting help and support," Gonzalez said. "The Lifeline has been proven to deescalate moments of crisis and help people find hope." Gonzalez could not comment on 2018 projections for the helpline.

What do more calls mean for crisis centers?

Crisis centers never have a predictable day, according to Bill Zimmermann at Rutgers University Behavioral Health Care in New Jersey. In June 2013, their crisis center answered 1,390 calls. In May 2018, they answered 3,699 calls.

"This work is like a busy emergency room to some degree, even though the patients aren’t physically here with us," Zimmermann said. "It’s busy, hectic, demanding work at times.”

Zimmermann said their crisis center has opened more lines to help address the increase, especially overnight when calls to suicide hotlines tend to spike.

Suicide rates increased more than 25 percent between 1999 and 2016, according to a Centers for Disease Control and Prevention (CDC) report released June 7. The states with the highest jumps in suicide rates were North Dakota, Vermont and New Hampshire, which saw 57.6 percent, 48.6 percent and 48.3 percent increases.

Cindy Miller, executive director of FirstLink, a crisis center in North Dakota, said crisis centers are also seeing an uptick in calls because more people are sharing their information on social media – especially after high-profile deaths of celebrities like Kate Spade and Anthony Bourdain in June. FirstLink fielded 2,512 calls about suicide in 2016 and 6,533 calls in 2017, a more than 160 percent increase in calls in a year.

"With social media, the number’s out there a lot more," Miller said. "I don't want to say it's a good thing, but now we're getting them help and support."

Crisis centers are encouraged that a higher call volume means more people are reaching out for help, said John Reusser, executive director of the Idaho Suicide Prevention Hotline. The hotline received 9,531 contacts in 2017 and 2,869 contacts in 2014, which includes calls, chats and texts to their crisis center.

Emily Carpenter, a database and resource specialist at FirstLink, said their crisis center has also opened more lines of communication. Carpenter said much of the increase in their call volume is due to their call-back program, in which individuals released from mental health facilities or hospitals can opt to be called within the first 24 hours of being discharged.

“We have gone to having more staff on at certain times of the day so we can always answer those calls and they don’t roll over to the next call center," Carpenter said. "We want people in our state to be able to talk to someone who’s in North Dakota and can maybe relate to them a little better, but there is always a backup center.

Who answers calls at a crisis center?

Crisis center staff include social workers, medical professionals and trained volunteers.

Jennie Rylee, a former environmental educator and current volunteer at the Idaho Suicide Prevention Hotline, said she was motivated because of her family history with suicide.

“My mom was an attempt survivor. I am an attempt survivor. As I did therapy and worked through that business, through depression, I thought I could turn this into something positive," Rylee said. “This is the most rewarding thing I’ve ever done, and I’m 62 years old."

Some crisis center volunteers and employees go beyond answering calls and chats. Jennifer Illich, director of helpline operations at FirstLink, said their employees make hand-written cards to support callers enrolled in their call-back program. Illich said she spoke with a former caller who uses her card to remind her to reach out if she needs assistance.

"When she’s in an anxious situation, she just pulls it out of her purse and peeks at it and puts it back in her purse," Illich said. "She said that gives her the strength to get through the anxious situation."

How crisis centers help

A crisis center can serve callers who are depressed or considering suicide and inform them on what services are available in their community for themselves and their loved ones, in addition to dispatching emergency services.

Some callers are hesitant to reach out to crisis centers because they are afraid volunteers and employees on the other end of the line are going to call police or emergency workers, even if the caller just wants to talk, according to Carpenter.

“It’s important for people to understand that we’re not here to get you into trouble or send the police. We’re here to provide that listening and that support so that you don’t need that service," Carpenter said. "Everything they tell us is confidential unless what they tell us poses a danger to themselves or someone else."

Listening to those struggling is the primary goal of crisis centers across the country, Rylee said. Source:

'Silence can be deadly': 46 officers were fatally shot last year. More than triple that — 140 — committed suicide.

Suicides left more officers and firefighters dead last year than all line-of-duty deaths combined — a jarring statistic that continues to plague first responders but garners little attention.

A new study by the Ruderman Family Foundation, a philanthropic organization that works for the rights of people with disabilities, looked at depression, post-traumatic stress disorder and other issues affecting first responders and the rates of suicide in departments nationwide.

The group found that while suicide has been an ingrained issue for years, very little has been done to address it even though first responders have PTSD and depression at a level five times that of civilians.

Last year, 103 firefighters and 140 police officers committed suicide, whereas 93 firefighters and 129 officers died in the line of duty, which includes everything from being fatally shot, stabbed, drowning or dying in a car accident while on the job.

Miriam Heyman, one of the co-authors of the study, said the numbers of suicide are extremely under-reported, while other more high-profile deaths make headlines. There were 46 officers who died after being fatally shot on the job in 2017, nearly 67% less than the number of suicides.

The number of firefighter suicides may only represent about 40% of the deaths, she said, meaning the deaths could total more than 250 — more than double the amount of all line-of-duty deaths.

First Responder Deaths - 2017

Line of duty deaths

Firefighters and EMT's


Law enforcement officers


Source: Ruderman Family Foundation

“It’s really shocking, and part of what’s interesting is that line-of-duty deaths are covered so widely by the press but suicides are not, and it’s because of the level of secrecy around these deaths, which really shows the stigmas,” Heyman said.

She said departments don’t release information about suicides, and less than 5% have suicide-prevention programs. It’s something first responders are ashamed to talk about and address, which is having a deadly result, she said.

“There is not enough conversation about mental health within police and fire departments,” the study says. “Silence can be deadly, because it is interpreted as a lack of acceptance and thus morphs into a barrier that prevents first responders from accessing potentially life-saving mental health services.”

The stigma isn’t just in silence, the study outlines. Families want to hide the reasoning behind the death of a loved one. Officers feel they’ll be looked down on or taken off the job if they speak up about depression. Dying by suicide means they aren’t buried with honor.

There have been some discussions and pushes for mental health programs in departments, but the process is slow.

The report highlights programs and policies to push the issue, such as peer-to-peer assistance, mental health check-ups, time off after responding to a critical incident and family training programs to identify the warning signs of depression and PTSD.

A project published this year by the International Association of Chiefs of Police detailed the issues around suicide and highlighted many of the same programs. It noted that first responder suicide is nearly impossible to track since it's often not reported.

"It is a departmental issue that should be addressed globally," the report notes. "Departments must break the silence on law enforcement suicides by building up effective and continuing suicide-prevention programs."

A big push is for police and fire chiefs to address depression and suicide more candidly and share their experiences.

Attention is sometimes given to PTSD in the immediate aftermath of a high-profile incident, such as a natural disaster, terror attack or mass shooting, like the recent high school shooting in Parkland, Fla.

“Here’s the reality, though: Police and firefighters witness death and destruction daily,” Heyman said. “It would be silly to think it wouldn’t put a toll on them.”

She said when first responders are affected and don’t get help, it can also have a negative result on the community they serve and can be thought of more as an “occupational hazard.”

“These individuals are the guardians for our community,” Heyman said. “What happens when their decision-making is flawed? We need for them to be healthy.”

A new emphasis on mental health for cops, other officers

The relentless pressures of prison life on inmates’ mental health — gang violence, solitary confinement and arbitrary discipline, among them — have long been subjects for psychological and academic research. But the cumulative impact on corrections officers, including an apparent high rate of suicide, has rarely been studied in depth.

That is about to change. In California, one of the nation’s largest prison systems — housing about 130,000 people on a given day— the union of active and retired corrections officers is participating in an extensive study over the next few years to assess the need for permanent mental health services for the state’s roughly 26,000 officers.

“We do a decent job with saying that ‘this system messes with the incarcerated, this system impacts their lives’, but what we don’t do, what we don’t say is, ‘what’s the impact that this job is having on the correctional officers?’ ” said Stephen B. Walker, the director of governmental affairs for the union, the California Correctional Peace Officers Association.

According to association data, the suicide rate for its members, in 2013, was 19.4 deaths per 100,000, compared with 12.6 deathsinthegeneralU.S.population. “We are finally saying, there is something wrong and we need to fix this,” Walker said.

Suicides, post traumatic stress disorder and other mental-health problems that afflict corrections officers as well as police officers are an underreported sector of the criminal justice system. The federal government doesn’t track suicides by law enforcement officers, although line-of-duty deaths are tallied. But an awakening of sorts — from the halls of Congress to the prisons of California — is under way.

Earlier this month, the California peace officers association completed the first major step of a partnership with the University of California, Berkeley, by analyzing the results of a 61-question survey from more than 8,600 corrections and parole officers statewide. The responses serve as the basis for an ambitious plan to develop, test and implement a range of mental health services for officers across the state’s prison system.

The survey was designed by Amy E. Lerman, an associate professor of public policy and political science at Berkeley, and lead researcher of the Correctional Officer Health and Wellness Project. The survey asked respondents about a range of topics that include their experiences with violence, suicidal thoughts, and how prisons can improve. The union distributed the survey and promised a free barbeque to the correctional facility that produced the highest participation rate.

Lerman shared a sample of the results with The Marshall Project: Three of four corrections officers said they had seen someone killed or seriously injured at work; when asked about PTSD, 65 percent of officers said they had experienced at least one of its symptoms; about one in nine reported having thought about, or attempted, suicide.

“We need more research,” Lerner said. “We need to know what works, and what type of investments makes a difference.”

Lerman and Walker’s teamwork will stretch into 2020. Their next steps include in-prison focus groups with corrections officers, and randomized field experiments that will try out yet-to-be selected mental health services. These could range from increased access to peer support officers to mandatory training on stress management. Corrections officers will then be invited to participate in a follow-up survey to assess their experiences with the sample offerings. Those results will be used to help design permanent mental health programs.

The California Department of Corrections and Rehabilitation, in a series of emailed statements, acknowledged that the agency had no substantive psychological resources for its staff, and is cooperating in the Berkeley partnership. “It is our responsibility as an organization to look closely at what we are doing,” wrote Scott Kernan, secretary of the corrections department.

Capitol Hill is taking up the cause too. In May, the Senate unanimously passed the Law Enforcement Mental Health and Wellness Act, which calls on the Department of Defense and the Department of Veterans Affairs to share with Congress a list of recommended “mental health practices and services” that could be adopted by federal and local officers. It also asks that the U.S. Attorney General research the effectiveness of annual mental health checks for cops and access to crisis hotlines.

What the bill doesn’t do, however, is require the tracking of police suicides. James Pasco, the executive director of the Fraternal Order of Police, the nation’s largest police union, says union officials met with the bill’s architect, Sen. Joseph Donnelly (D-Indiana), before the legislation was introduced. “We invariably asked that statistics-gathering be mandatory,” Pasco said.

Donnelly, who introduced the bill with Sen. Todd Young (R-Indiana), explained that requiring police departments to collect numbers, or even implement specific programs, would have been a “difficult” undertaking. “What we tried to do was to get the doable done right now” he said. A House version of the bill remains in subcommittee.

At the same time, some local law enforcement agencies are being lauded for taking action on their own. Since 2015, police departments across the country have vied for the annual Officer Wellness award given out by The National Law Enforcement Officers Memorial Fund — a Washington, D.C.-based nonprofit that tracks police deaths, but not suicides, and organizes National Police Week.

This year’s winner, the Stockton (Calif.) Police Department, was cited for its “wellness network,” which Chief Eric Jones defined as having “three sides: mental, physical and spiritual.”

Cops are given books to read on police psychology, compete in Crossfit competitions, talk about their feelings at roll call, and are encouraged to speak to either peer support officers or outside therapists as needed.

Jones says he had a series of “aha! moments” as officers confided in him about low morale after the city filed for bankruptcy in 2012. The department, which has more than 400 cops now, lost a quarter of its officers during the fiscal downturn. Shootings and murder rates increased to record highs.

Stockton’s force now has fewer complaints against officers, fewer workers’ compensation claims, shootings and homicides. “I definitely think if our officers, by and large are coming to work mentally and physically ready, and they enjoy their job, they are going to be much better at reducing crime,” Jones said.

Cops don't usually talk about 'horrible things.' Mental health professionals help them cope with trauma

When Police Chief Gregory Mullen started getting calls about a potential “mass casualty” at the Emanuel AME Church downtown, he knew the first officers on the scene might need some extra help.

Not reinforcements or more firepower, but help coping with what he suspected would be a horrific scene. And he was right.

In barely six minutes on the night of June 17, 2015, nine people at a Bible study at one of America’s oldest African-American churches were murdered when a young white man opened fire, spewing racial epithets and 77 hollow-point bullets. Eight victims died on the spot; one died later in the hospital.

To counsel the first responders, Mullen called in cops who had experience with tough crime scenes. Some of those “peer-group cops” were from Blacksburg, Virginia, and had responded to the slaughter of 32 students and teachers at Virginia Tech in 2007.

For decades, police have kept silent about the toll trauma takes on them, their families and their careers. One result, according to researchers, is that they have higher suicide rates than the general population.

To change that, police departments across the country are turning to nonprofit or state-funded programs that help cops cope by connecting them to their peers and to mental health professionals.

“There’s a much greater awareness of the effects of exposure to traumatic events in just the past five years,” said James Baker, a director with the International Association of Chiefs of Police.

Many of the nonprofit programs are based on the Law Enforcement Assistance Program (LEAP) that began in South Carolina 20 years ago. Eric Skidmore, a Presbyterian pastor, launched the program with a federal grant, and now runs it in partnership with the state police. State taxpayers can check a box to contribute on their income tax forms, and the nonprofit raises additional money from supporters.

Skidmore and his peer-support cops arrived less than 48 hours after the shooting at the church known as Mother Emanuel. “We did some psychological first aid,” Skidmore said. Later some of the responders attended a three-day seminar, where they talked in both large and small groups of officers who’ve gone through trauma, too.

Programs like LEAP also offer professional mental health counseling, teach techniques to dispel lingering memories, and even provide massages to relieve tension.

Arkansas, Georgia, North Carolina, Ohio, Texas and Virginia have similar programs, and Kentucky is creating one. In Florida, police departments in Miami-Dade and Seminole counties are leaders in providing strong psychological support for officers, Baker said.

Not a single Charleston officer has retired early or quit the force as a result of the Emanuel Church shooting, according to Mullen. He credits the sessions put on by South Carolina’s LEAP program.

“A really important part of law enforcement is making sure you keep your people mentally, physically, emotionally and spiritually fit so they can do the work they are meant to do,” Mullen said.

Cops typically don’t talk about “the horrible things that one human being does to another,” said Gregg Dwyer, a psychiatrist who works with the police assistance groups in Georgia, North Carolina and South Carolina. “There’s fear of what it will do to them on the job if they open up. They worry, ‘Who’s going to know? Will it cost me a promotion?’”

Dwyer, a former agent with the Naval Criminal Investigative Service (NCIS), said the military’s increasing openness to helping service members cope with trauma is starting to spread to police departments.

But many police officers are still reluctant to open up. “The ethos of policing is: ‘We’re super people and we can’t be weak. We’re not a bunch of sissies,’ ” said John Violanti, a research professor at the State University of New York at Buffalo who studies police health. “What they forget is that they’re human.”

Between 7 and 19 percent of America’s cops suffer from post-traumatic stress disorder, although those numbers may be low because police don’t readily report their emotional health, according to Violanti. And police are much more likely to commit suicide, he said.

Police have a 69 percent higher risk of suicide than the average worker, and detectives have an 82 percent higher risk, according to Violanti’s analysis of data from the Centers for Disease Control and Prevention. The cumulative effect of seeing mayhem over years makes cops more vulnerable to heart disease and diabetes, too, according to Violanti’s research.

“It’s the classic example of mind affecting body,” he said.

Cops also are working in a highly charged political atmosphere now, with criticism of police shootings of unarmed people, he said. “I relate it to the Vietnam War, where vets were spat on and called ‘baby killers,’ ” Violanti said. “It’s demoralizing.”

The ‘Warrior Rescuer Mentality’

Benny Back was a deputy sheriff in Surry County, Virginia, in 2005 when he got the call that an 8-year-old girl had been hit by a driver as she was crossing the street. It was his daughter, Isabella. Though he’d been in the Army and been a cop for two decades, the loss hit him hard.

“I started drinking heavily; I fell into alcohol, and had thoughts of suicide,” said Back, 51, who is now a deputy sheriff in Charles City, Virginia.

His brother, Capt. Aaron Back of the North Carolina State Highway Patrol, hooked his brother up with the LEAP program in South Carolina, and took him there for a three-day session. “My brother fought me all the way. He didn’t want to go, no one would understand, blah, blah, blah,” Aaron said. The program was so successful for his brother that Aaron helped start a LEAP program in North Carolina in 2012. “Quite honestly, it saved my life,” Back said.

When cops show up for a three-day seminar on dealing with trauma, they all have that reluctant “what have I gotten myself into” look, said Rita Villareal-Watkins, executive director of the Law Enforcement Management Institute in Huntsville, Texas, which has been running trauma sessions for five years.

At the beginning of a typical session at many of these programs, officers (and sometimes their spouses) sit around a big table with peer-group cops and mental health professionals. The officers tell their stories, sometimes for the first time. Everything is confidential — their police chiefs won’t hear about what is said in the sessions.

“It’s gut-wrenching,” said Watkins. “There’s a lot of emotion that first day. We share so much that the day is excruciatingly long.”

On the second day, the participating officers break into small groups, then meet one-on-one with a health professional or a peer-group cop, and maybe get a massage. “These people are carrying so much physical stress and they don’t even realize it,” Watkins said.

Then they participate in a technique to ease symptoms of trauma called Eye Movement Desensitization and Reprocessing (EMDR). It’s an internationally known mode of treatment that combines talk therapy with rapid eye movement like you experience in deep sleep.

People dealing with trauma can’t get the images of the violence they’ve seen out of their minds. “It’s like a 60-inch plasma color TV in front of your face all day long,” said Lt. Steve Click of the Ohio State Highway Patrol, who directs the Ohio program.

After EMDR training, he said, “it’s a 20-inch black-and-white in the corner somewhere.”

Karen Lansing, who’s known as the “cop whisperer,” is an expert on EMDR and has treated hundreds of police and U.S. military personnel who suffer from PTSD and other forms of trauma. Lansing was the first to study brain images and trauma in police. She says it’s tough to break through the “warrior rescuer mentality” that first responders and military people have.

When she does an EMDR session, she asks officers to close their eyes and recall the traumatic event and focus on every thought, feeling, physical reaction and emotion they experienced. Lansing and the officer break the episode into minute-by-minute segments and discuss them over and over.

“It’s a clinically controlled flashback,” she said. “We’re reactivating physical memory, what they tasted in their mouth, like the taste of metal, which is really adrenaline. What they actually felt as the bullet entered. What were the sounds around them,” Lansing said.

“We do it again and again and again until we neutralize these bombs.”

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

Top 20 Professoins Ranked by Suicidality

1. Farmworkers, fishermen, lumberjacks, others in forestry or agriculture (85 suicides per 100,000)
2. Carpenters, miners, electricians, construction trades (53)
3. Mechanics and those who do installation, maintenance, repair (48)
4. Factory and production workers (35)
5. Architects, engineers (32)
6. Police, firefighters, corrections workers, others in protective services (31) See
7. Artists, designers, entertainers, athletes, media (24)
8. Computer programmers, mathematicians, statisticians (23)
9. Transportation workers (22)
10. Corporate executives and managers, advertising and public relations (20)
11. Lawyers and workers in legal system (19)
12. Doctors, dentists and other health care professionals (19)
13. Scientists and lab technicians (17)
14. Accountants, others in business, financial operations (16)
15. Nursing, medical assistants, health care support (15)
16. Clergy, social workers, other social service workers (14)
17. Real estate agents, telemarketers, sales (13)
18. Building and ground, cleaning, maintenance (13)
19. Cooks, food service workers (13)
20. Child care workers, barbers, animal trainers, personal care and service (8)

Source: CDC

Is a Suicide Attempt a Cry for Help?

“She is not really suicidal. She just wants attention.”

“He did not really attempt suicide. It was just a cry for help.”

“If she had really wanted to die, she’d be dead.”

These are often the reactions of friends and family to a suicidal person. Sometimes, it is true that a person who made what appeared to be a suicide attempt did not really want to die. One large study found that of people who reported that they had attempted suicide, almost half nevertheless endorsed the following survey item about their intentions: “My attempt was a cry for help. I did not intend to die.”

The flip side of those study results is that the majority of people who reported a suicide attempt did intend to die. They endorsed one of two survey items: “I made a serious attempt to kill myself and it was only luck that I did not succeed” or “I tried to kill myself, but knew that the method was not fool-proof.” (On a side note, I take issue with the wording of these items, as no method is fool-proof.)

When Suicidal Behavior Really Is a Cry for Help

Even among those who reported a suicide attempt but did not actually intend to die, there still are serious problems for which these people deserve compassion and concern – certainly not derision – from others.

First, people who hurt themselves in what they view as a suicide attempt do so because of great pain, desperation, or other distressing emotions. If they are crying out for help, there is usually a good reason for them to do so – and a good reason for others to listen.

Second, it is normal for people to need and want attention. Everybody has a need for attention; what differs among people is how they go about getting it. Threatening or attempting suicide is a very unhealthy way to get attention or communicate distress to others. It is a sign that something is wrong. Even if the person does not really plan to die by suicide, he or she needs help. There are other, more healthy ways for people to let others know that they are suffering, angry, depressed, or otherwise in trouble and need help.

Third, even people who threaten or attempt suicide to get other people’s attention can still die. Mistakes happen. A study of teens found that half overestimated the amount of Tylenol needed to cause death. So, a teen who did not truly want to die but took Tylenol as a means to signal distress to others could still die. Who knows how many of the suicides every year are a cry for help gone awry?

Take All Suicidal (or Potentially Suicidal) Behavior Seriously

In short, suicidal behavior is a serious, potentially fatal problem. This applies to suicidal thoughts as well as attempts. If someone you know is saying they really want to die by suicide – or has already tried – take them very seriously. They deserve empathy, compassion, and assistance, whether from you or professionals (or both).

Which would be worse – to presume that somebody really is suicidal when they are not, or to presume that somebody is not suicidal when they really are? Although both situations are complicated, the second scenario can result in death. It is better to err on the side of safety.

Is Suicide Inevitable for Some People?

A 61-year-old man, E.H., survived suicide attempts, received care for depression in psychiatric hospitals, and battled alcoholism for many years. His father died by suicide. E.H. was convinced that one day he, too, would kill himself. In 1961, he fatally shot himself in the head.

Was his suicide inevitable?

Ernest Hemingway, the famous author and the man described above, died by suicide in 1961. Eventually suicide also would claim two siblings and a granddaughter. A controversial article uses Hemingway as an example of what the author calls “inevitable suicide”: “the patient whose suicide will occur regardless of the most expert and skilled therapeutic intervention.”

The article’s author, Benjamin Sadock, MD, blames this (supposed) inevitability on the unfortunate confluence of factors that can create excruciating despair, pain, and pathology: “When all of these areas—mental illness, genetics, and other risk factors— reach a critical mass, the extent of which remains to be determined, the likelihood of a particular patient taking his or her own life is increased to the point of inevitability.”

Dissenting Views: Suicide is Not Inevitable for a Specific Person

Two letters to the editor came out a few months after Dr. Sadock’s article. One letter, by psychologist Thomas Ellis, PsyD, states:

“…the word inevitable is appropriate in some contexts, such as, ‘It is inevitable that some suicides will occur among psychiatric patients.’ But it is a different matter to suggest that some individuals’ suicides are or were inevitable. To do so is to risk rationalizing patient care practices that should be examined and corrected.”

The other letter, by Thambu Maniam, MBSS, MPsychMed, likewise objects to the notion that any one person’s suicide was inevitable:

“I remember a psychiatrist, whose patient had recently committed suicide, saying ‘You can’t stop suicide. Whatever you do, they will still die.’ I wonder what consequences such a fatalistic view would have on his practice.”

My View: Suicide Prevention is Limited, but a Specific Person’s Suicide is Not Inevitable

It is true that suicide is not, with our present state of knowledge, 100% preventable. So in that sense, in general, some suicides are inevitable. But – and this is an important distinction – the suicide of any one person in particular never is or was inevitable.

As long as the suicidal person is alive, there is hope for change. Anything can happen in life at any moment to change the person’s situation, suffering or outlook.

For our part, as mental health professionals, we have many tools to help a suicidal client recover hope, strengthen reasons for living, learn to cope better with emotional pain, and recover from psychological problems such as depression. Cognitive behavioral therapy and other evidence-based treatments, active listening, risk assessment, safety planning, skills training in mindfulness and other coping techniques, and the therapeutic relationship itself are just some of the healing tools that mental health professionals can draw from. Physicians and prescribing nurses have the added tool of medications.

So why would Dr. Sadock declare some people’s suicides inevitable? He has good, if misguided, intentions. He writes that the concept of “inevitable suicide” can lessen the guilt of clinicians who unfairly blame themselves for the suicide of a client.

The implication seems to be that if a specific client was going to die by suicide no matter what, then the people treating that person are not to blame. But this is a false dichotomy. A suicide need not be “inevitable” for a clinician to be blameless.

A great many factors that can lead up to a suicide are well beyond the clinician’s control. This fact does not mean that any one specific person’s suicide is inevitable, only that psychotherapists and other mental health professionals are inherently limited in what they can do to prevent suicide in general.

“Inevitability of Suicide” versus “Limitations in Suicide Prevention”

As I said above, anything can happen at any moment to change a suicidal person’s path. This works both for us and against us. Although positive changes can occur suddenly, so can negative changes. There are so many things beyond the clinician’s control that the suicide of a client does not necessarily mean that the clinician did a bad job.

With our current state of knowledge and tools, it is impossible to predict who will or will not attempt suicide. Some clients understate their suicidal intent, to avoid psychiatric hospitalization or interruption of their suicidal plan. On top of that, mental illnesses respond unpredictably to psychological and pharmacological treatments, with no treatment offering 100% effectiveness.

And those are only a few of the limitations inherent to suicide prevention. We are limited in other ways, too, which I describe in my post: “You Can’t Do Everything”: Limitations in Helping a Suicidal Person. My motto is, “Do everything you can but know that you cannot do everything.”

Summing Up: The False Premise of Inevitability Undermines Hope

Even when mental health professionals bring all their skills and training into the room, even when they conduct a thorough risk assessment, even when they develop an attentive, empathic, therapeutic relationship with the client, even when they do do everything they can, the client still might die by suicide.

It might sound like I agree with Dr. Sadock about the inevitability of some people’s suicides. I do not. Recall that he defines inevitable suicide as “the patient whose suicide will occur regardless of the most expert and skilled therapeutic intervention.” I agree that some people will die by suicide despite their clinicians’ “most expert and skilled therapeutic intervention.” I disagree that this means those people’s suicides were inevitable. To say that any one person’s suicide is inevitable is a nihilistic view that degrades hope, belies possibility for change, and can lead to complacency on the part of the professional.

Instead of deeming suicide inevitable for any specific suicidal client, we need to look at the limitations that mental health professionals face with every suicidal client. These limitations merit research and other efforts to diminish them. I am grateful that we usually can help suicidal clients in spite of those limitations.

“You Can’t Do Everything”: Limitations in Helping a Suicidal Person

Just about every list of “suicide myths” mentions this one: “If a person is serious about killing themselves then there is nothing you can do.” But is it always a myth?

In important ways, yes, it is a myth. There are many things that loved ones of a suicidal individual can do to help – things like asking directly about suicidal thoughts, fully listening to the person, providing nonjudgmental emotional support, removing firearms and other lethal means from the home, giving a list of resources for help and support, and helping them to get professional help.

At the same time, especially when suicidal thoughts and behaviors persist for many months or years, loved ones may come to a point where they have to recognize their limitations. In some important ways, their hands are tied.

Recognizing My Own Limitations with a Loved One

I came to the realization many years ago that I could not fully protect a close friend from suicide. She went through an extremely suicidal time for over a year. One night, she came to my house at midnight with her wrist bleeding. She had attempted suicide. She refused to let me call an ambulance, and it even took much persuading before she would let me take her to the ER. They gave her stitches and discharged her to my house (she refused hospitalization and did not meet criteria for involuntary commitment). The doctors advised me to remove all sharp implements and pills from her reach.

My friend stayed with me a couple days. When she went back home, I was left with this feeling of abject helplessness, this recognition that she might kill herself, and also this sudden acceptance that ultimately I could not control if she died by suicide.

Even when she was at my house, even with all my sharp implements and pills hidden in the locked trunk of my car, I could not have prevented her suicide. I had to use the bathroom sometimes. I had to sleep. She could have walked out the door at any time and found other sharp implements, pills or means to die by suicide. Ultimately, though I did what I could, I was helpless.

Recognizing Your Limitations

No matter how desperately you may wish otherwise, there is only so much you can do to stop another person from dying by suicide. You cannot monitor a family member or friend every second of the day. You cannot remove all means for suicide entirely from their world. Although you can talk with them about their suicidal thoughts, you cannot read their mind if they choose not to share them

Even professionals are not fully able to prevent suicides. One study found that almost 1 in 5 people who died by suicide had seen a mental health professional within 30 days of their death. That means that in the United States, with almost 43,000 people dying by suicide in 2014, more than 8,000 of them had recently seen a mental health professional. A study in Finland found that almost 10% of suicides occurred within 24 hours, at most, of an appointment with a health professional.

Even inside locked psychiatric hospital units, even when patients are under constant supervision, some patients die by suicide. That is staggering. It is also illuminating. If mental health professionals and psychiatric hospitals cannot prevent all suicides, then how can friends and family be expected to do so?

Coping with Your Limitations

When I realized my inherent limitations with my friend, I came up with a saying (I’m sure I’m not the first):

Do everything you can, but know you can’t do everything.

It is hard, terribly hard, to sit with the fundamental helplessness you may feel about your loved one who is in danger of suicide. At these times, it can be helpful to really recognize that most people who end up dying by suicide have depression, post-traumatic stress or another mental illness, a genuine and sometimes severe illness, just like cancer or heart disease. Although the illness is treatable in most cases, and although most suicidal people go on to live many years without ever dying by suicide, the illness might prove to be fatal.

Michael J. Gitlin, M.D., is a psychiatrist who lost a patient to suicide shortly after finishing his psychiatric residency. He wrote about his experience in a poignant journal article. As somebody who specialized in treating people with severe depression, he articulated the high probability of suicide among some of his patients. He came to accept that his work was like that of a doctor working with cancer patients: Not everyone could be saved.

I am not saying that loved ones and therapists should not do what they can to prevent a person’s suicide. Of course they should! Many lives have been saved by the actions of concerned others who did their best to help. But if a life is lost, that does not necessarily mean that anyone failed, that anyone made a grave mistake, that anyone is to blame.

You do everything you can, with the understanding that “everything you can” cannot be everything.

When a child's friend dies by suicide.

First: Deal with your own feelings

When your child's life is touched by the suicide of a peer or a friend, you may find yourself experiencing a lot of different things about the same time. Initially, you will most likely be stunned by the death. Suicide is, in fact, a rare occurrence that is difficult for most of us to understand. When a young person makes the devastating choice, our personal sense of shock and confusion can be overwhelming. The questions of how and why did this happen are often fodder for neighborhood gossip and speculation. This is when its so important to remember that suicide is a complex act that is always related to a variety of causes.

We may never know all the reasons for any suicide, and within this vacuum of complete and accurate information we are often presented with halffacts and speculation. Especially after the suicide of a young person, we tend to feel if we can ferret out the causes, we can protect ourselves, and our children, from a similar fate. And while its true that understanding the risk factors and warning signs of suicide can be very helpful, we don't want to make judgments or assumptions about this particular death. So don't give in to random conversations about the reasons for death.

The most important thing any of us can say is that this young person was not thinking clearly and made a terrible choice, and the cost was his or her life.

If you knew the deceased personally, you may feel a jumble of emotions yourself. Give yourself sometime to let the news settle. Expect shock to mix with sadness and helplessness. Ultimately, the fact that this youngster completed suicide will be less central to your emotions than the fact that he or she is dead and will be missed by you.

It is critical for you to take time to deal with your own feelings before you approach your child.

Remember the directives from air travel about the use of oxygen masks . you must put on your own mask before you can help anyone else with theirs!

Next: Help your kids

This initial response of shock may be followed quickly by concern for your own children. If your child had a personal relationship with the deceased, your child's grief should be your first priority. Grief in childhood looks differently than it does in adulthood. Children tend to experience intense feelings, such as those that accompany a significant loss, in short bursts. Such feelings normally pass quickly, which is why it is important to seize those teachable moments when the door to conversation about the death may be open.

Start by expressing your own sadness and confusion about the death, and then ask your child to share his or her reactions. Validate whatever you hear. I can appreciate your sadness, confusion, anger, lack of understanding. Be prepared fore the classic response of "I don't know" and validate that too! I understand when something like this happens, it can be hard to know how you feel.

If you've been hearing rumors about the death, chances are your child has heard them also. Address the rumors with your child. There are a lot of rumors floating around about what happened. Have you heard anything? Explain that although some of the rumors may be true, they are only part of the story and we have to be careful not to make judgments based on limited information. Emphasize that the most important piece of the story is the fact that the deceased felt so terrible or was thinking so unclearly that he or she did not realize in the consequences of what he or she was doing. This is especially important to discuss if drugs or alcohol are implicated in the death. Remind your child, without preaching or lecturing, about the effects of drugs on impulse control and judgment.

Because children normally imitate or copy the behavior of peers, you may want to underscore the dangerous consequences of the deceaseds behavior. Sometimes children are intrigued by the circumstances of a suicide completion or attempt, so it is essential to state emphatically that there can be a fine line between dangerous and deadly behavior . and their friends death is a reflection of this. If they hear any of their friends talking about coping the behavior of the deceased, they need to tell an adult immediately!

This leads into the final part of the conversation: a discussion about help seeking. Emphasize that nothing in life is ever so terrible or devastating that suicide is the way to handle it. Ask your child to whom she or he would turn to for help with a serious problem. Hopefully, your name will be on the top of the list, but don't be upset if it isn't. Depending on your child's age, his or her allegiance may have shifted to peers. Agree that friends are a great resource but that when a problem is so big that suicide to peers. Agree that friends are a great resource but that when a problem is so big that suicide is being considered as its solution, its essential to get help from an adult, too. Ask which adults your child views as helpful, especially with difficult problems. If the list is short or nonexistent, make some suggestions. Good choices can include other adult family member, school staff such as teachers, counselors, coaches or the school nurse, clergy or youth ministers, a friends parent and older siblings or even neighbors. This identity of the person is less important than the fact that your child recognizes the importance of sharing problems with a trusted adult.

You may also want to recognize that your child may be concerned about the wellbeing of a friend or classmate and that these same adults are a great resource in those situations, too.

Its never good to keep worries about a friend to ones self, especially if the worrisome are about something as serious as suicide.

Revisit these messages about help seeking in other conversations. Unanswered questions and complicated feelings about a suicide linger, even if they are unspoken, and ignoring them does not make them go away. Talking about suicide can't plant the idea in your child's head. On the contrary, creating an open forum for discussion of difficult subjects like suicide can give your child the opportunity to recognize you as one of his trusted adults and will offer the chance to practice help seeking skills.


  • Deal with your own reactions
  • Avoid gossip about the causes
  • Remain nonjudgmental about the deceased
  • Share your reactions with your child
  • Ask for his/her response and validate it
  • Acknowledge rumors and put into context
  • Underscore the dangerous behavior of the deceased
  • Introduce topic of help seeking
  • Keep channels of communication open!