November of the Soul: The Enigma of Suicide
For many people, suicide is something they’ve considered at some point in their life. They’re likely to know someone who has died by suicide by the end of their life. More disturbingly, they’ll rarely, if ever, talk about it. November of the Soul: The Enigma of Suicide seeks to unravel the mystery around suicide and to lay out the truth, as we know it, about suicide. From the simple answer that most suicide deaths don’t occur in the fall or winter to more complicated nuances of this human experience, the misperceptions we hold are gently but firmly corrected. (See Review of Suicidology, 2000 for peak suicide deaths occurring in spring.)
Public-Private
Throughout much of written civilization, suicide wasn’t a private affair. At times, it was the only available protest against an unjust system or ruling. With so little voice, some would choose to die so that the injustice could be known. Slowly, over the ages, the reasons for suicide have become less public and more private.
Some suicides were (and still are) economic suicides. In other words, the suicide is brought about because the person believes that they’re better off dead. (See burdensomeness in Thomas Joiner’s Interpersonal Theory of Suicide in Why People Die By Suicide.) Inuit elders would walk away from their tribe into certain death if they felt they could no longer contribute or sensed that the resources of the tribe were strained.
Today, however, suicides are more likely to be motivated by a perceived sense of loss. They result in a cognitive constriction that causes people to believe that their death is worth more than their life. But this operates on a more personal level than the benefit of the tribe. (See Capture.) They may also choose suicide because of the perception that the pain they’re experiencing is unbearable and will somehow last forever. (See Suicide as Psychache.)
The relationship to suicide seems to be one that is a personal loss of hope. Problems are seen as permanent, pervasive, and personal – no matter what the reality is. (See The Hope Circuit and The Psychology of Hope.)
The Great Wall of Stigma
The idea of “us vs. them” is hardwired into us. (See Mistakes Were Made (But Not By Me).) We can’t help jumping to conclusions. We can’t stop breaking the world into in- and out-groups. The result is the basis of stigma. (See Stigma.) We seek out differences to allow us to push people into the out-group. Robin Dunbar, in his work with primates, states that our neocortex size drives the number of stable social relationships that we can have – and, as humans, we’re well above those numbers. (See High Orbit – Respecting Grieving.) This forces us into a state of cognitive overload that we defensively try to avoid.
As a result, we see characteristics of someone that we feel can never apply to us, and we push them into an out-group. Suicide is a sufficiently rare event that they can’t see it in themselves or their family, so they can – they believe – safely create an out-group of suicide attempters and those who have suicide in their family. The problem is that suicide prevalence in the population indicates that roughly 1 in 100 people will die by suicide. In today’s world, where we interact with thousands of people in our lifetimes, we’ll see more than ten families suffer through suicide – and with large families, at least one of those people may be in your family.
Prevalence
We like to think that suicide is a rare event – and it is statistically rare and tragically too common. If we use 14 people per hundred thousand per year of suicide deaths per year as a starting point, we can estimate the number of suicide attempts there are. Some estimate that it’s 20 attempts per death by suicide. That means we’re at 280 per 100,000 or about 1 in 360 people who make an attempt each year.
The prevalence becomes more real when we start to look at the number of people who consider suicide. Some might call this “suicidal thought” or a stronger form, “suicidal ideation.” Studies from Alberta, Canada, decades ago estimated this rate at about 1 in 3 people. More recently, the CDC surveyed US high school students and found 19% had seriously considered suicide, 15% had made a plan, 9% made an attempt, and 3% made an attempt that required medical attention in the preceding year.
High schoolers are not the general population. However, a 19% rate in a single year is strikingly high and an indicator that our estimates about the number of people in the population who consider suicide may be lower than the real rate. (High schoolers have less social pressure to hide their true suicidal thoughts due to lower perceived consequences.)
The message here is that the start of a suicide journey is much more common than any of us would like to believe.
Crazy Correlations
There are so many correlations that are tracked in the suicide space. Some of these correlations are confusing. Consider that many believe the rate of mental illness in suicide deaths is greater than 90%. The problem is that, viewed from the other direction, the percentage of people with serious mental illness who ultimately die by suicide, the rate is less than 5%. Yes, mental illness, and particularly some forms of serious mental illness, are risk factors for suicide – but it’s not a death sentence.
One factor is that it’s estimated more than 20% of Americans have some diagnosable mental illness. Additionally, another 10% of Americans could be said to be suffering from alcohol use disorder. Sometimes, this number is included in mental illness statistics, and sometimes it’s excluded.
As a practical matter, it doesn’t help to know that more than 90% of people who die by suicide have a mental illness if you can’t use that criteria to help you target prevention resources.
Another place where the statistics are hard is that prior sexual abuse is estimated to be 9% to 20% of the total number of the suicides. (See also The Assault on Truth for more about the prevalence of sexual abuse.) Abuse of all kinds is a key societal problem, with nearly half of all abuse victims developing two or more disorders by the age of twenty-one.
It Will Hurt Less to Die
One of the challenges is that cognitive constriction can cause people to believe that suicide will hurt less than what they feel today. The statement is, I suppose, technically true, because they’ll feel nothing. However, it misses the essential point that there will also be no joy. The focus on their current pain blinds them to the fact that it’s temporary. No pain or circumstance is permanent, pervasive, and uniquely personal. It will always change, it isn’t everywhere, and it’s not completely about you. (See The Resilience Factor for more on permanent, pervasive, and personal.)
A variation on this theme is the sense that if I can’t control anything in my life, at least I can control my death. This defeatist attitude fails to acknowledge that, in doing this, you’ll never have any control over your life. People, when they feel as if they’re trapped or helpless, can’t see a time when they’ll have control – or influence – over their lives. (See Compelled to Control for more about control.)
Appropriate Constraints
Home is where the heart is – but where is that exactly? Parents in the US spend less time with their children than parents in other countries – but more challenging is that it appears we’re more mobile. This presents a challenge when you’re faced with where someone should be buried. Are they buried where they were born, where they are currently living, or where they spent the most years living? It sounds like an academic exercise until you realize the underlying challenge, which is that we feel less grounded, less rooted, and less sure of our position in the world, both figuratively and logistically. The research around attachment points to secure attachment leading to more exploration – and exploring and learning is associated with a richer, more rewarding life. (See Attached for more on secure attachment, and see Creative Confidence for more on the results.)
We need roots and rules, as do our children. It’s every child’s dream to have no rules, no one telling them what to do. Well, it’s everyone’s dream to have no rules – until they have it. Having no rules and no structure is terrifying to a child. Having no rules and structure – to many children – means that there’s no one that cares. That’s even worse than not having rules.
Suicidal Crisis
Most people believe that people’s desire to die is a fixed quantity, that they either are or are not suicidal. The truth is substantially more complicated. First, suicidal ideation is the result of the ambivalence between a desire to live and a desire to die. Everyone has some degree of both at all times. It’s when the desire to die temporarily exceeds the desire to live that we have a crisis. If the person finds an acceptable means before this imbalance is corrected, they may make a suicide attempt.
A crisis may have temporarily focused us on the pain and troubles we’re facing, constricting our vision so we can’t see the positive parts of life. It can be that we’ve misinterpreted something small that makes us believe we won’t have more joy in the future or that one of our relationships is fading. In either case, when the balance shifts, so do our thoughts about suicide.
Someone can, because of shifting perceptions, be firmly in the camp of the living with no real suicidal ideation and ten minutes later have shifted their entire perspective.
Suicide as an Escape Route
If it gets too bad around here, I still have the option of suicide. It sounds odd, but the laws legalizing suicide, like Oregon’s Death with Dignity Act have had a strange effect. Many people complete the prerequisites and get access to lethal means – and then decide that they don’t want to use it. According to Suicide: A Modern Obsession, assisted suicide in Oregon account for 0.2% of all deaths. People want to know it’s an option – but they don’t necessarily use it.
The Suicide Prevention Promise
What could be wrong with a suicide prevention program? If it’s teaching people about suicide, how can that be bad? The answer is in the hidden assumption that there is such a thing as a single solution. A checklist for protecting teens, students, and coworkers doesn’t truly exist. We can stitch what we know together in a way that implies certainty and a linear process that doesn’t allow for individual variation – but we know that this cannot be right.
That isn’t to say that all suicide prevention programs are bad – far from it. Suicide prevention programs today need to acknowledge the limitations of their knowledge and effectiveness. The moment that you feel that you have it figured out is the moment when you know that you’re wrong.
Suicide Capital of the World
It’s easier to sweep suicide under the rug. Don’t talk about it. Don’t try to solve it, because to do so would require you to admit that it’s a problem. Sometimes, when loss survivors start to talk, it makes planners, politicians, and people uncomfortable. The dynamic becomes that, on the one side, you have people who want absolute silence about a topic, and on the other side, you have people who believe that speaking about it is a must. One side suppresses, and the other side shouts. (See Going to Extremes and Why Are We Yelling? for more.) The result is the suppressors see so much communication about a topic – like suicide – and the side sharing the information continues to shout it, because they know it’s not reaching the people.
Caught in Customs
Suttee is a ritual where a widow dies by flinging herself on the funeral pyre of their husband. The Japanese have several of their own forms of culturally-sanctioned suicides that signal something to others. These suicides are, ostensibly, individual decisions. However, the force of the cultural expectations can be overwhelming. (See How Good People Make Tough Choices, and Trust: Human Nature and the Reconstitution of Social Order for more.)
In The Happiness Hypothesis, Jonathan Haidt explains the powerful effects that cultural norms can have through his elephant-rider-path model. (See also Switch.) If we want to change suicide rates in a meaningful way, we must take on the difficult but important task of changing the culture.
Must Be Insane
Arguments have been made across history that to die by suicide, one must have been insane. Some people still believe that 100% of deaths by suicide have a mental illness. This is a logical fallacy. (See Mastering Logical Fallacies for more.) The presumption is that there’s no valid, logical reason to die by suicide. It ignores debilitating amounts of pain and sorrow that skew perception of the world so that there can be no hope left. (See The Psychology of Hope for more about hope.)
Avoiding the Label
For some, the desire to die by suicide is strong, but their values prevent them from doing it. (See Who Am I? and The Righteous Mind for values.) Instead, they resort to risky or self-destructive behavior that is likely to lead to their death but they can claim they didn’t die by suicide. Rarely is drinking oneself to death ruled a suicide. More often, it’s a tragic, “accidental” poisoning. When someone drives recklessly, their death is often ruled an accident.
All kinds of folklore has sprung up around the way to determine an accident from a suicide – but there’s no way to really know. If there are tire marks indicating hard braking, does it mean they changed their mind at the last moment, or did they realize they were about to have an accident? There’s no way to really know.
There is a relative fascination with psychological autopsies. They were first created by Shneidman (and simultaneously by Eli Robins at Washington University in St. Louis) at the request of the coroner. The goal was to infer intent through interviews and a review of the evidence. (See Autopsy of a Suicidal Mind.) While these may provide some information and utility, at the end of the day, there is no way to know what was running through the head of the person at the moment of their death.
The problem with categorizing these self-destructive approaches is that there is no clear line. Playing Russian roulette normally has a 1:6 chance of dying. Climbing Mt. Everest has a 1:10 chance of dying. Many would call playing Russian roulette a suicidal activity – but what about climbing Mt. Everest?
Answering the Call
Call centers for people in psychological crisis are an important part of our overall suicide prevention approach – but their efficacy is difficult to determine. Some studies have shown improvement, others none. Professionals feel ill prepared to respond to the calls they receive. Sometimes it seems that laypeople do better answering the phone than people with clinical training.
This surprising discovery may be a result of the expectation gap. Professionals believe that they’re expected to solve the problem. Laypeople believe that all they can do is listen. They expect that the person is still responsible for their own life.
The research on call centers places the number of people who are suicidal at less than a third of the callers, with those who are seriously suicidal much smaller than that.
Lock them Up
The professional response to someone discussing suicide is often an immediate move for involuntary hospitalization. The professional can’t risk their reputation and their malpractice insurance on a suicidal person. The problem is that there has never been any research on the efficacy of inpatient hospitalization for suicidal ideation. More troubling is the research is clear that the chances of death by suicide after inpatient hospitalization is substantially higher. So, while the instant answer is to lock people up – for their own protection – that may not always be the best approach. In Suicide: Inside and Out, David Reynolds explains how he could have tried to kill himself while on the inside.
The more pressing problem is prevalence. One high school social worker explained, “All the students come in at some point and talk about suicide, I can’t put them all in the hospital.” This striking realization is the same problem with attempts to screen everyone who interacts with healthcare. The instruments we have are overly sensitive and identify more than 300 people who won’t die by suicide – along with the one who will. We want to lean on dramatic interventions, but that doesn’t always make sense.
Screening and Assessment
The problem, as just mentioned, is that screening identifies too many people. The solution to this problem is to follow it with an assessment. Even presuming you can staff up to support the dramatic rise in the number of assessments that need to be done, there’s another problem.
The problem is that our ability to accurately assess the likelihood of suicide is pretty lousy. Sure, Edward Shneidman wasn’t bad at it – but the average clinician being asked to do these assessments has an only slightly better ability to predict who will and who won’t attempt than random chance. This starts with our bias to believe we’re better than we are, as Thomas Gilovich explains in How We Know What Isn’t So. It exposes the same difficulty we see in all predictions (see Superforecasting, Noise, and The Signal and the Noise) – they’re difficult.
If we know that experts can’t predict suicide, one has to ask why we’re spending so much money teaching non-professionals to do it. One wonders why we have so many indicators about suicide when they’re not very predictive.
The Basics
Still, even non-suicide specific behavioral health professionals get no training in suicide. A basic understanding would help them identify critical cases and learn how to validate in a way that deescalates the crisis. General practitioners or your everyday doctor, on average, get absolutely no training on suicide whatsoever. It would be good to help them, too. Understanding the basics without expecting prediction will naturally improve our ability to identify people who are asking for help – without using the words.
Here, too, programs that help laypersons identify and support suicidal individuals can be powerful – as long as we don’t expect too much.
The Enemy
Too frequently, we fall into making death our enemy. We see the dark robe and scythe, and we decide that it must be bad. Certainly, it’s not the right first choice. However, the real enemy is inhumanity. Even Gandhi gave poison to a suffering calf to hasten its death. We routinely euthanize our pets and livestock when they are in pain. However, when it comes to humans, it’s more complicated (as explained in Final Exit). That being said, it’s important to allow for the conversation about what is and isn’t humane. If we don’t, perhaps we’ll all be caught in the November of the Soul.