It’s a worthy question. What are the alternatives to suicide? That’s the question that Alternatives to Suicide: Beyond Risk and Toward a Life Worth Living attempts to answer with its subtitle. How do we transform the pain that people feel and their desire to die? Though an academic volume with multiple authors and the readability challenges associated with both of these aspects, the answers that you find may surprise you.
Flip a Coin
One of the depressing and discouraging statements about the predictability of suicide is that even the best work on screening, assessing, and predicting who will die by suicide in the short term is only slightly better than the odds of flipping a coin and getting heads. Estimates vary about the ability of assessment to predict suicide, but they’re in the 50% range. While the behaviors we’re doing imply that we’re much better at determining who will and won’t die, the realities are different.
Interact with healthcare, and you’re likely to be confronted with a set of questions about your suicidality. It may start with depression and hopelessness, or it may directly ask about suicide thoughts, but you’re likely going to be asked. Frequently, we see PHQ-2 (Patient Health Questionnaire-2) asked – and if the person answers in a way that’s concerning, they are automatically asked the PHQ-9 (Patient Health Questionnaire-9) questions. Sometimes, people use the Columbia Suicide Risk Screener (CSRS) or the Ask Suicidal Questions (ASQ) screens. The stories of patients being encouraged not to answer in a way that would trigger concern are perpetual. No healthcare provider wants to do the extra work, nor do they want to see the person held for extended periods of time waiting for one of the few people trained to do a formal assessment.
It’s called universal screening, and it’s a requirement by accreditation bodies. They require that you have the process if you want to receive their stamp of approval. And because their accreditation means that you can bill insurance and the Centers for Medicare and Medicaid Services (CMS) – which is almost all of a hospital’s business – hospitals do what the accrediting body requires whether there’s efficacy or not.
That Which Needs to Stop
Shneidman described suicide as a way to stop psychic pain that he called “psychache.” (See The Suicidal Mind.) One of the common factors in suicide is a desire to stop something – whether it’s directly called out as psychological pain or not. With the cognitive constriction that accompanies a suicidal crisis, people may not be able to see other solutions to stopping their pain – except suicide. (See Cognitive Therapy for Suicidal Patients for cognitive constriction.) The key to finding alternatives to suicide is to find alternative ways to stop the pain without stopping their heartbeat.
The research is inconclusive. Some believe that all suicidal people exhibit signs and create invitations for others to intercede for them. Others look at research on suicide attempters that leads to the conclusion that many attempts – greater than 50% – were not considered a few hours before the attempt. Because of these numbers, studies have attempted to connect suicide with impulsivity – with very little success. The measures we use for impulsivity seem to not effectively capture the possibility that someone will consider suicide.
However, when the focus is changed to skills for emotional regulation, the story changes. It appears that those who are more capable of emotional regulation are also more capable of riding out the short term storms that seem to lead too many to suicide. It’s like Mischel’s Marshmallow Test has an impact on preventing suicide as well. Learning that things will likely get better if we can just wait a bit seems to protective. Rick Snyder in The Psychology of Hope explains that hope is made of willpower and waypower. Waypower is understanding the path forward. Willpower is that capacity to hang with it and keep trying. (See Willpower and Grit for more on the power and makeup of willpower.)
Meaning in Life
Viktor Frankl famously wrote that “Those who have a ‘why’ to live, can bear with almost any ‘how’.” (See Man’s Search for Meaning for more.) Meaning in life – even a little meaning – can be a powerful protective force. Simon Sinek believes that everyone should Start with Why. It’s about finding meaning in your life, and that meaning can be small. As Atul Gawande explains in Being Mortal, giving patients even something as simple as a plant to take care of can help them live longer lives.
We crave the idea of being useful. Thomas Joiner’s Interpersonal Theory of Suicide (IPS) posits that lack of connectedness, feelings of burdensomeness, and ability to inflict self-harm all drive suicidal behavior. (See Why People Die by Suicide.) Being helpful to something or someone else directly combats that feeling of burdensomeness.
Robert Putnam signaled a problem when he wrote Bowling Alone. Social capital – our connections with others – were eroding, and no one knew what to do about it. Sherry Turkle takes it further in Alone Together, as she describes how we are becoming technologically connected and interpersonally disconnected. There’s been an assault on our feelings of connectedness – and it’s not getting better. In 1990, about 75% of us felt we had a best friend. By 2021, that number is down to about 59%. In short, if connectedness to others is a protective factor against suicide, its impact is fading.
Three Step Theory
Klonsky and May built on Joiner’s IPS theory and proposed that it’s a three-step process to get to suicide. The three-step theory posits that pain and hopelessness move people to the first stage of suicidal ideation. To get to the second step, they propose that pain must outweigh connectedness. The final step of attempting suicide requires the capability to attempt – or the capacity for self-harm. Generally, this is the integration of an ideation-to-action framework with Joiner’s IPS theory such that the process of getting from idea to action has a path.
The caution that I’d have with the three-step theory is that the process of the three steps can potentially happen very, very quickly. It’s still a framework, since pain and connectedness aren’t quantified into scales that can be measured against one another in an objective way. It’s about the person’s perception – and that is often colored by cognitive constriction.
Who Failed Who
Bumper stickers of people who have rescued dogs ask the question, “Who rescued who?” implying that the dog may have saved the person’s life. While, in the case of the bumper sticker, it’s not meant in the literal sense, there’s often a reversal that happens when a treatment fails to move from blaming the practitioner or the process and instead transferring the blame to the patient.
We know that this isn’t right, that it’s frequently not the patient who failed but rather the poor therapeutic alliance, the skills of the professional, or the technique itself. However, that doesn’t prevent many people from defecting the blame and placing it on the patient. (See Mistakes Were Made (But Not By Me) for more.)
Once There’s a Plan, There’s Always a Plan
One of the challenges with suicidal ideation is that even the mental health professionals, whom you would typically seek out for help, are often disturbed by the word suicide and reflexively move to defend themselves. Litigation around suicide encourages providers to suggest emergency rooms and hospitalizations at rates substantially more frequent than would otherwise be prudent. Instead of focusing on the patient and what they need, the provider moves to protect themselves – whether it’s good for the patient or not.
One of the bigger problems with suicide assessments is that once you’re high risk, you never move back down the risk scale. Whether you’ve made a previous suicide attempt or you’ve just developed a plan for your suicide, there’s no backing down from the high-risk category. You see, if you’ve tried once, you may have figured out what you did wrong in your plan. If you’ve “only” planned a suicide, they know you’ve got an idea how you’ll do it.
This neglects the basic understanding that once you’ve created a plan, it will always stay with you. It’s not the sort of thing that you forget. You can’t. (See White Bears and Other Unwanted Thoughts for more.) Therefore once you’ve developed a plan once, you’ll always be at an elevated risk – no matter what your risk for suicide is in the moment.
Tactics like suicide contracts for those professionals willing to treat people who dare say the word “suicide” are more for their benefit than the patients. It absolves them of some responsibility if they believe that the patient committed to telling them despite ample evidence that safety contracts make patients none the safer.
Ultimately, this is the result of professionals who believe that they’re responsible for preventing patients from dying by suicide. The truth is that if someone really wants to die by suicide, you’re not going to stop them. (See Suicide: Inside and Out.) Instead, it’s healthier for the person who is suicidal to accept that it’s their responsibility to keep themselves alive and the professional is just someone on the team to help make that happen. It’s powerful for the professional to admit to themselves and their patients that they’re unable to save anyone at all – they always have to save themselves with help.
Suicide is the Solution, Not the Problem
Okay, it’s a bad solution. However, suicide is a solution to problems and pain. Only the patient themselves truly knows the entirety of their life, their experiences, and their pain. We can, from the outside, only get glimpses of what’s inside. It’s not unlike addictions, which are largely seen as the problem when they are, in fact, poor solutions to other problems the person is facing. Often, these are the same kinds of pains that suicidal people struggle with. (See The Globalization of Addiction, Dreamland, and Chasing the Scream for more about substance use and addiction.)
When we recognize that people see suicide as the solution and they’re the experts on their lives, we can bring to them things that are outside their perspective and experiences that may give them at least a few Alternatives to Suicide.