See also: Suicide among LGBT youth and Homosexuality and psychology
The likelihood of suicide attempts are increased in both gay males and lesbians, as well as bisexuals of both sexes when compared to their heterosexual counterparts. The trend of having a higher incident rate among females is no exception with lesbians or bisexual females and when compared with homosexual males, lesbians are more likely to attempt than gay or bisexual males.
Studies vary with just how increased the risk is compared to heterosexuals with a low of 0.8-1.1 times more likely for females and 1.5-2.5 times more likely for males. The highs reach 4.6 more likely in females and 14.6 more likely in males.
Race and age play a factor in the increased risk. The highest ratios for males are attributed to caucasians when they are in their youth. By the age of 25, their risk is down to less than half of what it was however black gay males risk steadily increases to 8.6 times more likely. Through a lifetime the risks are 5.7 for white and 12.8 for black gay and bisexual males.
Lesbian and bisexual females have opposite effects with less attempts in youth when compared to heterosexual females. Through a lifetime the likelihood to attempt nearly triple the youth 1.1 ratio for caucasian females, however for black females the rate is affected very little (less than 0.1 to 0.3 difference) with heterosexual black females having a slightly higher risk throughout most of the age-based study.
Gay and lesbian youth who attempt suicide are disproportionately subject to anti-gay attitudes, and have weaker skills for coping with discrimination, isolation, and loneliness, and were more likely to experience family rejection than those who do not attempt suicide. Another study found that gay and bisexual youth who attempted suicide had more feminine gender roles, adopted an LGB identity at a young age and were more likely than peers to report sexual abuse, drug abuse, and arrests for misconduct.
One study found that same-sex sexual behavior, but not homosexual attraction or homosexual identity, was significantly predictive of suicide among Norwegian adolescents. In Denmark, the age-adjusted suicide mortality risk for men in registered domestic partnerships was nearly eight times greater than for men with positive histories of heterosexual marriage and nearly twice as high for men who had never married.
A study of suicide, undertaken in Sweden,
involved the analysis of data records for 6,456 same-sex married
couples and 1,181,723 man-women marriages. Even with Sweden's
tolerant attitude regarding homosexuality, it was determined that for
same-sex married men the suicide risk was nearly three times higher
than for different-sex married men, even after an adjustment for HIV
status. For women, it was shown that there was a tentatively elevated
suicide risk for same-sex married women over that of different-sex
Are You Thinking of
I cannot pretend to understand your situation. You are a stranger, first of all, and everybodys story is unique. So Ill refrain from the clichés: Itll get better. This too shall pass. You are a good person and deserve to live. Those statements may well be true, and I hope you will consider them. But if they were enough, nobody would die by suicide.
Instead of giving you superficial reassurance, I am going to ask you some important questions. I invite you to consider them thoughtfully, and to sit with your answers. They may surprise you.
Have You Tried Everything that Can Help?
You obviously feel tremendous pain, hopelessness, or other problems that are causing you to want to die. Have you tried out everything possible to alleviate those problems?
If you are depressed, have you tried every different type of antidepressant medication out there? (At last count, there were 30). Even if a few types of antidepressants havent worked for you, that doesnt mean that none of them will.
Have you tried therapy? Research indicates that various therapies, such as cognitive behavioral therapy and dialectical behavior therapy, can help to reduce suicidal thoughts, improve depression, and strengthen coping skills.
Have you increased your exercise? Exercise can be as effective as antidepressants in relieving depression, and it helps reduce anxiety, too.
If you are experiencing a life situation with devastating consequences perhaps you are being bullied or facing jail time can you consider the possibility that the situation may change, or that it may become more bearable in time?
If you are hearing voices telling you to kill yourself perhaps the voices say that you are a bad person or that you do not deserve to live can you consider that the voices simply are wrong? Can you talk back to the voices? Have you tried every type of antipsychotic medication there is? (There are at least 18, not including mood stabilizers.) Might the voices come
to a stop, or change what they tell you, or become less believable with time?
Similarly, if you are plagued with thoughts of worthlessness, hopelessness or unlovability, can you entertain the possibility that those thoughts are not true? You do not need to believe everything that you think or feel. I have heard the saying before (though I forget where) that many people have a prosecutor residing in their head, and they lack a defense attorney. You can learn to defend yourself against self-condemning thoughts and to feel better about yourself and your life again. (Cognitive behavioral therapy especially helps with these types of problems.)
Whatever you are dealing with, can you consider that you still can craft a purpose for yourself in life in the months and years to come, whatever that purpose may be?
What Would You Say to a Suicidal Person in Your Situation?
Compassion and suicideThink of everything that is going wrong in your life. Think of all the reasons you have for dying by suicide.
Now imagine that someone you care about very much came to you with the same problems, the same reasons, the same desires to die. What would you tell them?
Would you say to this person you care about, Youre right, you should kill yourself? If not, why?
What Are Your Reasons for Living? (Or What Were They?)
Something has kept you alive this long. What has kept you going?
Reasons for livingWhat have you lived for in the past? Is it possible that you will want to live for those same things again in the future, if this crisis passes?
Here are common reasons for staying alive that people provided in a study by Marsha Linehan and colleagues:
Other reasons might include pets, dreams of traveling, love of the mountains you name it. Whatever keeps you here may well be worth staying for.
Do any of the above reasons apply to you? If not, could they in the future?
Where Is Hope?
Hope and SuicideThe antidote to suicidal thoughts is hope, and conversely, hopelessness is their accomplice.
What do you hope for yourself for the future? What can you do to help you survive long enough for those hopes to be realized?
Are there things you hope for immediately, like a chocolate bar, a good nights rest, a day off from work? What are the little things that you hope for that might not be getting your attention during this time of crisis?
Have you lost all hope? If so, think back on what gave you hope in the past. When did those things stop fueling your hope? Could they again?
Maybe you are thinking Things will never get better or I have nothing to live for. Can you be certain your thoughts are correct? More to the point, even though it is painful to have such thoughts, is it possible you are wrong?
Remember, some conditions like extreme stress, or depression can cloud a persons thinking, making hope invisible. People with these conditions may be unable to remember the good things in their life and unable to tap into the good things that may come. But hope does not really die. It just hides. Even amid a terrible storm in the head, it is still there behind the clouds, just like the sun.
Think of Other People Or Not
Family and suicideI would like to ask you to think of people who would suffer from your death. But I know that thinking of other people can be very complicated.
Some people are angry at those they believe have failed them. They may feel, often rightly so, that their suicide will cause guilt in those they left behind, and for a small number of suicidal people, this may be a fate that they welcome. In this context, suicide takes on a vengeful quality, whether that is the primary purpose or a byproduct of suicide.
Other people may feel convinced that they are a burden on their loved ones, and that their suicide would be a way to spare their family and friends. Even more common, perhaps, are the people who are suicidal precisely because they have no one who cares (or believe that to be true, even if it is not).
I also know that when the pain and desperation become excruciating for a person considering suicide, the love and support of others becomes only a small solace. Even parents of young children die by suicide, not because they do not love their children and not because they disregard the pain it will inflict on their children. No, for many people who are suicidal, their pain is so great that they desperately want to escape it. Even though they know their death will bring great pain to those left behind, a more frightening scenario for them is having to continue enduring their own pain, day after day.
I recognize that sad reality. So the question of who your death will hurt might not be relevant to you. But if it is relevant, please do consider that those who care about you will be devastated.
Remember the saying: To the world you may be only one person, but to one person you may be the world.
To which people are you the world?
Whose world might you become in the future, whether or not you have met that person yet?
What people might you help, whether professionally or personally?
How Have You Coped in the Past?
Think of another time when you really struggled in life. Perhaps you did not think of suicide, but you felt extremely sad, or angry, or hopeless. How did you get through that? What helped you? Who helped you?
If you have ever experienced this kind of despair and suicidal thinking before, what stopped you from killing yourself then? What did you do, feel or think then that you might be able to repeat now?
Is It At All Possible that Things will Change?
Hope change and suicideCan you know for certain that your problems will never improve, or that you will never learn to cope with them better?
Even though it does not feel like it now, there is hope for change. The horrible situation you are in might get better, or it might become more bearable. The pain you feel may ebb, or you may develop techniques for coping with it. Hope may return. Goodness may come.
Consider that among people who survive a suicide attempt, about 90% do not eventually die by suicide. Even these people who made the decision to die find reasons to live again.
Can you know for certain that you wont rediscover reasons for living, or reconnect with those that already exist? Maybe not now, but there may well come a time when you look back on your suicidal state of mind and are glad that you did not die.
There is a good saying: Dont quit five minutes before your miracle.
Similarly, I have a piece of artwork on my wall that says, Any moment can change your life. You just have to be there.
This applies to you, too. It applies to everyone. Finally, What If You Survive a Suicide Attempt with Serious Injuries?
Sadness regret and suicide attemptThis is a tough question to ask, and even tougher to answer. Consider that you might survive your suicide attempt. Would the injuries you inflicted on yourself make your problems even worse?
You could suffer permanent injuries from jumping, trying to hang yourself, or doing other bodily injury to yourself. Consider what happened to Kristin Jane Anderson, who attempted suicide by lying down on railroad tracks when a train approached. She lost both her legs. (See her excellent, inspirational book, Life, In Spite of Me, about rediscovering hope and purpose in life in the years that followed.)
If you shoot yourself, you may still survive. Some people who shoot themselves do permanent damage to their face, experience severe brain damage, or become paralyzed. In another book by an attempt survivor, David Wermuth describes the ordeal of becoming blind from shooting himself in the head.
Some people who survive an overdose damage their kidneys or liver in the process. A transplant is sometimes necessary. Some others suffer permanent brain damage.
I said this is a tough question to ask, because I do not want to challenge you to come up with a foolproof method for killing yourself. Instead, I want you to consider that things dont always go as planned. Whatever problems you struggle with now could be made even worse with a suicide attempt.
In Closing: Suicidal Thoughts as a Symptom
Many people think of suicide from time to time. The philosopher Camus noted, There is but one truly serious philosophical problem and that is suicide. The philosopher Nietzsche said, The thought of suicide is a great consolation: by means of it one gets through many a dark night.
To seriously consider suicide is a sign that something is wrong. Our natural instinct in life is to survive. People endure unimaginable horrors in order to stay alive as but one example, just think of the man who cut his arm off with a pocket knife in order to liberate his body from a boulder, having been trapped beneath it for five days and seven hours.
If your instinct to survive has become weakened, it is a sign that you need help. Please seek that help, whether from a trusted friend or family member, clergy, physician, therapist, or some other supports you have.
What can you do now, right now, to help yourself or to let someone help you?
For a list of resources you can contact
immediately, via hotlines or online, click
Is it Time to Confront
Everyone seems to be seeing a shrink these days. What's the perfectly sane and well-adjusted guy to do? Give it a try
I almost turned around and walked out. It was that bad. Beige walls, ambient mood lighting, decorative bamboo shoots, and on the coffee table in front of me one of those miniature Zen rock gardens. There was also an incessant trickling. I peered into the gloom of the waiting room and saw its source: one of those plug-in waterfalls with a craggy slate cliff. There was no receptionist, so I took a seat. I picked up Mother Jones and put it down. I picked up the rock garden and started raking pebbles; then I realized what I was doing and put that down, too.
What was I doing?
Therapy, psychoanalysis, counseling . . . call it what you will. I'd always called it a sham, a cop-out, an excuse. Granted, I don't come from a touchy-feely family. When I was a teen, my parents divorced, my mother moved in with a woman, my father remarried a widowed socialite, and my brother and I were shipped away to school. Yet none of us even considered therapy. Imagine that happening today, in this era of self-help books and life-coaching seminars. What's happened to America? When did we stop solving our own problems? We've all gone soft, and I wanted to find out why. So I booked a session with a shrink.
Okay, there's more to the story--a personal side. Truth be told, I was curious. As I'd crept through my late 20s and early 30s, the number of people I knew who were in therapy had grown to the point at which I found myself in the minority. And everyone talked about it! Dates came bustling into restaurants, apologizing because their shrinks had kept them late. Married friends mentioned how counseling had helped their sex lives so much, as if I wanted to know.
And it was not just a New York phenomenon. My therapy-devoted friends were in Atlanta and Los Angeles, in Kalamazoo and Fort Lauderdale. They were bankers and housewives and salesmen. They were older and younger. And most interesting of all? There was nothing wrong with them: no severe anxiety or debilitating depression, no strange phobias or suicidal tendencies. Sure, they had their issues--who doesn't?--but they were hardly head cases. Yet they looked forward to their weekly sessions the way I look forward to poker night. Therapy was their escape.
It was Sigmund Freud who, in the late 1800s, first theorized that psychological problems are rooted in the unconscious mind. The techniques he developed to bring those problems to the surface have, over 100-plus years of refinement, become the foundation of modern psychotherapy. But none of my therapy-attending friends ever mentioned the analysis of dreams or the cataloging of Oedipal impulses. No, it seemed they just spent their time ranting about scheming bosses or annoying spouses while their shrinks sat there quietly, feigning interest, fighting sleep. If things turned worse--if the sadness or anxiety became constant--perhaps the doctor would write a prescription or call another doctor. Therapeutic solutions and chemical cures. Life without mental illness--it's a powerful idea.
Popular, too. According to the National Center for Health Statistics, the number of American adults who visited mental-health professionals jumped by more than a third between 1997 and 2005, to almost 24 million. That's just over 10 percent of us. And the patients aren't all women: 38 percent of today's therapy seekers are men, presumably emboldened by James Gandolfini's Tony Soprano and Robert De Niro's Paul Vitti.
Sitting in the waiting room,pondering the craziness of the "crazy" craze, I thought back to the night when this all started for me: at my 35th-birthday dinner. A group of friends began talking about how invaluable therapy had become in their lives, and when I raised a dissenting voice, I was quickly shouted down.
"How can you know what you're talking about if you've never tried it?" my friend Haley asked. The rest of the table jumped in. I was surrounded, outnumbered. And they had a point. A few days later, I called Haley to request her therapist's number and ask what the woman was like.
"She's laid back but tough," Haley said. "She doesn't just sit there and ask questions. It's more of a conversation."
"But I'm fine," I insisted.
"Oh, honey, no one's fine. That's the first thing you'll learn."
Editor's note:Fine isn't a feeling in itself. When most man say "I'm fine" what they are actually feeling is "Furious Isolated Numb and Empty."
Those words stuck in my head. Was I really fine? Certainly there were things that bothered me--inconvenient corners of my life that I tended to ignore or explain away, phrases that emerged in arguments with girlfriends, bad habits that never quite died. But the big picture still looked rosy. I lived in a great city, was surrounded by supportive friends, and now had something I could legitimately call a career. So why was I really sitting in this waiting room? It wasn't just because I was culturally curious. Or because of my friends. It was the birthday . . . 35. It felt like the end of something big. A graduation into adulthood.
But I wasn't an adult--not in any conventional sense. I wasn't married. I didn't have kids or a car. I owned no real estate. I didn't even have health insurance. And yet all of this seemed perfectly normal. I'd chosen a certain life and was now living it. A successful book, a film deal . . . what a great year it had been for me. So why hadn't I had fun? Why had my girlfriend and I broken up? Why did I run off to Europe for 2 months to get away from everything?
I looked up. She was smiling: a thin, stylish woman with wavy hair and a pleasantly disarming bohemian glow. I shook her hand and followed her to an airy office at the end of a long hallway. She pointed me toward the couch (yes, there really was a couch) and sat down in a chair facing me. I'd dreaded this moment. How do you confide in a complete stranger? How do you share the thoughts you've never shared with anyone else? Yes, this woman was trained (and paid) to listen. Yes, it was supposed to be easier to talk about your life with someone outside of it. But I didn't actually buy any of that. I mean, seriously. The entire setup was so artificial. How should I play along? Where would I begin?
Well, at the beginning, if you're Freud. First memories and all that. But so far, this had nothing to do with Freud. She hadn't asked me to lie down or recount dreams. No, we just started talking. This and that. Occasionally, she asked a pointed question. Sometimes she wrote things down. On my book tour, I'd grown tired of talking about myself, so I created a kind of persona, a second, more public version of myself. It was a phenomenon I hadn't pondered or discussed with anyone because, well, that would be even more self-serving. And anyway, who in her right mind would listen?
It took me a moment to realize I was saying all of this out loud. In less than an hour, I'd delved deeper into my, what, unconscious than at any time in the past year. And this I told her, too.
"I'm not sure we've reached your unconscious yet," she said. "But we have awakened some of the bats that were sleeping."
At my next appointment, I came rushing in, frustrated by all the small aggravations of life. I slumped into a chair and took a deep breath, and the outside world began to fall away. I could no longer ignore it: I'd been looking forward to coming back. Last week's visit felt like something worth pursuing--an intriguing first date or an adulterous affair. And I was cheating on the part of me I didn't like. I just started talking: women, work, goals I should be pursuing--
"You're saying 'should' a lot," she said.
"Yes. As if you have a preconceived notion of yourself. Some other possible life you're battling against. Tell me, what do your parents do?"
"Is this the Freud part?"
She laughed. "Maybe, a little bit. We all have different versions of ourselves. And they're rooted in our pasts."
"They're both lawyers," I said.
"Oh, dear. This may take a while."
There is a moment in therapy--if it's going well--when you decide to tell the truth. For me it was the middle of the fourth session. And I don't mean I'd been lying until then. It's just that I hadn't come completely clean. This was, after all, a relationship of sorts. The person sitting across from me was someone I'd quickly come to value and respect. I wanted her to like me. I wanted her to be impressed. And yet I was playing that coy game we all play. When she said she was looking forward to reading my book, I told her she must have better things to do. The false modesty was pathetic. I'm sure she saw through it, even if she didn't let on.
She changed the subject. I changed it back.
"About the book," I said. "Of course I want you to read it."
"So why did you say you didn't?"
"I don't know. Why does anyone say anything?" And then I caught myself again. I did know. "Okay, I didn't want to sound self-involved."
She leaned forward slightly. "You're very hard on yourself. You should want your work to be read; otherwise, why do it? You can't just stay silent, hoping to be noticed. Not in this day and age."
I almost said that flagrant self-promotion was part of what had made "this day and age" so superficial in the first place. But this was psychotherapy, not philosophy. And I'd just made a small breakthrough of sorts, peeled away a layer of myself. She knew it, too.
Suddenly, we were off and running. She poked and prodded. I reacted and explained. For the first time, I could imagine these mini-realizations leading to a larger, life-altering discovery.
The following week I came armed with a question.
"Tell me, where does all this end?"
"What do you mean?" she asked, looking up from her notes. She smoothed the wrinkles in her skirt.
"You don't like it when I ask the questions, do you?"
"Therapists have their own therapists for that," she said.
"Oh, that makes me feel better."
"That you have someone to vent to."
"I think you know this is about a lot more than just venting," she said. "We're on a journey. And the end is never as important as how you get there."
"But if we keep peeling off layers, there may be nothing left."
She laughed at this and was silent for a time. I thought back to that first day in the waiting room and of all those ideas and misconceptions. Psychotherapy wasn't what I had thought it would be. It was instead a reflection of who I was. It wasn't spiritual or New Age, because I'm not spiritual or New Age. But something positive was happening, so why not give it a chance? Was I going soft? Maybe a bit, or maybe I'd been hard-edged for too long.
I realized then that I was staring out the window. When I turned back, she was regarding me curiously, her brow slightly furrowed. And then, as if reaching a decision, she opened her notebook and clicked her pen.
"I think you're ready," she said. "So let's start at the beginning. What are your first memories?"
Find the Right Therapy for You
Psychotherapy works -- but only if you visit the right kind of therapist. Here are five common reasons men visit shrinks, and the recommended therapy for each problem.
Depression: Cognitive Behavioral Therapy (CBT)
When men believe they have no reason to be happy, they turn away from activities they enjoy. "The cognitive part helps patients identify their negative thoughts, and the behavioral aspect pushes them to stay active," says Greg Simon, M.D., a psychiatrist in Seattle.
Phobias: Exposure Therapy
"Contact with the feared event is critical to overcoming it," says Jeffrey S. Berman, Ph.D., a University of Memphis professor. Exposure therapy slowly desensitizes you. Say you're afraid to fly. Over a few months, you visit an airport, sit on a plane, and taxi around. Then you're cleared for takeoff.
Substance Abuse: 12-Step Programs
Alcoholics Anonymous and Narcotics Anonymous are still the key treatments for alcohol and drug abuse. A 2006 study in Addiction found that people who sought treatment by using a 12-step program were 44 percent more likely to be clean and sober 3 years later.
Anxiety: Psychodynamic Therapy
CBT is the standard treatment for anxiety. But a recent study suggests that psychodynamic therapy, which raises awareness of unconscious motivations, is a great alternative. In the study, patients had a 153 percent greater reduction in symptoms after 12 weeks than those receiving relaxation training.
Marital Troubles: Family Therapy
"Family therapy treats relationships, not
individuals," says Jacques Barber, Ph.D., a professor of psychology
at the University of Pennsylvania. The goal is not to pinpoint the
cause of a problem -- i.e., place blame -- but to reveal how the
couple's interactions feed it.
Prevents Repeat Suicide Attempts
Short-term psychotherapy may be an effective way to prevent repeated suicide attempts.
Using detailed Danish government health records, researchers studied 5,678 people who had attempted suicide and then received a program of short-term psychotherapy based on needs, including crisis intervention, cognitive therapy, behavioral therapy, and psychodynamic and psychoanalytic treatment. They compared them with 17,034 people who had attempted suicide but received standard care, including admission to a hospital, referral for treatment or discharge with no referral. They were able to match the groups in more than 30 genetic, health, behavioral and socioeconomic characteristics. The study is online in Lancet Psychiatry.
Treatment focused on suicide prevention and comprised eight to 10 weeks of individual sessions.
Over a 20-year follow-up, 16.5 percent of the treated group attempted suicide again, compared with 19.1 percent of the untreated group. In the treated group, 1.6 percent died by suicide, compared with 2.2 percent of the untreated.
Suicide is a rare event, said the lead author, Annette Erlangsen, an associate professor at the Johns Hopkins Bloomberg School of Public Health, and you need a huge sample to study it. We had that, and we were able to find a significant effect.
The authors estimate that therapy prevented 145
suicide attempts and 30 deaths by suicide in the group studied.
Cognitive Therapy for
Suicidal Patients (CT-SP)
Many behavioral health providers have had training in cognitive-behavioral therapy (CBT), but few are knowledgeable about how to best use CBT when working with a suicidal patient. Cognitive Therapy for Suicide Prevention (CT-SP) is an evidence-based, manualized cognitive-behavioral treatment for adults with suicidal ideation and behaviors. Although this treatment protocol was initially developed for individuals who recently attempted suicide, the protocol can also be applied to individuals with acute suicidal ideation.
CT-SP is based on Dr. Aaron Becks cognitive-behavioral model. According to this theory, an individuals biopsychosocial vulnerabilities can interact with suicidal thoughts and behaviors to produce a suicide mode. Suicide is distinct from any medical or mental health conditions and can occur in the context of many diagnoses. Accordingly, treatment directly targets suicide-related thoughts and behaviors and is considered transdiagnostic in nature.
Like other CBT treatments, CT-SP is structured and time-limited. CT-SP is typically conducted in a 10-session protocol (approximately 50 minutes in length per session) and follows a session structure consistent with a typical CBT session. CT-SP generally includes three broad phases: an early phase, an intermediate phase, and a later phase.
The early phase of treatment focuses on treatment engagement, risk assessment, and crisis management. Treatment begins with the therapist completing a thorough suicide risk assessment, in addition to gathering other relevant information. Crisis intervention strategies, such as developing a Safety Plan and conducting Means Restriction Counseling, are also completed during this phase. Finally, the therapist guides the patient in obtaining a detailed narrative timeline of the most recent suicidal crisis. A cognitive-behavioral case conceptualization is generated collaboratively with the patient and used to create an individualized treatment plan based on the idiographic needs of the patient.
During the intermediate phase of treatment two main types of strategies are implemented. First, behavioral strategies are implemented to help the patient develop cognitive, behavioral, and affective copings skills. Examples include relaxation training, activity monitoring, and increasing social resources. Secondly, cognitive strategies are implemented to help modify unhelpful beliefs associated with the risk of triggering a suicidal crisis. Patients are educated about the cognitive model and are taught ways to evaluate their thoughts and beliefs, to include modifying core beliefs and identifying reasons for living.
The final phase includes several relapse prevention exercises intended to consolidate skills learned during therapy. The main component of the relapse prevention exercises is a guided imagery task, in which the patient is directed to implement skills learned during therapy in response to imaginal exposure of past and potential future suicidal crises. Once the patient is able to demonstrate generalization of skills learned, a debriefing and summary of skills learned is conducted. At this time, the provider will conduct a thorough risk assessment and offer additional treatment session or referrals as clinically indicated.
For Therapists Who Want
or Need to Improve Their Suicide Prevention
If you are a psychotherapist, it is likely that your graduate studies included precious little training in suicide prevention. You can get that knowledge in other ways. To name a few:
Several organizations have published guidelines for clinical practice with suicidal individuals. Those practice guidelines contain a wealth of information on topics related to suicide risk assessment, treatment planning, interventions, safety planning, and more:
VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide
This clinical practice guideline is from the Veterans Administration and Department of Defense, but the content is applicable to all adults. Topics include risk assessment, management of urgent or emergent risk, treatment interventions based on the different levels of risk, safety planning, and continual monitoring and re-assessment.
Working with the Suicidal Person: Clinical Practice Guidelines for Emergency Departments and Mental Health Services
Published by the Victoria (Australia) Department of Health, these guidelines go beyond the standard material on the assessment and management of suicide risk. In addition, they include guidelines related to special populations such as the elderly and the chronically suicidal, aggression in emergency departments, and bereavement services.
American Association for Suicidology Annual Conference
This conference, held every April, consistently features excellent presentations on clinical interventions with clients at risk for suicide, including those with intense suicidal thoughts or a recent suicide attempt. Pre-conference training workshops, lasting from a half day to two days, are especially salient. You usually can find information about upcoming and past conferences at the American Association for Suicidology website.
Suicide-specific courses are the exception rather than the norm, but they do exist. Check with your local university to see whats available.
Continuing Education Courses
Numerous outfits offer continuing education courses, including universities, professional organizations, training institutes, and businesses like PESI.com. Opportunities often come and go, so here I am listing some classes that are offered on a fairly consistent basis:
Assessing and Managing Suicide Risk
This one day workshop, offered by the Suicide Prevention Resource Center, is based on core competencies that are considered essential to assessing and managing suicidality. These competencies include examining ones attitudes and approach toward suicidal people, understanding suicide, gathering accurate information from the client, formulating the clients level of suicide risk, developing a treatment plan, documenting the assessment and treatment, and understanding legal issues related to working with suicidal clients.
Recognizing and Responding to Suicide Risk
This 2-day training is similar to the Assessing and Managing Suicide Risk course described above, while also expanding on it with experiential exercises and clinical case studies.
Suicide Risk Assessment (3 hours)
Suicide Risk Assessment and Management (6 hours)
The above two courses are offered through Behavioral Tech, LLC, which was founded by Marsha Linehan, PhD, the developer of dialectical behavior therapy (DBT). The courses Suicide Risk Assessment and Suicide Risk Management are each 3 hours long. Treatment with Suicidal Persons is 6 hours long. Suicide: DBT Protocol for Assessing and Managing Risk is usually 2 days long.
Cognitive Behavior Therapy for Depression and Suicide
This 3-day workshop includes a day of instruction devoted to CBT with suicidal clients. Topics include risk assessment, techniques for preventing and managing suicidal crises, and ethical issues.
Community Training Opportunities
Several groups offer suicide prevention training to lay people, and these trainings also have value for professionals. Here, I describe three particularly well known workshops offered to communities.
Applied Suicide Intervention Skills and Techniques (ASIST) and SafeTALK
This 2-day ASIST training covers important, basic skills such as recognizing suicide risk, planning for safety, intervening effectively, tapping into community resources, and avoiding stigma and judgment in work with suicidal people.
The group that developed ASIST, LivingWorks, also has another training, SafeTALK. This 3-hour class is focused on helping people to move beyond common tendencies to miss, dismiss or avoid suicide, recognize people who are thinking of suicide, and connect person with suicidal thoughts to suicide first aid. (TALK stands for Tell, Ask, Listen, and Keep Safe.)
To see whether any ASIST or SafeTALK workshops are scheduled near you, check out LivingWorks Find-A-Training site.
QPR Gatekeeper Training for Suicide Prevention
QPR (Question, Persuade, Refer) is a course designed for community gatekeepers that is, people who might be in a position to encounter a suicidal person and refer the person to a professional. This 1-hour course may be rudimentary for mental health professionals who are already well versed in risk factors for suicide. The QPR Institute also offers more advanced courses on an online basis, which I describe below.
You have several options for online training. Some are even free.
The one-hour QPR training course is pretty basic for professionals. The advanced courses are better suited to clinical practice. They each take anywhere from 3 to 12 hours to complete (not including the Online Counseling and Suicide Intervention Specialist course, which takes 40 hours):
Suicide Prevention Resource Center (SPRC) Online Training
SPRC offers free, self-paced online courses related to suicide prevention. Right now the courses are designed primarily for administrators, researchers, and policy planners. One course is immediately applicable to practice: Counseling on Access to Lethal Means (CALM).
There may be no such thing as a free lunch, but the Internet contains an amazing amount of free webinars on topics related to suicide prevention, sponsored by various organizations:
Injury Control Research Center for Suicide Prevention
This center, housed at the University of Rochester Medical Center, has an archive of webinars. Topics include suicide in relation to domestic violence, military and veterans, indigenous communities and middle-aged men, and alcohol abuse. There also is a webinar about non-suicidal self injury.
Massachusetts Coalition for Suicide Prevention
This suicide prevention coalition has sponsored numerous webinars since 2010. The group keeps the webinars (and their transcripts) available to others on the sites webinar library. Topics include suicide prevention in relation to bullying, veterans, Black youth, transgender communities, schools, older adults, sexual assault survivors, eating disorders, and self injury. Two webinars also address grief and healing after suicide loss.
Centre for Suicide Prevention
This Canadian organization has an excellent series of webinars centered on the theme The 5 Things We Wish All Teachers Knew about . Though targeted at teachers, the webinars contain information that is valuable to anybody who encounters suicidal youth. Topics include The 5 Things We Wish All Teachers Knew About
- Anxiety Disorders, Depression, and Suicide
- Lesbian-Gay-Bisexual-Transgendered Youth and Suicide
- How to Talk to Parents About a Child at Risk of Suicide
- Substance Use and Suicide
- Social Media, Contagion and Suicide
- Self-harm and Suicide
Mental Health Commission of Canada
This groups suicide prevention webinar series covers topics such as community suicide prevention, trauma-informed care, injury prevention, and the use of technology (such as apps) in suicide prevention.
Suicide Prevention and Resource Center
The Research to Practice webinar series contains more than 30 webinars recorded since 2004. Many are oriented toward research, policy, or community suicide prevention, but they still have relevance to clinicians. Webinar topics include a Native communitys successful suicide prevention strategy, suicide prevention in rural primary care settings, alcohol use and suicide, and bullying and suicide.
Books, Books, and More Books
In this sites Resources section for mental health professionals, I recommend in more depth several books on assessing and treating suicidality. Here is a simple list of those books and many more:
Adolescent Suicide: An Integrated Approach to the Assessment of Risk and Protective Factors, by Peter M. Gutierrez, PhD, and Augustine Osman, PhD
Adolescent Suicide: Assessment and Intervention, by Alan L. Berman, PhD, David A. Jobes, PhD, and Morton M. Silverman, MD
The American Psychiatric Publishing Textbook of Suicide Assessment and Management, by Robert I. Simon, MD, and Robert E. Hales, MD, MBA
The Assessment and Management of Suicidality, by M. David Rudd, PhD
Building a Therapeutic Alliance with the Suicidal Patient, Edited by Konrad Michel, MD, and David A. Jobes, PhD
Clinical Manual for Assessment and Treatment of Suicidal Patients, by John A. Chiles, MD, and Kirk D. Strosahl, PhD
Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications, by Amy Wenzel, PhD, Gregory K. Brown, PhD, and Aaron T. Beck, MD
Comprehensive Textbook of Suicidology, by Ronald W. Maris, PhD, Alan L. Berman, PhD, and Morton M. Silverman, MD
Dialectical Behavior Therapy with Suicidal Adolescents, by Alec L. Miller, PsyD, Jill Rathus, PhD, and Marsha M. Linehan, PhD
Managing Suicidal Risk: A Collaborative Approach, by David A. Jobes, PhD
Myths about Suicide,by Thomas Joiner, PhD
Night Falls Fast: Understanding Suicide, by Kay Redfield Jamison, PhD
The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors, by Shawn C. Shea, MD
Preventing Patient Suicide: Clinical Assessment and Management, by Robert I. Simon, MD
The Suicidal Mind, by Edwin S. Shneidman, PhD
The Suicidal Patient: Clinical and Legal Standards of Care, by Bruce Bongar, PhD, and Glenn Sullivan, PhD
Teen Suicide Risk: A Practitioner Guide to Screening, Assessment, and Management, by Cheryl A. King, PhD, Cynthia Ewell Foster, PhD, and Kelly M. Rogalski, MD
Treating Suicidal Behavior: An Effective, Time-Limited Approach, by M. David Rudd, PhD, Thomas Joiner, PhD, and Hasan Rajab, PhD
Why People Die by Suicide, by Thomas Joiner, PhD
The list I provide here of ways to improve
suicide prevention skills is by no means exhaustive. If you know of
an option not listed here that you would like to share, please feel
free to leave a comment!
Inadequate: Suicide Prevention Training in Graduate Schools
With the exception of psychiatrists, most mental health professionals have received very little, if any, training in graduate school on suicide-related topics:
Competence in the assessment of suicidality is an essential clinical skill that has consistently been overlooked and dismissed by the colleges, universities, clinical training sites, and licensing bodies that prepare mental health professionals.
The above statement comes from W.M. Schmitz Jr., Psy.D., and colleagues. They authored a report for the American Association of Suicidology on the state of suicide prevention training in graduate programs for future psychologists, social workers, counselors, and other mental health professionals.
Their verdict? www.ncbi.nlm.nih.gov/pubmed/19349444
The typical training of mental health professionals in the assessment and management of suicidal patients has been, and remains, woefully inadequate.
Some Startling Statistics
Summarizing from previously published research, the task force reported that roughly half of students in accredited psychology programs received any didactic training at all in preventing suicide. Often, this training was very limited.
Additionally, only 2% of accredited counselor education programs and 6% of accredited marriage and family therapy programs offered a suicide-specific course in their curriculum.
The task force also reported findings of a national survey that my colleague Barry Feldman, Ph.D., and I conducted. In our study, 60% of social workers said they had received some instruction on suicide prevention in their graduate school program. Of those, 75% received fewer than 4 hours of training.
I would have to agree with the task forces overall verdict: These numbers are woefully inadequate.
Good News and Bad News
The good news is that most psychiatry programs provide suicide prevention training to future psychiatrists: A national study found that 91% of psychiatry programs train students in suicide risk assessment and intervention. (OK, Im disturbed that this number is not 100%, but I am viewing the glass as 91% full rather than 9% empty.)
The bad news is that many other mental health professionals may be unprepared to help a client whose life is in danger, based on the amount of training (if any) that they received in graduate school.
What Training is Needed?
Suicide assessment and intervention skills are so important that every mental health professional should be well versed in them. A persons life is at stake. When working with a suicidal client, the professional should know how to:
Conduct a suicide risk assessment, which requires uncovering suicidal thoughts in a person; identifying warning signs, risk factors, and protective factors for suicide; appropriately documenting the assessment; and engaging in safety planning
Create a treatment plan that addresses a persons triggers for suicidal thoughts, as well as modifiable risk and protective factors
Determine the most appropriate level of care for the client, including when hospitalization is needed without overreacting or underreacting
Apply evidence-based interventions to help clients cope with suicidal thoughts, avoid acting on them, identify reasons for living, and feel hopeful again
Understand the different theoretical explanations for why suicide occurs and how to best intervene
Avoid power struggles with clients whose primary goal is to end their pain, versus the therapists goal of averting suicide
Identify important ethical and legal issues that arise when treating suicidal people, especially those related to confidentiality, informed consent, client self-determination, duty to protect laws (depending where one lives), and involuntary hospitalization
Explore cultural influences and stigma that might affect how clients views on suicide in general, their own suicidal thinking, and help-seeking
Coordinate care and seek corroborative information from the clients other health care providers, family, friends, or anyone else with important information related to client safety
(This list of skills is based on many sources, including my own experiences helping suicidal people as a crisis worker and as a psychotherapist, various sets of core competencies identified for suicide assessment and intervention, and books such as The American Psychiatric Publishing Textbook of Suicide Assessment and Management, and The Practical Art of Suicide Assessment.)
What Can You Do?
If you are a mental health professional and want to increase your knowledge and skills in suicide prevention, you have many options. These include continuing education workshops, online courses, professional conferences, webinars, practice guidelines, and other avenues for independent learning.
I will provide specific information about each
of those options in my next post, so please stay tuned!
How to Find a Therapist
Who Does Not Panic about Suicide
The wonderful blog attemptsurvivors.com recently published a post, Wanted, Therapists Who Wont Panic. Some therapists do in fact panic when faced with a client who says he or she wants to die by suicide. This can take several forms.
A panicky therapist may all too quickly recommend psychiatric hospitalization, even when it is not really necessary. (Suicidal ideation alone is not reason enough for a person to be hospitalized. In fact, it is very difficult to be admitted to a psychiatric hospital these days, even if you are thinking of suicide!)
Some therapists get angry with a client who attempts suicide. Some even stop working with the client altogether. The therapist may say that the therapy obviously is not helping, and therefore the client needs a new therapist.
Finally, some therapists simply choose not to take on new clients who are suicidal. I worked at a telephone counseling line for several years, and I was shocked by how many therapists listed in our referral database had checked no when asked if they would accept new clients who were thinking of suicide or had recently made an attempt.
When people finally admit that they need help from a mental health professional, the last thing they need is rejection. And rejection from a mental health professional is probably the last thing they expect.
Finding a Panic-Free Therapist
There are ways to figure out if a therapist is one who will shy away from treating suicidal clients or overreact when they do. Here are some tips about areas to look out for:
Look for a therapist who states that suicidal crises are an area that they treat. Therapist-finder sites like Psychology Today, HelpPRO, and GoodTherapy.org allow therapists to list the problem areas in which they have expertise. If a therapist has not checked off the sites category for suicidal thoughts, then the therapist may lack the experience, education, or interest necessary to work with suicidal clients.
Therapists Acceptance of Suicidal Clients
When you call to make an appointment, ask if they accept clients in a suicidal crisis. If the therapist immediately says no, then you are spared the heartache of going for an appointment, sharing exquisitely personal information about yourself, and being turned away afterward.
Even if the therapist says they accept suicidal clients as new clients, still pay special attention to their response. Do they qualify in any way their willingness to work with suicidal clients?
Therapists Training in Suicide Prevention
You might ask what training they have received on assessing a clients risk for suicide and working with suicidal clients. Most graduate school programs do not require training in suicide assessment or intervention, and most therapists report having received scant, if any, training in the area.
Therapists Ability to Talk Openly about Suicide
In early sessions, make note of whether your therapist asks you about any possible suicidal thoughts or, if you have already brought up the topic, whether they delve more deeply into your thoughts of suicide. Some therapists avoid bringing up suicide, out of fear that it will give clients the idea. Others may have personal experiences or attitudes about suicide that make them hesitate to introduce the topic.
Therapists Ability to Listen Fully about Suicide
Along with asking about your suicidal thoughts, a therapist needs to listen. Does your therapist give you the space to tell your story? Do they gain an understanding of why you think about dying by suicide, and why the thoughts may or may not make sense to you? Do they respond with empathy rather than advice or judgment?
Some therapists ask a mental checklist of questions to assess the risk that you will make an attempt. Those questions are important. Equally important, if not more important, is offering you the space to tell your story, to be heard, and to be understood.
Therapists who Specialize in Suicide Prevention
Keep in mind that there is a difference between a therapist who works with suicidal clients and a therapist who specializes in working with suicidal clients. It is not necessary for a therapist to specialize in suicide prevention to be competent, well trained and experienced in working effectively with suicidal clients.
If you do seek a specialist in suicide prevention, look for someone who has published research or clinical articles about suicide, participated in a suicide-related professional conference, used the CAMS approach (Collaborative Assessment and Management of Suicidality), or undergone specialized clinical training in suicide prevention. Specialists also are likely to belong to a suicide-specific professional group such as the American Association of Suicidology.
You will not really know how well a therapist will work with you in a suicidal crisis until you actually work with them. But these tips will help you find somebody who is committed to working with suicidal clients and who can work relatively comfortably with suicidal clients.
I say relatively comfortably, because even the most experienced psychotherapists feel some fear or discomfort when a client is in extreme danger of dying by suicide. Healthy concern for your safety is not the same as panic.
A Question for You
For those of you in therapy, how have you
determined whether a therapist can talk openly, and listen fully,
about suicide without overreacting?
Working with Suicidal Clients:
6 Things You Should Know
One of the scariest things therapists work with is suicidality.
Suddenly, therapy feels like, and sometimes is, a life-or-death situation, one where clinicians hold a great deal of responsibility. To make matters worse, suicide continues to be one of the leading causes of death in the U.S. , and many believe the prevalence rates are a gross underestimate .
The numbers highlight the inevitability of encountering suicidality in our line of work. Early-career psychologists and practicum students may feel overwhelmed by the intensity and risk of working with suicidal clients.
Trust me, I know how that feels.
This year I have been administering suicide risk assessments for the local county mental health services as a member of George Fox Universitys Behavioral Health Crisis Consultation Team . I have seen people on the worst nights of their lives, at rock bottom, and under extreme distress. As team members, we receive intensive training and supervision to prepare us to do this work, and now I want to pass along what Ive learned.
So, what should we do when a client is suicidal? Here are six things you should know:
1. Know About Laws and Protocol
Legal and ethical requirements play an important role when we work with suicidal clients.
Before you begin working with clients at your site, make sure to brush up on the federal and state laws related to reporting suicidality in your client population. For example, in the state of Oregon clinicians may be mandated to report suicidal behaviors in order to maintain the clients safety and provide additional care (see ORS 419B.005, 40.262 R 507).
Ethically, the most relevant issues involve confidentiality and avoidance of harm . In good conscience, can you trust your client to keep themselves safe? Confidentiality may be a hallowed principle in our field, but safety must outweigh privacy during crisis.
Have a conversation with your supervisor about reporting procedures for your site. If your client discloses suicidality, you need to know the proper protocol for ensuring their safety (and the safety of the practice). Also, consult your sites handbook for any documentation for suicidality. If your site does not currently have documented procedures, offer your support in adding them to the handbook.
2. Know How to Ask
Always remember to ask each of your clients about suicidality.
Even that sweet old fellow who reminds you of grandad, or the 11 year old girl who presents with mild anxiety about cooties. Asking about suicidal thoughts can feel awkward at first, but your comfort will increase with practice.
The experience of suicidality is commonly broken down into three parts: ideation, intent, and plan.
Suicidal ideation, or SI, includes the thoughts and feelings about dying, ending ones life, etc. One of my mentors at George Fox University said that most of us have thoughts about suicide at times, but stress is what pushes people to the next level. The next level, in many ways, is intent.
Intent includes the desire or motivation to carry through with suicidal thoughts. A client may have frequent or intense ideation with little-to-no intent because of protective factors (more on that later).
A plan includes the ideas for how one might carry out suicide. Clients who deny having a plan may not have strong intent or ideation (or, they may be attempting to hide suicidality).
When I ask about suicidality, I follow this structure:
For ideation, ask Are you having any thoughts of suicide or self-harm?
For the how questions, I also recommend using the 0-10 scale. For example, I might say how often do you have these thoughts on a scale of 0-10, where 0 is not at all and 10 is constantly or 24/7.
Another important factor to note is how quickly these ratings might change throughout the day on a regular basis. For example, one client with suicidal thoughts might go from 2 to 10 in just a few moments when presented with certain stressors; whereas, other clients may generally have a much slower incline. For patients who have more time, there is more opportunity to notice the change and engage in safety planning activities, thus increasing protective factors and decreasing risk.
After you have asked these questions, you can often have a much better understanding of your clients current level of suicidality.
3. Know About Suicide vs. Self-Harm
An important distinction to make when assessing for suicidality involves differentiating suicide from self-harm, sometimes referred to in literature as non-suicidal self-injury or NSSI.
Suicidality and self-harm fall under a broad definition of self-directed . As a therapist, recognizing the difference between suicidal and non-suicidal self-directed violence is important.
Some clients may be thinking about hurting themselves, but they may not necessarily want to die. Suicidality may include elements of self-harm with the additional goal of death (e.g. desire to cut wrists with intent to bleed out, or practicing self-harm behaviors to gain confidence in and progression toward suicidal acts).
The prevalence of emergency department visits appears to be higher for self-harm than for suicidality . For many, self-harm is a coping mechanism for stress and emotional pain. Intervention tailored specifically for those behaviors may be more appropriate than those intended for suicidality.
Behaviors that may be considered self-harm (rather than suicidal behaviors) might include:
Although your client endorses self-harm, do not rule out suicidality. The emotional pain that motivates clients to self-harm may also promote their desire to kill themselves when stressed or if left untreated.
4. Know About Protective and Risk Factors
In addition to identifying the presence of suicidality and self-harm, you can estimate the relative risk of your client based on research.
The current literature is rich with correlations, predictive factors, and mortality rates, many of which can be very specific. For example, da Silva et al  found that people with Bipolar disorder who had good insight were less likely to commit suicide than those with poor insight. I highly recommend taking time to research your clinical population to better identify what factors put someone at your site at-risk, as this can provide you with a much more refined sense in your work.
In general, a few risk factors have been identified that most directly relate to suicidality. Fremouw, Tyner, Strunk, and Mustek  developed the Suicidal Adult Assessment Protocol (SAAP) which nicely lumped together many of the main factors we look for in suicide risk assessment. These factors are included below in no specific order.
Some of the moderate-high risk factors include:
Although people may have some of these factors, the risk may be decreased by protective factors, such as:
5. Know About Your Resources
The first time I did a risk assessment, I felt really alone. How was I, a meager psych intern, supposed to keep this person safe?
Luckily, psychologists and counselors only represent one piece of the continuum of care for at-risk clients. Lets talk about what resources will be available for you and your client.
Hospital Emergency Department
If you believe your client may be at-risk, sending them to be evaluated at the Emergency Department (ED) is one option for getting them into more intensive care. Many major hospitals have behaviorists on-site (or on-call) who are trained in suicide risk assessment, and they can help with the process of stabilizing the client and coordinating care. Local law enforcement can provide transportation from your site to take the client to the ED if necessary.
Keep in mind that the Emergency Department setting is a fast-paced environment that may not feel highly supportive to a person in the midst of psychiatric crisis. But, it is a safer place for them to be than at home, alone, and contemplating suicide as a viable option. Many clients may need to have an opportunity to process their experience of visiting the Emergency Room with a therapist after the visit.
Acute Inpatient (Psychiatric) Hospitalization
Inpatient care is considered to be top-tier treatment for high-risk suicidality, including stabilization, intervention, medication management, and social work services. In order to qualify for this level of care, a client must fulfill your states requirements for voluntary/involuntary commitment. In Oregon, the basic criteria includes an imminent risk of harm to self/others or an inability to care for self (ORS § 426.005). These criteria may differ from state to state.
Subacute facilities, as the name implies, typically offer similar services for clients who do not fully meet criteria for inpatient care. For example, your client may be at-risk yet also has good insight and is able to self-manage without the intensive support of around-the-clock psychiatric services and observation.
Respite care facilities are ideal for clients whose suicidality is brought on by at-home stressors (or similar) and need time away for a brief period. Many respite care facilities can assist with things such as medication compliance and regular check-ins. The criteria for respite care differ dramatically from site to site, so I recommend having a call list of available services in case your client is not an appropriate fit.
Many local services can offer basic necessities for clients, such as food and shelter. Additionally, some services offer employment assistance, counseling, or family support. Similar to respite care, these services can be quite diverse depending on your area, and many local services are population specific (i.e. womens centers, LGBTQ support, Christian-based, etc.).
If you are seeing this client for therapy, you have likely built a relationship that will keep them coming back for treatment. Empathize with your clients pain, clearly communicate your understanding and desire to keep them safe, and incorporate evidence-based practices for self-harm and suicide in your work together.
6. Know What to Do
After you have identified the presence of suicidality/self-harm and calculated some of the risk, you can feel more confident about taking the next step in treatment. So, what is the next step?
First, calculate your clients safety risk.
If your client endorses suicidality and is at-risk:
1. Dont panic! Remember that this is relatively common and many clients experience this. Also consider what you are communicating to your client through your response. Staying calm can help them to know that you are okay, they are okay, and together you can handle the situation.
2. If you are a student/intern, contact your supervisor and notify them of your clients disclosure. After all, you are practicing under their license and therefore they will make the final call. If you are licensed, get consultation if necessary.
3. Depending on your setting, you will likely ha
ve a policy for working with clients who are suicidal. Make sure you are familiar with the organizational/administrative policies before beginning client work.
4. Clients who are at an imminent risk of harm to self (whether by suicide or inability to care for self) are often good candidates for hospitalization and inpatient care. This process may require that the client is assessed in the emergency room in order to get a referral.
5. Create a safety plan (Adult Safety Plan, Youth Safety Plan) that includes recognizing warning signs that they may be at risk of harming themselves, ways to distract themselves, people to call, crisis hotline numbers, and a referral to be assessed and/or enter inpatient care as needed. If possible, include family members or friends (with the clients permission) in the plan. Additionally, removing access to means of suicide needs to be included in the plan.
6.If the client is unwilling or unable to commit to a safety plan or enter treatment, discuss their reasons and, if necessary, alert local law enforcement to escort the client to your referral.
7. Make sure to document well and clearly articulate any reasons for referral and reasons for choosing your course of action. For example, Client endorsed occasional thoughts of death but denied intent or plan to harm self. Client agreed to safety plan and a follow-up therapy visit was scheduled in one week.
8. If a client is seeing you for therapy as part of their treatment plan, be sure to continue the discussion. Ask the client to rate their current level of suicidal ideation. Find out how it changed or stayed the same since the last visit. Revisit the safety plan and discuss what worked or what didnt and revise if necessary.
If your client endorses low levels of suicidality:
1.If you are a student/intern, discuss the clients disclosure with your supervisor. If you are licensed, get consultation as needed.
2.Collaborate with the client and create a safety plan if necessary. In other words, develop a plan for how the client may cope when they feel stressed. Part of your plan will likely include continuation of therapy.
3.If possible, connect your client with additional supports in the area.
4.Provide them with local crisis numbers (for example, Oregon has county-based crisis hotlines - Curry County's is 877-519-9322) for them to use if their suicidality increases. They should also be aware of the National Crisis Text Line (text "SOS" to 741741) since many, especially youth, prefer texting versus talking.)
5.Make sure to document well and clearly articulate the clients risk as well as any protective factors, or reasons for living, the client can identify.
If your client denies suicidality:
1. Communicate to them that you want therapy to be a space where they can discuss those kinds of thoughts/feelings whenever they come up.
2. Provide them with resources, including local crisis numbers and community supports if needed.
3. Document that the client denied suicidality and include any protective factors they might have.
Suicidality is very common, and also very taboo. Make sure to create a space for your clients where they can talk about suicidal thoughts while knowing that you will be there for them.
You have the ability to help your client regain their health, sense of purpose, and life.
Yet suicidality affects us as well and as compassionate, empathically attuned beings we tend to soak up those intense feelings of distress and hopelessness. Use your self-care support network, discuss it in supervision, and talk to your therapist.
You can do this, but you dont have to do it alone.
**A big thanks to Dr. Luann Foster of George Fox University, one of my fabulous supervisors in my work in suicide risk assessment, for her training, mentorship, and contribution to this article.
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Control and Prevention. (2014). National Suicide Statistics.
Bakst, S. S., Braun, T., Zucker, I., Amitai, Z., & Shohat, T.
(2016). The accuracy of suicide statistics: are true suicide deaths
misclassified?. Social Psychiatry and Psychiatric Epidemiology,
51(1), 115-123. Jurecska, D. E., Tuerck, M.
(2009) National Register Graduate Student Corner: Training
Psychologists asConsultants to Hospital Emergency Departments.
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Meyer, R. E., Salzman, C., Youngstrom, E. A., Clayton, P. J.,
Goodwin, F. K., Mann, J. J.,
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concerns, and a necessary target for drug development: a consensus
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da Silva, R. D. A., Mograbi, D. C., Bifano, J., Santana, C. M., &
Cheniaux, E. (2016). Correlation Between Insight Level and Suicidal
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1-7. Fremouw, W., Tyner, E., Strunk, J.,
& Mustek, R. (2005). Suicidal Adult Assessment
ProtocolSAAP. Washington, DC: American Psychological
The Use of No-Suicide
Suicide prevention experts discourage the use of no-suicide contracts. With a no-suicide contract, the client signs an agreement promising not to do anything to harm or kill himself or herself within a specified period of time. The contract may also require the client to take some specified action if they want to act on suicidal thoughts, usually going to an emergency room or calling 911.
The no-suicide contract has quite a few disadvantages that can harm the therapy and the client:
If suicide really could be prevented with a simple contract or agreement, then suicidal people would never need our help. A person stricken with intense suicidal thoughts would, by virtue of the no-suicide contract, call on their strengths, resources, and self-control to manage their impulses and stay safe on their own. The task of therapy is to help build those assets, not to presume that they already exist.
For these reasons, I teach my social work students not to use no-suicide contracts. The more helpful alternative is safety planning.
A safety plan, created in collaboration with the client, provides steps the client can take to stay safe. Gregory Brown, PhD, and Barbara Stanley, PhD, described the various components of their safety plan intervention here. Their safety plan centers on clients doing the following:
I may write more about safety planning , but in the meantime, see this site: www.psychologytoday.com/blog/promoting-hope-preventing-suicide/201209/safety-planning-suicide-prevention-in-the-emergency-de
This site contains a blank safety planning form that you can fill out with clients:
Adult Safety Plan
Youth Safety Plan
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.
Lauras 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
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
Suicide Prevention Lifeline:
1-800-273-8255 or the Crisis
Text Line: Text "SOS" to
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. Its 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 arent 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 childs 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?
Its 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 dont 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 theres 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.
Editor: I often hear the statement "Men kill themselves at four times the rate of women because they use more lethal means". The real question here is not that they use more lethal means, it's why they use more lethal means.
Where's the discussion that it based in cultural training? Starting with "Big boys don't cry", the discouragement, very intense in sports, deride a man who shows feelings (except anger) or vulnerability, or weakness. The constant message: handle it, deal with it, cowboy up and Lord knows, don't be a victim.
The cultural training starts from the day men are born, preparing them for military combat where they may face another man and must be prepared to kill him.
Men use lethal means because, unlike many women who use less lethal means in a cry out for help, men cannot fail. What would it feel like if they end up in the hospital and their buddies come in and say "You can't even do this right."
I've often asked women's group how it would feel to be brought up all your life knowing that someday your country was going to ask you to kill other women? While women do serve in combat units elbow to elbow with men in many countries, it's just beginning to happen in the US Let's see if it changes the dynamics. - Gordon Clay
Clearly much work needs to be done before we
arrive at a reliable picture of whats 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. Thats a lesson we need to take on board in
research, clinical care and prevention efforts alike.
Suicide, Guns, and Public
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 attemptsthe means they useplays a key role in whether they live or die.
Means reduction (reducing a suicidal persons 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 persons 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.
The mission of the Means Matter Campaign is to increase the proportion of suicide prevention groups who promote activities that reduce a suicidal persons 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.
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 youre 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 whats 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.
KEEP THEM SAFE
How First of all, its good for everyone to be on the same page. After the Ask step, and youve determined suicide is indeed being talked about, its 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? Whats 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 arent entirely sure what to do next.
The Harvard T.H. Chan School of Public Health notes that reducing a suicidal persons 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, theyll 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 youll 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 someones connectedness to others and limiting their isolation (both in the short and long-term) has shown to be a protective factor against suicide. Thomas Joiners 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.
HELP THEM CONNECT
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 youve connected them with the immediate support systems they need, make sure to follow-up with them to see how theyre 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 youve said you would do and havent 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
ongoing contact may be
an important part of suicide prevention. Please visit our
Matters page for
As Suicide Problem Grows in Oregon,
Legislators Debate Solutions - Apr 28 2017
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, theyre 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. Theres a reason why Oregons 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. Its a problem thats 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 firstname.lastname@example.org.
Sometimes its way more than a case of the Mondays.
A new survey on mental health suggests that people dont 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 werent 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 wouldnt 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 APAs 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 APAs Center for Organizational Excellence. As much as it shouldnt matter and people should be able to go and talk about these things openly, thats 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 wont 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 Labors Office of Disability Employment Policy, for a free, confidential consultation on workplace accommodations. Arm yourself with your rights if you think its 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, its best to focus on the impact its 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. Youre going to treat it as, Id like to speak with you about this health issue going on in my life, because Ive 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 supervisors 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 Im dealing with and addressing that applies to whether its hypertension, diabetes or depression. Youre 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 theyre 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 youre too anxious to have the talk in the first place, review your main talking points when youre 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. Its 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 theyre openly talking about their mental health problems, then it sends a message to the entire community (that) its 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 its 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
This years 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 nations 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 wouldnt 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 arms 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 theres a chasm between awareness and action for many employers.
Six out of ten [of those currently suffering] arent saying anything to their manager. That means theyre 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, weve 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 managers 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 isnt 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 managers 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 its 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.
This years 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, theres 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.
UK charity Mind: https://www.mind.org.uk/
World Health Organisation: http://www.who.int/mental_health/world-mental-health-day/2017/en/
Mental Health Foundation:
can be prevented
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
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.
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]
The ethics of doing nothing. Suicide-bereavement and research: ethical and methodological considerations. [Psychol Med. 2014]
PMID: 24998511 DOI:
Perspective on Suicide
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 arteven 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 oneaddressed 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 Benjamins death was the result of heart failure, concerned that if the authorities discovered Benjamins death was a suicide it would weaken the entire groups chances of obtaining exit visas.
The standard historical interpretation of Benjamins 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 Benjamins suicide. The next day, this decision was reversed, and the group was allowed to leave for neutral Portugal, and eventually for New York.
Walter Benjamins 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 Benjamins 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 rubblenot 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
Benjamins 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. en.wikipedia.org/wiki/Theses_on_the_Philosophy_of_History. Accessed June 18, 2018.
3. Benjamin W. The Destructive Character. www.revistapunkto.com/2011/12/destructive-character-walter-benjamin.html. Accessed June 19, 2018.
6. Camus A.
The Myth of Sisyphus. Trans. Justin OBrien. New York:
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. Ive 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 Im 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 nights 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.
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 suicides 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.
"I've noticed you've been down lately.
What's going on?"
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
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 its so hard to talk about in the first place. Heres their advice:
Seeking professional help is OK ? even if it doesnt 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.
Caos 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 arent 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 youre 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 youre 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.
Its 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 persons 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 arent mutually exclusive.
One of the main reasons mental health usually isnt 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 familys 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 youll 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 doesnt 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."
Choice and Intent
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, OShanick 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.
'Like a busy
emergency room': Calls to suicide crisis centers have
doubled since 2014
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 Lifelines 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 arent physically here with us," Zimmermann said. "Its 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 numbers 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 dont roll over to the next call center," Carpenter said. "We want people in our state to be able to talk to someone whos 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 Ive ever done, and Im 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 shes 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.
Its important for people to understand that were not here to get you into trouble or send the police. Were here to provide that listening and that support so that you dont 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: www.usatoday.com/story/news/2018/07/18/suicide-hotlines-uptick-calls-suicide-rates-rise/698556002/
'Silence can be
deadly': 46 officers were fatally shot last year. More than
triple that 140 committed suicide.
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.
Its really shocking, and part of whats interesting is that line-of-duty deaths are covered so widely by the press but suicides are not, and its because of the level of secrecy around these deaths, which really shows the stigmas, Heyman said.
She said departments dont release information about suicides, and less than 5% have suicide-prevention programs. Its 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 isnt just in silence, the study outlines. Families want to hide the reasoning behind the death of a loved one. Officers feel theyll be looked down on or taken off the job if they speak up about depression. Dying by suicide means they arent 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.
Heres the reality, though: Police and firefighters witness death and destruction daily, Heyman said. It would be silly to think it wouldnt put a toll on them.
She said when first responders are affected and dont 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
That is about to change. In California, one of the nations 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 states 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 dont do, what we dont say is, whats 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 doesnt 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 states 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 Walkers 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 doesnt do, however, is require the tracking of police suicides. James Pasco, the executive director of the Fraternal Order of Police, the nations largest police union, says union officials met with the bills 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 years 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.
Stocktons 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
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 Americas 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.
Theres 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 whove 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 Carolinas 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 dont 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. Theres fear of what it will do to them on the job if they open up. They worry, Whos going to know? Will it cost me a promotion?
Dwyer, a former agent with the Naval Criminal Investigative Service (NCIS), said the militarys 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: Were super people and we cant be weak. Were 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 theyre human.
Between 7 and 19 percent of Americas cops suffer from post-traumatic stress disorder, although those numbers may be low because police dont 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 Violantis 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 Violantis research.
Its 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. Its 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 hed 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 didnt 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 wont hear about what is said in the sessions.
Its gut-wrenching, said Watkins. Theres 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 dont even realize it, Watkins said.
Then they participate in a technique to ease symptoms of trauma called Eye Movement Desensitization and Reprocessing (EMDR). Its an internationally known mode of treatment that combines talk therapy with rapid eye movement like you experience in deep sleep.
People dealing with trauma cant get the images of the violence theyve seen out of their minds. Its 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, its a 20-inch black-and-white in the corner somewhere.
Karen Lansing, whos 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 its 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.
Its a clinically controlled flashback, she said. Were 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.
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He did not really attempt suicide. It was just a cry for help.
If she had really wanted to die, shed 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 peoples 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.
Inevitable for Some People?
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 articles 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 areasmental 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. Sadocks 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 persons suicide was inevitable:
I remember a psychiatrist, whose patient had recently committed suicide, saying You cant 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 Persons 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 persons 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 peoples 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 clinicians control. This fact does not mean that any one specific persons 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 persons 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 clinicians 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 Cant 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 peoples 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 peoples suicides were inevitable. To say that any one persons 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.
Cant Do Everything: Limitations in Helping a
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 (Im sure Im not the first):
Do everything you can, but know you cant 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 persons 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
from alcohol, drugs and suicide hit highest level since
The national rate for deaths from alcohol, drugs and suicide rose from 43.9 to 46.6 deaths per 100,000 people in 2017, a 6 percent increase, the Trust for America's Health and the Well Being Trust reported Tuesday. That was a slower increase than in the previous two years, but it was greater than the 4 percent average annual increase since 1999.
Deaths from suicides rose from 13.9 to 14.5 deaths per 100,000, a 4 percent increase. That was double the average annual pace over the previous decade.
Suicide by suffocation increased 42 percent from 2008 to 2017. Suicide by firearm increased 22 percent in that time.
Psychologist Benjamin Miller, chief strategy officer of the Well Being Trust, says broader efforts are needed to address the underlying causes of alcohol and drug use and suicide.
"It's almost a joke how simple we're trying to make these issues," he says. "We're not changing direction, and it's getting worse."
The health and well-being trusts propose approaches including:
While overdose antidotes and treatment for opioid use disorder are needed, Miller says, "it's not going to fix" the underlying problems that lead people to end their lives, whether or not it's intentional.
In most states, deaths from alcohol, drugs and suicides increased in 2017. In five Massachusetts, Oklahoma, Rhode Island, Utah and Wyoming those deaths fell.
Deaths from synthetic opioids, including the narcotic pain reliever fentanyl, rose 45 percent. Such deaths have increased tenfold in the past five years.
Loribeth Bowman Stein says the lack of social connection fuels hopelessness: "We dont really see each other anymore."
"We dont share our hopes and joys in the same way, and we arent as available to one another, physically and emotionally, as we need to be," says Stein, of Milford, Connecticut. "The world got smaller, but lonelier."
LoriBeth Bowman Stein of Milford, Conn. says people aren't connected as much as they used to be.
Miller agrees. When people feel a "lack of belonging," he says, "they seek meaning in other places."
That can lead them to withdraw into addiction. The new report emphasizes what should be done differently.
Kimberly McDonald is a licensed clinical social worker who has worked in a hospital, for county government and in private practice. She lost her father to suicide in 2010.
"We are a society that criticizes and lacks compassion, integrity, and empathy," the Richmond, Wisconsin, woman says. "I work daily with individuals who each have their own demons."
McDonald's father took his own life after diagnoses of Lewy body dementia and Parkinsons disease.
"He knew the trajectory of where the disease would take him," she says.
John Auerbach, the former Massachusetts state health secretary who heads Trust for America's Health, says the country needs to better understand and address what drives "these devastating deaths of despair.
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For every person who dies by suicide, 280 people think seriously about it but dont act, according to the National Suicide Prevention Lifeline.
There's not one answer to what makes someone move from thinking about suicide to planning or attempting it, but experts say feeling connected to other people can help.
"Reaching out ... can save a life," said Jill Harkavy-Friedman, a clinical psychologist and vice president of research at the American Foundation for Suicide Prevention. "Everybody can play a role.
Tip 1. If someone seems different, don't ignore it
The most important thing you can do is look for a change in someone's behavior that suggests they are struggling, said April Foreman, a licensed psychologist who serves on the American Association of Suicidology's board of directors. It could look like a friend who would always pick up your calls but now seems to be avoiding you. Or a family member who was an adventurous eater now barely eating or skipping meals.
"Trust your gut," Foreman says. "If youre worried, believe your worry."
Foreman notes changes in behavior are some of the most telling indicators, but it's also important to look for specific warning signs:
Tip 2. Don't be afraid to ask. Then act
The most important thing you can do if you think someone may be suicidal is to ask. It may be hard, but it works. Don't buy into the disproven idea that there's nothing you can do to help, or that bringing up suicide might do more harm than good.
The National Action Alliance for Suicide Prevention and the National Suicide Prevention Lifeline have identified these five steps to help reduce deaths:
Ask: In a private setting, ask the person you're worried about directly if they're thinking about suicide. Studies have shown that it does not "plant the idea" in someone who is not suicidal but rather reduces risk. It lets the person know you're open to talking, that there's no shame in what the person may be feeling. If a person tells you they're thinking about suicide, actively listen. Don't act shocked. Don't minimize their feelings. Don't debate the value of life itself. Focus on their reasons for living. You could ask questions such as, "What's kept you safe up to this point?" or "What stops you from killing yourself?"
Keep them safe: Determine the extent of the person's suicidal thoughts.
"We want to know, are you thinking about killing yourself? Do you have a plan? What were you thinking of doing? Do you have the materials to do that? Have you gathered those things? Where are they? What could I do to help you stay around until this passes?" Harkavy-Freidman said.
If a person does have a plan, it's important to take action to remove the lethal means. (Guns were used in 23,000 of the 45,000 deaths by suicide in 2016, according to the Centers for Disease Control and Prevention.)
Be there: If someone tells you they're thinking about suicide, continue to support them. Ask them to coffee. Give them a call. Some people will eventually stop having suicidal thoughts and feelings, others will continue to struggle throughout their lives.
Deena Nyer Mendlowitz, 40, of Cleveland, is a suicide attempt survivor who has had chronic thoughts of suicide since she was 8. Mendlowitz said one of the moments she felt most supported was when she was going through electroconvulsive therapy and a friend brought her a meal.
"I just felt like I had a regular disease at that point, because they were doing an action they would have done for a friend who was going through anything else," she said. "And I thought, somebody cares about me in the regular way they care about people."
Help them connect: Encourage them to seek additional support. That could mean calling the Suicide Lifeline (800-273-8255), suggesting they see a mental health professional or helping them connect with a support group.
Jennifer Sullivan, a 21-year-old college student at Worcester State University in Massachusetts, struggled with suicidal ideation as an adolescent. It grew worse after she was raped twice, she said. Joining a sexual assault support group made her feel less alone.
"I met a fantastic group of young ladies," she said. "One became one of my best friends. When I had feelings of wanting to die or cut, I would tell her I was having a bad day."
Follow up: Keep checking in. Call them, text them. Ask if there's anything more you can do to help.
Tip 3. Pay special attention when someone is going through a difficult time
You can check in on people based on what you know about them, said John Draper, director of the National Suicide Prevention Lifeline.
"All those warning signs that weve listed for what makes a person look suicidal are fairly generic and hard for us to be able to spot unless youre a diagnostician," Draper said. "However, you know when a person is having relationship problems or going through a divorce you know when somebody has serious financial loss. ... These are very human recognizable signs that people could be needing help."
While experts caution that suicide is never the result of a single cause (bullying, a breakup, job loss), when those events are combined with other health, social and environmental factors they can heighten risk.
Tip 4. If someone makes an attempt and survives, continue to be there
One of the risk factors for suicide is a prior attempt. Studies show that suicide survivors often experience discrimination and shame and may struggle to talk about their feelings because they are worried people will judge or avoid them.
"When I started publicly speaking about my experience ... people would treat me differently," said Chief Warrant Officer Cliff Bauman, a suicide survivor in the Army National Guard. "Somebody, if he was my friend and we laughed and joked the day before, now suddenly doesnt know how to approach and talk to me."
If someone you know is a suicide survivor, the Suicide Lifeline says:
Tip 5. You dont need to have all the answers
It's important to encourage someone who is having suicidal thoughts to call the Lifeline (800-273-8255), find a support group or reach out to a therapist, particularly one who specializes in evidence-based suicide prevention techniques such as Dialectical Behavior Therapy and Cognitive Behavior Therapy for Suicide Prevention.
Resources to get help
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) any time of day or night or chat online.
Crisis Text Line provides free, 24/7, confidential support via text message to people in crisis when they dial 741741 and text "SOS"
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/Veterans 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 1-800-73-8255 and press 1 of text to 838255
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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 deceaseds 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 friends 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 friends 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 wellbeing 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 ones 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.
I am a 78-year-old retiree, living in Australia. I notice that there have recently been a few articles about the contentious subject of suicide in Psychiatric Times. My first wife died from suicide about 40 years ago, and my second wife died 3 years ago after a short illness.
Some people do commit suicide, and this has surely happened since humans first walked the earth. This is not a treatise on the causes or possible reasons for suicide, but the complexities behind the act have puzzled me for many years. In particular our seeming abhorrence and our obvious dismay, regret, and great sadness that anyone should even contemplate the need to end their life, by whatever means has taxed my understanding and the meaning of my life.
What follows below is my considered opinion.
I ask the questionwhy is suicide considered such a bad thing? Now I am not advocating that anyone should commit suicide. I am just trying to pick apart the emotional clutter that accompanies this very personal and private act. The only answers I get are that it is a waste of a (usually) young persons life; that they were loved; that they had unlimited potential, now never to be realized; that they had a future to live for . . . etc, etc.
This is partially correct but is not a real answer. The person concernedthe person now deceasedobviously had a different view of life. I am not discussing his or her viewI have no idea what that was. I am discussing our viewthat of the outsiderthe ones left behind.
Why are we outsiders (I deliberately use this word because we are outside that persons inner world) affronted because someone considers livingin their current situationto be so bad, so threatening, so limiting as to be not worthwhile continuing? Are we discomforted because this rejection, this dismissal of all we have striven for (in our world), may reflect poorly on us, those left behind, regarding the way we have organized the world? Are we disturbed by the confronting prospect of having to admit that we make mistakes and that the way in which the economy, our legal, welfare, and education systems are set up may actually cause distress, that we are not always fair or just in our dealings? Do we feel guilty that we have developed a financial system that promotes the massive imbalance between the very wealthy and the very poor and the disadvantaged?
We have to recognize that we are all, all, party to the ills of the world. We created them. If we look with even a modicum of insight, we should see in ourselves the cause of these shortcomings and see ourselves reflected in the eyes of the distressed. And we should be dismayed.
Is this why we consider suicide a bad thing and are so shocked when it occurs?
It is needful to remember that we, each one of us, have our own experiences of life. These are our own. No one can see the world through our eyes with the same imagery and emotional response. No one can see the world through our eyes with our life experiences and our interpretations of those experiencesthese are our own.
So, I ask the question againwhy is suicide considered such a bad thing? Obviously for the person concerned the prospect of death is more alluring than continuing living as currently experienced. What is wrong with that? It is their choice.
Then, for some to say that only God can decide when or where a person dies is surely a gross over assumptionhow do they know? What special insight do they possess? Is it not possible, because (I assume) God gave us free will that God may have already decided to allow a person who wants to die, to die?
Furthermore, to declare (as some authority figures do) that most people who commit suicide suffer from a mental illness or disorder is surely wrong. It is also highly presumptuous on the part of the person making such a declarationhow do they ACTUALLY know! This is categorizing a person, who now has no recourse or ability to refute the presumption. This is putting a label on someone. And what about those outsiders left behind to live with the eventthe family and friends?
Are they to be made to suffer further pain with the stigma provided by so called experts who provide the knowledge that their son, daughter, friend, brother, sister must have been mentally deranged to have committed such an act. This implies that no normal person would ever do such a thing! What about self-sacrifice when there is loss of life? Isnt this an act of suicide? But if it saves the life of others it is considered noble! (There is no greater love than this, that a man should lay down his life for his friends, English King James Bible: John 15:13).
Research on completed suicides is notoriously difficult. It is always referring to an historic actsomething that has already happened. Police, the coroners, autopsy, psychiatric and psychological, and counselling reports are analyzed and carefully combed through to try and establish some reason or motive for the suicide. This is fraught as it is impossible to know what was actually going through a persons mind at the precise moment they took their own life. At that moment they made a choice. Why? We can never know.
Shall we now look at what suicide actually is? Someone taking his or her own liferight? It seems that the act is only considered suicide if it results in the quick death of the person concerned. But what about those who commit suicide in the long term? Those who drink or drug themselves to death over a number of years, what about them? They may suffer from abuse, or from unbearable pressures associated with their domestic arrangements or at work. They may determine that the easiest and most socially acceptable way of easing this pressure or pain, is to get drunk or to get stoned on a regular basis. It may take some time but in possibly 5 or 10 years they will be dead. The emotional (and economic) cost of this (long-term suicide) far exceeds that of any number of quick suicides.
To get back to the mental illness or disorder accusation. Disordered from what? What are these people supposed to be disordered from? From normal? As far as I can discover, there is no accepted definition of normal. Possibly those considered disordered react to lifes trials and tribulations differently from those around them. Are they wrong? Or are we outsiders just being intolerant and lacking in understanding or compassion? Maybe these people are just eccentricGod knows there are enough odd-ball people in the community! Some behavior may be considered maladaptive or possibly antisocial by outsiders but not by the people concernedotherwise they wouldnt act the way they do!
Similarly, why should anyone live according to anothers expectations?
The Scottish philosopher David Hume (1711-1776) wrote the essay, Suicide, wherein he said, I believe that no man ever threw away Life while it was worth keeping.
What follows is a warning relating to antidepressant drugs, with which you will be familiar:
US FOOD AND Drug Administration Product Information Warning
Patients with major depressive disorder, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality), whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Although there has been a long-standing concern that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients, a causal role for antidepressants in inducing such behaviors has not been established. Nevertheless, patients being treated with antidepressants should be observed closely for clinical worsening and suicidality, especially at the beginning of a course of drug therapy, or at the time of dose changes, either increases or decreases.
Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse or whose emergent suicidality is severe, abrupt in onset, or was not part of the patients presenting symptoms.
From the above it is apparent that psychopharmaceutical medications are not always the answer! Finally, I give you a quote from the Indian sage Jiddu Krishnamurti (1895-1986), who said, It is no measure of health to be well adjusted to a profoundly sick society.
There we have itin a nutshell!
From the Editor:
As anticipated, the commentary The Complexities Behind the Act of Suicide by Andrew Campbell-Watt in the March 2019 issues of Psychiatric Times generated a wide range of feedback. Our intent in publishing this commentary was to give voice to the author, a 78-year-old man who has reflected on the suicide of his first wife for over 40 yearsa person deeply affected by a suicide who was compelled to share his personal perspective after deliberating on the meaning of suicide for decades after the loss of his wife. As clinical psychiatrists, understanding how individuals grieve, process, and in some cases make peace with the suicide of a loved one can only serve to enhance our own empathy for our patients and any person whose life has been impacted by suicide.
Many factors can shape a persons understanding of the reasons, experiences, and circumstances that ultimately converge on an individuals decision to take their own life. As Mr. Campbell-Watt states, often we will never know the personal deliberations that occurred in the moments before a completed suicide. As psychiatrists, it is our ethical and professional duty to intervene to prevent a person from suicidal actions. Often, days, weeks or months after our intervention to prevent a suicide the person involved is grateful for our intervention, especially when the circumstances, experiences, symptoms or substance abuse issues have been thoughtfully addressed and that great healer time has enacted its gift. However, this is not always the case, and a subset of individuals will continue to attempt suicide until they succeed.
Suicide is, indeed, a complex act. We encourage a healthy and respectful discussion on the many facets of suicide, some of which may invite us to explore beyond our personal beliefs and opinions. We will post follow-up letters to the editor to encourage this discussion and exploration.
John J. Miller, MD Editor in Chief, Psychiatric Times
From Our Readers: Nancy B. Graham, MD
The commentary in the March, 2019 issue on suicide written by Andrew Campbell-Watt was profoundly disturbing to me as a psychiatrist. I do not know what professional or educational credentials Mr. Campbell-Watt possesses to qualify his writing knowledgeably on this topic in this newspaper. Obviously, much of our psychiatric work is devoted to deciding when people might be a danger to themselves and to try to prevent their suicides.
He asks why suicide is such a bad thing. There are many reasonable answers to that question, but I suspect he would accept few of them.
First, suicide has been considered an evil, selfish act throughout thousands of years in all Judeo-Christian cultures. Only in so-called pagan cultures (e.g. the Greeks, the Romans, the Japanese samurai society) would suicide be an acceptable or even noble act.
Next follows the reality that practicing psychiatrists have all seen suicidal patients stop wanting to die when their mental illness was treated or their social or emotional or physical needs were met. Many of our patients, after nearly dying from a suicide attempt, no longer have any wish to die. In fact, people who survived leaps off the Golden Gate Bridge have usually said they regretted their decision to die on the way down. The wish to die is generally a transient wish linked to certain changing circumstances.
Third, Mr. Campbell-Watt does not consider the traumatic and permanently lifealtering effect of suicide on the family and friends of the deceased. This act is never a solitary affair and grieving people are forever left with unanswered questions, never fully quenched pain, and a great hollow inside. Most patients who have tried to kill themselves have told me they werent thinking of their loved ones when they acted, because their pain was so great. Is that not then, though understandable, a profoundly selfish act? The rate of suicide, by the way, is greatly increased in the children of parents who killed themselves. What a wonderful legacy to give your kids!
He also conflates suicide and dying to save another life. Suicide is performed only to end ones lifethat is the purpose and method of escape. Sacrificing ones life for another is NOT suicide. The person dying does not do the act to die but to save life. How different are the motivations though each person dies!
In the end suicide is exactly what the word means murder of self. Murderjust contemplate that word. How much better is the suffering person trying to murder himself than the one who murders another? He is taking a life he never gave himself and slaughtering that life, admittedly out of pain. But there is help for pain. Pain is a momentary thing, even if it lasts some years. All pain comes to an end naturally in time. If the sufferer endures the pain, he may be restored to health, partially or fully. As long as he lives, there is hope, yet suicide takes away hope. Even those who, as Mr. Campbell-Watt, puts it, commit long-term suicide by abusing their bodies still have the opportunity to change for the better and live a full life. Again, drug abuse or other destructive habits are not an active attempt to kill oneself but to feel better.
The commentarys author does not mention that slippery ethical slope at the top of voluntary, adult suicide to the mud-slicked bottom of involuntary killing of various people. Its not so far from there to helping the elderly, the chronically sick, the handicapped, the deformed, and the unwanted on to their reward. Ask the Netherlands how involuntary euthanasia is working out for them after they allowed voluntary suicide. Read about the patients who pin notes on their chests saying, Do not kill me when they go in the hospital. Follow the news stories about the babies and children whose parents decide they should die because of their poor health. Once it seems expedient for some people to move on, it is much easier to see how others should, too.
Finally he asks why anyone should live according to anothers expectations. Killing oneself is not living at all and has nothing to do with others expectations. Incidentally we all live according to some social expectations, and those who dont end up in prison or dead; society dictates that we shall not rob others, we shall not rape others, we shall not kill others, we shall not abuse others. Those are very good rules. Total personal autonomy is not only antisocial and harmfulit is impossible.
Sincerely, Nancy B. Graham, MD Richmond, KY
From Our Readers: Alicia Vaughn
Dear Mr. Campbell-Watt,
I read your piece in Psychiatric Times with great interest. Many of the questions you raise have puzzled me, too. While I did find some of your ideas disturbing, Dr. Nancy Grahams letter was equally troublesome, to me. Respectfully, may I suggest to both of you that Is suicide such a bad thing? is the wrong question? Is it wrong, evil, and selfish? only compounds the problem and obfuscates the way forward.
As someone who has lived with suicidal thoughts for much of my life, these questions have worked against my efforts to remain alive. Guilt and shameand their unholy offspring, stigmaencouraged my parents to keep secret my first suicide attempts just as strong religious traditions in my part of the country continue to fuel the difficulties I face in managing my mental health issues.
You ask many questions about suicide but curiously, you leave the one area that would seem of most interest to readers of Psychiatric Times unexplored. Where I live, firearms, drugs and other means by which I could commit suicide are readily available. As long as I dont disclose my intentions to anyone, ending my life is a relatively straightforward endeavor. Its when I decide to try to stay alive, and begin to navigate the American health care systema process euphemistically referred to as getting helpthat complexities arise.
Perhaps its different, where you live, but the central issue in the United States is that if I commit suicide while in the care of a mental health professional, that person can be held liable for my death, a fact of which Im sure not a single Psychiatric Times reader is unaware. Its no surprise to me that among clinicians who assume those risks are countless outsiders who are decidedly affronted by the idea of suicide.
This peculiar dilemma and its infuriating collection of resultant complexities have shaped the psychiatric care available to me more than anything having to do with the complexities behind the act of suicide itself, or even my own needs, as a person experiencing suicidal thoughts.
Please picture this...Im at a psychiatric clinic, sitting across from a caring, well-trained and experienced outpatient provider. The moment I utter the s word, all efforts to see my circumstances [and] symptoms... thoughtfully addressed as Dr. Miller describes, are immediately suspended to allow for thorough risk assessment. From this point forward, my relationship with my doctor will split its focus between the treatment of my symptoms and the management of the threat I pose to his or her livelihood. Every decision he or she makes now must balance what might be best for me against what can be defended in court.
So there we are, this doctor and I, in the same room, with the same goal: keep me from dying by suicide. To effect that outcome, what does this clinician really have to offer me?
He or she can try to alleviate the symptoms of my depression, but that may or may not affect my suicidal thoughts. What about drugs specifically developed to reduce the likelihood of suicide? There are none. What about this doctors specialized training in treating suicidal clients? Theres very little to be had, Im told. Does he or she have access to a knowledge base of relevant research? What research is currently underway, I wonder, apart from that aimed at improving risk assessment so as to better indemnify those individuals who care for patients likely to succumb to suicide?
As far as I can tell, my outpatient provider has little choice but to rely on assumption, anecdote and personal experience in place of evidence-based medicine. The bewildering statements Dr. Graham offers throughout her letter: the wish to die is generally a transient wish... pain is a momentary thing... killing oneself has nothing to do with others expectations... evince the familiar dismissive, accusatory approach favored by the majority of my 28 years worth of health care providers.
While Dr. Grahams truisms might not be true, they do make suicide is wrong easier to accept. Rolling them out again and again also makes it easier to convince me that attempting suicide means Im petulant, short-sighted and selfish. Those three in turn justify the ever-present implication that a doctors duty includes the application of additional guilt and shamemaybe even a little intimidationbecause the standard of care requires I be made to understand that suicide is wrong, lest attempts to investigate my motivations, validate my feelings or accept that ultimately, my personal autonomy in this context is absolute might be mistaken for approbation. To trade condemnation for productive efforts at meaningful change might accidentally reward me, the wrongdoer.
What Im getting at is that getting help often proves far from helpful. The Is it so bad? / Is it wrong? debate devalues the humility required to ask the questions that need asking, and the courage required to answer them with enough honesty to facilitate actual improvement. Absent that humility, my doctor and I are left in a sadly adversarial situation, full of bullying and empty assurances (even if theyre born of genuine empathy for the worried human being charged with my care) that yes, I feel better now.
While I appreciate Dr. Grahams sincere belief that her patients regret their actions, all she can really know is what they report to her, and if suicide is wrong is in the room, what they say might speak less of their genuine experience than of the guilt and shame engendered by her (hopefully) unspoken but plainly apparent contempt for those who, even admittedly out of pain, attempt to end their lives.
Ive had 28 years to wonder why doctors resort to such negative tactics. I dont know that I ever arrived at an answer, but at some point, that question turned into a different one: What is it reasonable for me to expect from someone who assumes the risk of treating me in return for (I kid you not) $60 per visit? Who in their right mind (pardon the expression) would accept that risk?
Once I arrived at those questions, it upset me less that most outpatient providers wont accept me as a patient, not with my history of medically-serious attempts, multiple hospitalizations and failed medication trials. I understand now that the risk I represent is just too great.
Ive also spent the last 28 years evaluating and re-evaluating the risk my family and I take, every time I seek help. How profoundly will another pointless hospitalization jeopardize our financial future? How likely is it that a doctor on my insurance companys panel will have the training and experience to help me avert a sixth attempt instead of intensifying my feelings of helplessness?
It has been several years since my last serious struggle with suicidal thoughts. These days, I am not involved in any efforts to end my life. Should thoughts of suicide arise in the future, will I try to get help? Not if the resources available to me are the same ones available to me at the present time. The risk that such help will not prove helpful and that the cost will only add to the stressors driving my suicidal thinking is just too great.
I feel a great deal of empathy for you, Mr. Campbell-Watt; I cant help but imagine that you are a lot like my own husbandhurt and confused, with as genuine a desire to understand your wife as my husband has to understand me. My suicide is not yet an historic act, however, and the questions which matter to me do so in an immediate and concrete way.
So I ask you, and Dr. Graham, Dr. Miller, and all Psychiatric Times readers: If its too risky for me to seek treatment, and too risky for psychiatrists to accept me as a patient, is that so bad? Is that wrong?
I think it is.
Sincerely, Alicia Vaughn