Suicide under Fire

The prospect of suicide in a team member shakes the boots of anybody looking to get into the peer support gig. Often, it is also the barrier to getting involved. On the topic of discussing suicide, some common questions I hear, “What do I say? What do I do? What if I put the idea in their head when I ask? Likely due to this anxiety, there is an exclusive drive towards uncovering the sacred “signs and symptoms” of suicidal behavior. Therapists themselves are not free from this anxiety.

And yet, looking at the research shows us clearly that predicting and assessing risk is nowhere near acceptable in terms of accuracy, reliability, and validity. Kees Van Heeringer, a professor of psychiatry and author of “The Neuroscience of Suicidal Behavior” takes the reader on a slideshow through all of which the typical myths are stripped down to their research-backed core. In the section most pertinent to us, “Predicting the Unpredictable”, Kees wastes no time, to sum up, the research in terms that we can clearly understand, “… one could as well flip a coin to decide whether there is a risk of suicide” (pg. 165). And yet, there is this endless droning of “risk assessing” and “understanding” arguably, though never overtly identified as such, to “predict” and intervene. Indeed, suicide is the topic of where the most intense intervention is focused. This may be our largest waste of resources as well if Kees has the research right.

This isn’t exactly new information either. In 1986, Beck (the creator of Cognitive Behavioural Therapy) conducted a study looking at over 2000 adults (as cited in Depression and Suicide, Reinecke, Washburn, Becker-Weidman). Initially, the findings seem to produce somewhat optimistic results – a cut-off score (a mathematical indication that suicide was present) identified 9 out of 10 completed suicides. Success! No? Oh, that is if we ignore that 1,137 participants who also received scores for the cutoff rate, did not go on to complete suicide. This unwanted result ultimately made this predictability rating a dismally effective test at close to 48 percent of the time. One could flip a coin, indeed.

In the book, “Cognitive Therapy for Suicidal Patients”, the authors Amy Wenzel and Aaron Beck (same guy as the 80’s study mentioned above) in a model for understanding suicide ultimately disclosed that “… the presence of any one of these constructs does not guarantee that an individual will engage in a suicidal act. Rather, dispositional vulnerability factors, negative schemas, and life stress interact and increase the probability that suicide schemas will be activated”. You don’t need to know the psycho-jargon to identify clearly what they are saying here, which is, “We put together this model. It’s a good model, we think. But, it won’t concretely predict suicide. Sorry”. To put it another way, they identify that these factors increase the risk for suicide – but, it’s an increase in risk in the same way that if you drive on the highway daily you have an increased risk of a car accident. Or, if you interact with people often you have an increased risk of getting a cold. I could go on. But, I won’t.

It seems less than effective to continue to bore you with numbers. What do we do about this?

We’re so focused on preventative matters, we’re forgetting the thing that perhaps matters more (and maybe even a “preventative” mechanism in and of itself) – the connection to our brothers and sisters. Understanding that there are, of course, typified things that those contemplating may engage in (withdrawal, drastic mood change, odd, impulsive behaviors, etc.) we also know now that this may be a false hint. The point is that if we have a great connection to our people, we can have direct conversations regarding these observed changes and an offer to help if they want it.

Talking openly about suicide and introducing some way to have an open door for those that need to talk about it is paramount as well. It’s crucial that the open door leads to people that are literate in mental health and suicide (Zalsman and colleagues, 2016). This removes some of the pressure that individuals who are thinking of suicide may feel. The pressure is that on top of having these intrusive, disturbing thoughts, they can’t talk about them or believe that talking about it is “wrong” is some way. And we know trying to stop a thought is, paradoxically, exactly how you increase the frequency of it occurring. Don’t believe me?

Don’t think of a pink elephant.

So, how can non-therapists intervene? Well, unfortunately, there isn’t a ton of things one can do. But, there are some. Check-in with your people. If you notice pulling away, withdrawal, change in mood or even change in work attendance, check-in. Delay “work appraisal” or “disciplinary action” only for a moment to explore whether something further is going on. Address the disciplinary aspects following that, if necessary. Staying with the individual until professional help can be sought is certainly the strongest and best thing. Escorting to the hospital as a last result is another, unfortunately, necessary step if supervision can no longer be maintained. Encouraging members to get their mental health checkup is crucially important. The longer these thoughts percolate, like coffee, the stronger they get. Getting Suicide Intervention Training to help teach you how to talk with someone engaged in suicidal ideation are also mandatory training in my books. Applied Suicide Intervention Skills Training (ASIST) is a great training program. Updating your knowledge of suicide through reading is also a great place. A somewhat technical, but still very approachable read, “The Neuroscience of Suicidal Behaviour” by Kees Van Heeringen is a great place to start as well.

In the end, suicide is a behavior. A behavior made from a place of intense negative thinking married with significant feelings of hopelessness.  While we can do all manner of things to try and stop that behavior, there is nothing ultimately to guarantee it to stop. This is the hardest and toughest lesson in mental health. It is the choice of the individual in the end. A choice that is hindered because they feel there are no other options for them to end their suffering. Therefore, we want to try as hard as possible to show there truly are a number of different possible choices for them to choose from and guide our members to them if able. Only through the realization that this singular choice is not their only choice, can we hope for anything that sounds a little like “prevention”.