The Suicidal Person: A New Look at a Human Phenomenon
Understanding the suicidal person is at the heart of prevention. If you don’t understand them, how can you help them? The Suicidal Person: A New Look at a Human Phenomenon examines the suicidal person while retaining their humanity. Instead of simplifying them to a mental disorder or relying on a formulaic, linear set of cause and effect for suicide, it examines what in our humanity makes us susceptible to suicide.
Beyond the Medicine
Konrad Michel was trained as a medical doctor. He was indoctrinated in the medical model, yet he also recognizes its limitations. Certainly, biological systems can – and do – interfere with the proper functioning of the mind, but there’s more to it than that. There’s more than a simple machine on a mobile frame to our consciousness and humanity.
Experiencing the suicide of a patient early in his career, he was left in silence to process the experience without the support of those around him. No conversations. No discussions. No review. Just silence. He was left with a sense of guilt at the failure to protect his patient.
The implication was somehow that he should have known and prevented it. This is despite the general acceptance that there are two kinds of people working in mental health: those who have experienced a suicide and those who will. The probability is certainly strong that an active professional will experience this kind of loss.
His Own Son
Michel acknowledges the loss of his own son. An expert in the field of suicidology couldn’t protect his son from the thing that he was seeking to prevent. Some would be quick to judge Michel. I, on the other hand, am quick to laud his bravery in sharing this very personal tragedy. It takes courage to admit that you don’t have control and to share your hurt. (See Find Your Courage for more on courage, and Compelled to Control for the limits on control.)
I know firsthand that you can’t control the trajectories of your children. (See No Two Alike and The Nurture Assumption for more.) One of our children triggered our journey into understanding burnout by demonstrating just how little control we had in preventing his questionable decisions. (See https://ExtinguishBurnout.com for the resources we compiled on burnout.)
Reasons to Be Depressed
Just because you have a reason to be depressed doesn’t mean that you should be. Read that again. There are two pieces to it. First, everyone has reasons to be depressed if they really focus on it. Perhaps you’re not tall enough, handsome enough, rich enough, smart enough, or athletic enough. Maybe you’ve been betrayed. Maybe you’re worried about a layoff – or, if it’s already happened, how you’re going to find a job again. We’ve all got plenty of reasons to be depressed – but not all of us are. (See Hardwiring Happiness for tools to escape this negative framing.)
Second, depression isn’t a state you want to be in if you can avoid it. The results of depression are worse health or death. Suicide is correlated with depression – though not everyone who has depression dies by suicide, nor does everyone who dies by suicide has depression.
There are some people who have every reason to be depressed. They’re struggling to make ends meet, and they’re happy. They’re working 60 hours a week to pay for their kid to get through college. They’re caring for an aging parent. All these burdens, yet they don’t descend into depression.
It’s not as easy as simply deciding not to be depressed. There are real reasons both physiological and psychological why people are depressed – and there are things that can be done to reduce the chances for depression – and to move away from it if you’re there.
Reasons for Suicide Attempts
John Bancroft created a simple survey to assess reasons for an overdose. He gave the survey to health care providers to predict what happened and to people who had overdosed (and had obviously survived). The differences between the two groups were striking and reflect the pejorative way that these health care providers see patients who’ve overdosed.
56% of the patients selected “The situation was so unbearable” – and none of the providers did. They missed out on the fundamental reason for the overdose. Similarly, patients endorsed “Lost control and don’t know why” 27% of the time while none of the providers did. The health care providers saw the overdose as a manipulation based on the 71% of providers who endorsed “To make people understand how desperate you felt” when patients endorsed it only 20% of the time. Similarly, providers endorsed “To influence someone to change their mind” 54% of the time while their patients only selected the item 7% of the time.
Part of this discrepancy may be driven by the sense that provider assessments are “objective” where patient assessments are “subjective.” As a result, most physicians don’t ask for reasons and seek to understand the outside factors. Techniques like Motivational Interviewing have made it clear that this isn’t the right strategy – but the message hasn’t reached mainstream medicine.
State of Mind
There are many who believe that it takes a great deal of strength to override the natural aversion to self-termination. However, this isn’t a single thing that must be overcome. There is the first barrier of self-harm. For some, they’re quite willing to harm themselves as evidenced by the number of people who use cutting as a way of coping with their emotions. The dynamics of this are complicated. In some, if not many, cases the person has learned that emotions are unsafe and, as a result, have suppressed them. The result is that they feel numb and recognize that they should be feeling something. Cutting generates a pain sensation that signifies that they can still feel and generates some sense of safety and control.
The second layer is a willingness to extinguish the flame of their life. This does take a different conviction. It requires a degree of certainty that suicide is the right answer, one that is often generated by an altered state of mind called “cognitive constriction” by Shneidman and others. (See The Suicidal Mind.) David Kessler in Capture takes a larger and more nuanced view, where the state is more than just constriction but also reinforcement of the ideas. Caught in a loop, individuals become more convinced of their beliefs. Cass Sunstein, speaking of extreme positions, expresses the same sense of reinforcement in his book, Going to Extremes.
This state of mind change may explain why, when asked who could have helped before a suicide attempt, 52% of people said “nobody.” Suicide is often described as an “unbearable” state of mind. The person believes that there is no hope. (See The Psychology of Hope for more on hope.)
Triggering Suicidal Modes
Michel believes in the creation of a suicidal mode that can be triggered. It’s the activation of this suicidal mode that puts patients at risk. Suicidal mode is that state of mind where suicide seems like the right answer – and where access to means may result in tragedy. The triggers to enter that state of mind are varied.
Looking at this from the perspective of M. David Rudd’s fluid vulnerability model of suicide, as described in Brief Cognitive-Behavioral Therapy for Suicide Prevention, we see that there’s a baseline risk and an acute risk following an event. What’s not defined well is what that trigger is. Certain things can reliably identified as potential triggers – job loss, death of a loved one, divorce, etc. However, even in the presence of these events, many people don’t enter a suicidal mode.
The key to the distinction (in my view) is trauma. Trauma, as explained in Trauma and Recovery, is a temporarily overwhelming event. What is overwhelming is different from one person to another for two reasons. First is the coping capacity of the person. Peak, Antifragile, and The Rise of Superman speak of what humans are capable of – and the conditions necessary for them to develop skills of any kind. The skills to compensate for a wide variety of potentially overwhelming events are no different. For instance, someone who has developed anti-loneliness skills (generally speaking, connections) will be more resilient after a death than those who have not. (See Loneliness for more.)
Second (and equally, if not more, important) is that the way that each person is impacted by an event – the degree to which they connect with it and feel it – is shaped by who they are separate from their coping capacity. Consider an adult who has an avoidant insecure attachment style. Generally speaking, they’ll be impacted less by a divorce because they expected it. (See Attached for more on the avoidant attachment style.)
Also consider how seeing a dead animal along a roadside might trigger someone if the animal looks like their beloved childhood pet; though long gone, they remain in the person’s memory. For most, a dead animal along the roadside is an unfortunate occurrence. When connected with the death of a beloved childhood pet, it may itself be triggering.
From a prevention point of view, this is problematic. Certainly, it’s difficult on the outside to know what might connect with a person and traumatize (or retraumatize) them. It’s even more troubling to know that often people don’t know themselves what may trigger them. It could be a passing smell of their grandma’s perfume or the smell of cedar as they remember walking into her closet.
Unhelpful Healthcare
One of the persistent challenges with suicide prevention is that individuals don’t feel safe expressing their suicidal thoughts. They don’t feel comfortable sharing it with friends because of the belief that they won’t understand or the perceived burden it would place on them. They don’t share their thoughts with healthcare providers for similar and different reasons.
They may consider that healthcare providers have “real” problems to deal with. They don’t need to be bothered by some troubling thoughts. On the other side, they may have an unfortunately real fear that the professional they’re talking to might “lock them up.” Involuntary commitment solves the anxiety of the healthcare provider while denying the person with suicidal thoughts of their personal liberties.
Either way, the trust that would be necessary to disclose suicidal thinking isn’t high enough in many cases for friends – and especially for healthcare considering the threat of loss of liberty.
Rethinking Risk Factors
Michel makes the point that too many people believe that risk factors are prescient instead of recognizing them as statistical reductions from a sea of former data. Mutual fund advertising often includes the disclaimer “past performance is no guarantee of future results.” Similarly, just because someone does or does not have risk factors for suicide doesn’t indicate whether they’re personally going to die by suicide. Craig Bryan makes this point clear in Rethinking Suicide where he uses a car accident analogy. Teenagers are more apt to have an accident – but we don’t know which ones.
Certainly, to be responsible we need to consider the risk factors and mitigate those where possible, but some demographics are unchangeable. It’s a good thing to address food and shelter insecurity. It helps to provide proven treatments for depression. There are things we can do – but whether we do or not is no guarantee of a specific outcome.
If we want to save people, we need to look for the person in The Suicidal Person.