A disproportionate number of the books that I read are written by American authors. This is particularly true when it comes to books on suicide. Even though the London Anti-Suicide Bureau opened nearly six decades earlier than the Los Angeles suicide prevention center, the work seems centered around America. That one of the reasons why I was interested in Suicide: A Modern Obsession: it was written by a pair of authors from Ireland. I could get a different perspective.
For professionals who encounter patients that attempt or die by suicide, questions about competency are bound to arise. It doesn’t matter whether they engaged as a medical professional or a behavioral health professional, it’s difficult to lose a patient. It’s easy to think that a bad outcome must have been from something you did or didn’t do. It’s easy to look for the ways where you let the patient down.
However, the truth is that none of us are perfect, and even the venerable Edwin Shneidman lost patients and assessed incorrectly. We’ve got to learn that we can’t know everything, try everything, or positively control the outcomes with suicidal people. Sometimes, there is truly nothing to be done.
One of the challenges in working with people who have suicidal ideation is that some of them are facing real challenges. Divorce, unemployment, medical, and financial challenges are real. One of the early observations of the London Anti-Suicide Bureau was to recognize that sometimes people who are considering suicide just need material help. Whether it’s food, shelter, medical, or other services, the Bureau started referring people to get their material needs met.
This is an often under-discussed aspect in suicide prevention. Of course, there’s cognitive therapy to help people view their situations differently, but what if they’re viewing their situation accurately? The answer is sometimes to help them see that there are others in the world – outside of themselves – who are willing to support them, who believe in every human life and in them specifically. We can’t forget that sometimes there are real needs that need to be met.
I was somewhat surprised by the appearance of the abortion discussion. The United States has had abortion legalized since 1973 until somewhat recently. The result was that it rarely came up in the context of suicide. In Ireland, however, abortions are prohibited except where the mother’s life is in danger – and suicide represents a real danger to the mother’s life. The belief is that the mother may attempt suicide because she is pregnant and doesn’t want the baby. Because of this, there’s a consideration about whether the mother is – or isn’t – inclined to attempt suicide.
There are some things to know about unwanted pregnancies. In the United States, approximately one in four women will have an abortion prior to her forty-sixth birthday. It’s also important to note that Malcolm Gladwell argued in The Tipping Point that New York’s drop in crime in the 1990s was due to aggressive policing and fewer “broken windows.” Others, including Steven Levitt in Freakonomics, argued that fewer unwanted children were around owing to the 1970 legalization of abortion in New York. Others argue that the drop was due to longer prison sentences. Of these arguments, subsequent research seems to support Levitt’s assertion regarding the availability of legal abortion – though the other possibilities can’t be eliminated.
There’s research from the UK and the US that indicates a variety of impacts as a result of unwanted pregnancies, including mental illness and suicide. This is particularly the case when the mother was raped.
The concern expressed for Ireland’s law is that, by claiming suicide risk, mothers could avoid the intent of the law. More broadly, it would lead mothers who are not suicidal to manipulate professionals to avoid the ban. The argument, known as the slippery slope, is a difficult one to accept without any additional foundational evidence. (See Mastering Logical Fallacies for more.)
I Can Fix Them
Patricia explained of her marriage to Michael, “I thought I could fix him with care and love, but I was wrong.” It’s a reflection of the same sort of sense of control of others that professionals struggle with. We believe that we can protect our loved ones, heal their wounds, and enable their strengths, but there’s a limit to our ability to influence – even positively – the success of others.
We cannot accept ultimate responsibility for someone else’s suicide. It’s theirs to own. We can be disappointed, angry, devastated, and despondent – but it’s not ours to own.
Unemployment and Death
The relationship between unemployment and suicide seems relatively consistent. We’ve seen it happen time and again in multiple countries. The problem is that it doesn’t seem to happen everywhere. Some countries – those with stronger social support – seem less prone to increases in suicide during higher unemployment. There may be a lesson to be learned here. We may be able to reduce suffering if we’re just willing to support those who are suffering economic consequences better.
There is, appropriately, concern about which things encourage and which things discourage copycat suicides. The Werther effect is the impact that media has on additional suicides. (See also Assessment and Prediction of Suicide.) The opposite effect, called the Papageno effect, is the ability for the media to encourage a reduction in suicide rates. These effects are real and warrant the involvement of the media in suicide reduction efforts. Unfortunately, the effects, except in extreme cases, are modest.
A mistake made by one suicidal individual exposes a quirk in the thinking of some suicidal people. Having decided to jump from the opposite side of the bridge that he found himself on, the individual was afraid to cross six lanes of traffic to get to the other side of the bridge and jump. Pause for a moment to consider this. Dying was the point, but the idea of being hit and killed by an automobile while crossing the bridge was not acceptable. It’s an extreme form of protection of the selected means – but it’s also a statement that there’s a disconnect between death and pain.
It could be argued that they would have been hit by a car but not killed, and that would have increased their pain. Joiner argues that people must have a willingness to inflict self-harm and pain. (See Why People Die by Suicide.) It may be that the ability to disconnect pain from suicide is limited.
I grew up in the 1980s and 1990s with the conflict of Ronald Reagan and Mikhail Gorbachev. I can still remember Reagan’s plea to dismantle the Berlin wall. I was aware that Russians were quite fond of their vodka, but I didn’t understand the extent to which they used alcohol to cope with the conditions in the country. Nor did I know about Gorbachev’s work to curtail alcohol consumption or the radical impacts it had on reducing suicide.
There’s no doubt there’s a relationship between alcohol use – and particularly abuse – and suicide. While it’s not true that everyone who dies by suicide has abused or is abusing alcohol, there’s a non-accidental prevalence. Some are quick to point out that the actual intoxication rates of those who die by suicide are relatively low – on the order of 30%.
No doubt that losing someone to suicide will have an impact for the rest of your life. Any death loss is impactful, and some argue that a loss due to a suicide is more impactful, because the person chose to end their life. However, there is the opportunity for those left behind to find their way to purpose. Invariably, when I ask a room full of people who work on reducing suicide, everyone raises their hand at having experienced a loss due to suicide – either personally or professionally or both. The positives being acknowledged, no one would agree that them finding their purpose is worth a Suicide.