Both of these volumes were originally collections of Lewin’s papers, so the boundaries of the original works were already somewhat arbitrary.  Ensuring that, collectively, the wisdom would be available drove the combination of the works.

Democracy or Autocracy

In a time before McCarthy, it was safe to ponder the benefits and weaknesses of different forms of government.  It was safe to look for the strengths of autocracy while living in a democracy.  It’s not surprising that Americans believe democracy is a better form of government.  After all, that’s what the founding fathers created.  Lewin’s perspective wasn’t on gross domestic product or raw output of a structure.  True to his purpose and perspective, he focused on the psychology of the various forms of organization.  He wanted to map out the forces that kept organizations stable and those that disrupted them.  He wanted to understand how a government which someone might not interact with every day might shape day-to-day interactions.

It reminds me of a discussion of leadership.  (See Leadership.)  Reinventing Organizations proposes different levels of organizational maturity with representative colors.  What’s striking about this is the acknowledgement that, sometimes, telling someone exactly what to do is the appropriate response.  It’s not that it should be the case every time – but sometimes it is right.  Similarly, Lewin points out the times that autocracy is just easier.

The Role of Education

“It seems to be easier for society to change education than for education to change society.”  Here, the data isn’t so clear.  Lewin conditionalizes the statement (seems) and leaves open the work of others, like Robert Putnam, who explains in The Upswing what a large impact education had on America during the course of 120 years.  While education isn’t swift in the ways that it shapes a society, it can be powerful.  Elephants aren’t the fastest creatures on the planet, but they do have a lot of force they can bring to bear once they’ve made their decisions.

The forces that move education – particularly in higher education (secondary education) – aren’t as controllable as the autocracy might like to believe.  While it’s also possible to shape elementary grades, and there have been instances of that, the effects take a long time to mature.

Lewin makes the point that someone cannot easily learn democracy with autocratic methods.  If the educational system is focused on autocracy, then other learning may be hard.  Consider the case of teaching racial relations as explained in A Class Divided.  No amount of lecture could have taught the children what it feels like to be discriminated against (in a small way).

Power Gradients

I can only imagine what Lewin might say if he were alive today.  He noticed that even in the late 1940s, American children were given a more equal footing with parents than children in Germany.  It seems that democracy had permeated them, and they thought they were equal to their parents.  In light of books like The Coddling of the American Mind, we can see this enhanced entitlement and have to wonder if it’s gone too far.  Mihaly Csikszentmihalyi reported that the famous Dr. Spock was concerned with some of his guidance in Baby and Child Care at the end of his life.  The guidance was largely permissive – and the impacts of enabling children were concerning.

Interference

One way that the two societies are different surfaced in the way that adults monitored or enabled children’s play.  What is now called “helicopter” parenting was discussed in Lewin’s writings.  He encouraged the same kinds of low-touch interactions that The Anxious Generation calls for today.  We want to allow children to work out their problems themselves – if they don’t learn it, how will they be able to resolve conflicts when they grow up?

In an ideal world, parents should support in ways that prevent scars but promote bruises.  (Sort of like what Robert Putnam found in Our Kids.)

Being Adults

In America, Lewin reports, it’s much more likely that people will agree to disagree – and be willing to work together and respect each other even in the presence of disagreements.  Here, too, Lewin’s perspective of today would be interesting.  It seems as if we have lost this professional courtesy.  We’re faced with polarization (see Why We’re Polarized) and extremes (see Going to Extremes).

Lewin reports in that in Germany (in the 1940s) seemed to lean more towards moral disapproval.  It’s as if they took a page out of Mastering Logical Fallacies and decided that name calling was the right way to handle disagreements.  Perhaps it’s because the only way they learned to solve agreements was by bullying and overpowering the other person.

A Tale of Two Views

Lewin proposed that we could view culture as an equilibrium – a place where it all balances out.  More specifically, he believed in a dynamic equilibrium or, in his words, “equilibrium in motion.”  We’d think of this as the kind of patterns that emerge around strange attractors.  The second view seems related both to the first and the broader body of his work.  He sees culture as the constellation of forces that are working to create areas of relative rigidity and patterns of relative flexibility.  Culture is in motion – a motion that you have to learn to work with.

Teaching Theory

There’s a lot we’ve learned about teaching and learning.  Works like Efficiency in Learning and How People Learn have cataloged a portion of that research.  Lewin explains that, without safety, people cannot learn.  It’s one of the fundamentals for learning that is clear.  Some frameworks, like Knowles et al.’s vision of The Adult Learner, extend this to expose the relationship of the learning to the student – something that is often missed.

Lewin also briefly raises the issue of those who are not connected with reality.  He suggests that reeducation is necessary when people lose touch with reality.  I’ve two concerns here.  First, reeducation is often the word used when people disagree with someone’s beliefs and want to change them – forcibly.  (See After the Ball for some historical perspectives on the ways that gays treated themselves and were treated by others.)

The second concern is that it’s notoriously difficult to help people regain touch with reality.  While we have ways of adjusting perceptions, some are so incorrect that it may be difficult to adjust them back into some degree of connection.  Lewin notes that a step-by-step approach is more effective than trying to go directly to the end goal.  This is something that Motivational Interviewing concurs with, as does DBT.  (See DBT Explained.)

Social Chemistry

Lewin argues that sociology has every right to its research.  Why is it any less valid than chemistry or physics research?  The argument has been made about the variability of results, lack of repeatability, and so forth.  However, there’s a very simple statistical answer for all of this.  When we’re dealing with people, we’re dealing with expensive, complicated creatures that don’t have a high degree of conformity.  But more importantly, owing to the expense, we tend to use smaller sample sizes – and that statistically means more variation in our results.

One could argue that physics and chemistry can do research with small sample sizes – but it misses the fundamental point.  Physics and chemistry necessarily work at least at an atomic (if not subatomic) level.  That means any substance that is tested necessarily has more atoms (or molecules) than we can ever hope to survey in humans.  Consider that one mole (unit of measure) contains 602 sextillion items.  We couldn’t get to that number if we included every human on Earth.

So, while we should respect the research done in sociology, we need to accept the fragile nature of the results.

Psychological Future

One of the threads that Phillip Zimbardo pulled on is the way that we view time.  In The Time Paradox, Zimbardo discusses the different ways that we view time in a positive and negative way, both the future and the past.  He also brings in aspects of determinism and hedonism.  Here, Lewin makes the case for the perception of the future as a psychological future – meaning the way that we think about it matters.  It’s not a truth about the future (since it’s not possible to be proved) but is instead a prediction of the future that can be accurate – or it can be overly optimistic or overly pessimistic.  (See The Signal and the Noise and Superforecasting for more about prediction of the future.)

What we make of our future goes a long way towards building or crushing hope.  (See The Psychology of Hope for more.)

Change is Different than Stability

Change is, of course, different than stability.  They are definitionally different, but Lewin explains that they’re not just different, they’re markedly different.  They don’t even behave the same way.  Subtle changes in the forces that act on individuals and the collective forces for the organization are as different as a desert wind and a desert downpour.  It is as the economists say, “Free is a different territory than not free.”  (See Predictably Irrational.)

If we want to better understand how we relate to others, how that is influenced by the structure of relationships as well as the forces of pressure that shape us, you may find the answers in Resolving Social Conflict and Field Theory in Social Science.

The post Book Review-Resolving Social Conflicts and Field Theory in Social Science first appeared on Thor Projects.

Free Play

I can remember times in my life of entertaining myself with a paper clip and a rubber band.  I can remember summers of relative boredom.  I can also remember times when we played games we made up and improvised.  This is the kind of play that is recommended by Haidt in this book and Stuart Brown in Play.  It’s an opportunity for kids to get bruises but not scars.  It’s a framework for experimentation where the stakes are not too high.  It’s a place where kids develop a sense of agency that they can do things.

The kind of freedom and play that I experienced has become rare.  We societally became scared.  We decided that the increased media coverage of crime in the 1990s meant the world was a scarier and more frightening place than ever before, and that this continued in an upward swing as time progressed.  As I mentioned in my review of Anthro-Vision, the statistics don’t bear out this conclusion.  The truth is that violent crime rose and peaked in about 1990 and then started to decline.  (See also The Tipping Point for a proposed reason.)

However, the statistics aren’t the stories in our head.  The rise of constant news from cable TV and then the internet has convinced us that crime is more prevalent than it really is.  Growing up in the 1980s, it wasn’t that bad things didn’t happen.  It was that we didn’t know about them.  While the media has been blamed for increasing violence, the truth is that it’s changed our perception of violence.  In Moral Disengagement, Albert Bandura takes aim at television, but the longer view doesn’t support his conclusions that television was making us more violent – particularly in light of the decrease in crime while television and violent game consumption increased.  The Blank Slate points this out effectively – but it hasn’t changed perceptions.

Community Parenting

One of the other challenges that Haidt points out is that we used to have community parenting – even in America.  Kids were expected to be corrected by other parents.  But, as he exposed in his prior book, The Coddling of the American Mind, that is no longer the case.  Parents have become the defenders of their children – well beyond what is healthy.  Robert Putnam in his book Our Kids (which follows his immensely popular Bowling Alone) explains how there is a good sort of protection and enablement of kids – but one that takes place inside of community.

Today, correcting a child who isn’t yours is just as likely to end up with an argument with the other parent as it is to engender a thank you.  We’ve lost something important in how we work together to ensure the next generation.  This is a central point to Robert Putnam’s latest work, The Upswing.

Community Boundaries

Perhaps part of the challenge is that the world we live in today is different.  Before we had the internet or even interstates to take us to other geographies quickly, there was a certain difficulty picking up and leaving a community to find another.  The result is that you had to learn how to repair relational rifts.  If you’re a farmer with thousands of acres who doesn’t get along with your neighbor, it’s not easy to pick up and move.  Nor is it easy for the barber to find a new set of friends when he gets into a disagreement with the butcher.  The nature of community living make the barriers to entry and exit high enough to force important learning.  Robert Putnam would say that it forced us to build social capital – the kind of capital we can call on in times of need.  (See Bowling Alone.)

The need for appropriately rigid boundaries is not unique to societal concerns.  Richard Hackman in Collaborative Intelligence explains both the benefits and weaknesses.  Too rigid, and you can’t accept new people – too lax, and the team never is able to work together.  Charles Vogl in The Art of Community explains how boundaries provide shape to a community and separate it from others.

Our car culture and then virtual worlds have all but destroyed the barriers to exiting a community.  In their wake, we’re left less able to stay in relationships when we disagree.  (See also Alone Together.)

Always Broken

Every generation // Blames the one before // And all of their frustrations // Come beating down your door. – “The Living Years,” Mike + The Mechanics

We believe that we’re uniquely positioned at a time of crisis in our world.  But so did our parents.  So did their parents.  Every generation has some concerns about the fate of the world, all the way back to Socrates and his concern that writing and books would ruin us.  Some of this concern is just the sheer impact of change and the awareness that things will not continue to be the same forever.  Some of it is that this prevents our ability to predict, which makes us uncomfortable.  (See Mindreading.)

So, while Haidt is concerned, he recognizes that every generation is concerned.

Decoupling Excellence and Prestige

An odd thing happened.  Throughout history, prestige was tightly coupled to excellence.  The work of Anders Ericsson in Peak explains what it takes to become the best at something.  Throughout history, that was what was required to earn prestige.  However, the rise of mass media decoupled excellence and expertise from prestige.  Now, one could become an “expert” by simply asserting statements as fact (with no supporting data).  If you could manipulate media (whether television or social media), you could gain prestige from followers who don’t know that you don’t really know anything.

Instead of people getting advice from real experts without much notoriety, there’s a trend towards listening to those people who have the most followers.  The problem with this is that their number of followers is based on them saying what the followers want to hear – not the truth.  We see this all the time in the ways that our children and their spouses take in news and make decisions.  Instead of experts, they turn to TikTok and trust what a stranger says.

Feelings of Fear (and Not Safety)

John Bowlby and Mary Ainsworth discovered that the way someone was attached to their parents changed the way that they would explore the world.  (See Attached and Attachment Theory in Practice.)  The sense of safety that children drew from knowing that there was someone who was looking out for them made it safe enough to explore the world.  The problem may be that we’ve created a world that we’ve convinced others isn’t safe.  It’s filled with murderers and rapists.  There are people who are going to mug you and steal all your money.  So, we retreated into the perceived safety of the virtual world.

The virtual world removed barriers.  It made it easier to connect with people all over the world – including the bad people who want only to take advantage of us.  Nigerian princes who desperately wanted to share their fortune with us keep dying.  All we have to do is share some banking details so that they can wire us the money.  Our kids are being extorted for sexually explicit images.

However, somehow the belief remains that our physical world is unsafe but the virtual world isn’t.  It’s a reversal of the truth that is difficult to wrap one’s mind around.

Harms

Haidt proposes that there are four key harms that are being inflicted on youth today:

1. Social Deprivation – we connect less even as we are more technologically connected (See also Alone Together.)
2. Sleep Deprivation – We are a society that is chronically getting insufficient sleep.
3. Attention Fragmentation – We’re constantly interrupted and unable to focus. (See also The Organized Mind.)
4. Addiction – We’ve become addicted to substances and social media. (See also The Globalization of Addiction.)

Users and Customers

Very few fields call their customers “users.”  Computers is the one place where the people who actually use the computers to do work are called users instead of customers.  Customers are those who pay for services.  An odd thing happened with the rise of social media.  The people who use social media aren’t the customers.  The truth is that social media companies don’t directly benefit from the number of users and the attention they pay to the platform.  What they benefit from is the advertisers who pay to get in front of those users.

As a result, social media companies don’t treat us like valued customers – because we aren’t.  We are simply users.  We’re users that aren’t important and can be replaced.

Parenting by the Numbers

All of us want to raise our children to be healthy, productive members of society.  However, that’s not as easy as it seems, as Judith Harris Rich points out in No Two Alike and The Nurture Assumption.  In our desire for certainty, we are constantly scanning the horizon for a class to be taken, a workshop to attend, or a book that has all the answers.  We fail to realize that there’s no silver bullet answer to raising children to not become The Anxious Generation.

The post Book Review-The Anxious Generation: How the Great Rewiring of Childhood Is Causing an Epidemic of Mental Illness first appeared on Thor Projects.

Individual and Community

At the heart of our struggles, Putnam believes, is a struggle between community and individual.  Neither is perfect.  Each has their own challenges.  In times when we’re focused individually, we miss out on our fundamental human need to connect and to be a part of things.  When we’re locked into tight communities, we have no room to express our individuality and our unique spirit.  The argument isn’t for one or the other but rather for finding a sense of relative balance, where we can get the greatest value from community while making room for our individuality.

The metrics that Putnam uses to evaluate the degree to which we’re “I” focused or “We” focused are broad, and the trends over the course of the century are strangely consistent.  There’s an inverted U that starts from the early 1900s, when we were very I focused, to the 1960s in a time of toxic conformity, and back to today, when we’re struggling to find and form communities that matter (the kind that he spoke of in Bowling Alone and, particularly, Our Kids).

In times of community, we feel as if we’re all in this together.  We believe that we’re all fighting towards a common enemy instead of fighting each other to get ahead.  In times of our individual focus, we believe that we can do anything to get ahead.  We can earn “the American dream” even if it means trampling others.  While this sounds morally objectionable when framed that way, we live our lives in the struggle, and sometimes we don’t realize the impact of our actions on others.  We feel justified in demonizing those who believe differently than we do instead of having a logical, rational debate on the issues.  (See Mastering Logical Fallacies for more on why character attacks are bad.)

Common Good

When we speak of community, there are benefits in terms of a focus on the common good that balance the challenges of conformity and the lack of acceptance for individuals who are different.  On the one hand, we have the kind of lack of tolerance that led to LGBTQ+ people remaining “in the closet.”  Even late into the cycle of I-We-I, After the Ball caused a stir as it sought more acceptance for gays.  On the other hand, we know that working towards the common good – cooperating – makes groups more competitive against other groups.

Reviewing the work from Richard Dawkins in The Selfish Gene, the work of Robert Axelrod in The Evolution of Cooperation, as well as SuperCooperators and Does Altruism Exist?, we see that sometimes the genes and ideas that replicate best are those that are the most cooperative even beyond kinship lines.  Even Adam Grant in Give and Take acknowledges that those who are out for themselves fill the middle of the success ladder, while givers – those focused on cooperation and sharing – are at the bottom and the top.

Equality and Growth

There’s a debate that rages about the impact of income inequality, with some believing that growth isn’t possible during times of relative income equality, but history doesn’t bear that out.  We see economic growth both in times of income inequality and in times of relative equality.  However, it’s a hot topic that finds its way into a number of thoughtful works – including Deaths of Despair and the Future of Capitalism.

Following the same pattern, income equality was large during the 1920s and shrunk through the 1960s with a return to historic highs of inequality today.  A specific change that deregulated the financial services industry has been estimated to make up 15-25 percent of the impact on inequality.  The financial meltdown of 2008 didn’t teach us enough about the dangers of an unregulated financial industry.  (See The Halo Effect.)

Progressive and Regressive Taxes

One of the factors that helps to mitigate the income (and wealth) disparities is a progressive tax system that increases as people earn more.  Generally speaking, our income tax system in the United States operates this way with higher levels of taxation at higher levels of income.  However, there are many problems with this system including the definitions for active vs. passive income.  Overall, however, progressive taxes shrink the gap between the high earners and the lower earners with systems like ours allowing the lowest earners to not pay any income taxes at all.

However, not all taxes in the US are progressive taxes.  Our social security tax, which is a part of payroll or self-employment taxes, is a regressive tax.  That is, it taxes more those people who earn less.  The actual mechanism in place is a cap on earnings for the tax.  After the cap is hit, no further taxation happens – thus rewarding the high earners with some income free of this tax.

Across Party Lines

Why We’re Polarized explains some of the movement away from working together, as does Going to Extremes, but Putnam’s argument is much more broad reaching and subtle.  Here, he’s talking about the broader societal forces that push us away from the idea that we should try to find a way to work together.  Instead of accepting people as having valid but different views, we’ve fallen into a trap of vilifying others in ways that prevent any meaningful cooperation.  We’ve left with tentative compromises that seem to fall apart quickly.  We’ve forgotten that “the other fellow might be right.”

Sociability in a Box

The rise of clubs connected with a growing desire for connection and community, as our moves toward cities and ultimately suburbs disrupted the rural communities that we came from.  Organized clubs offered “sociability in a box.”  That is, they contained a framework for the group from mottos, slogans, and procedures that could be applied quickly and easily.  It was, in a sense, the Industrial Age for the development of groups.  Groups could be mass produced just like “modern conveniences.”

However, this trend didn’t survive well after 1956.  For organizations with members, the average fell from 111,000 to just 13,000 in 1998.  What we found was that there were more organizations – but each with fewer members.  Organizations like Greenpeace drove huge memberships with a large direct mail program but hemorrhaged membership when the organization decided that such mailings weren’t consistent with their values.  Their membership plunged 85 percent within three years.

Not only were we joining less – but we were attending less.  In 1976, sixty-four percent of Americans had attended a club meeting in the preceding year.  By 2005, the number was slightly more than half that, at thirty-three percent.

Churchless

Much has been made of the decline in church membership and attendance, including coverage in Churchless and The Great Evangelical Recession.  However, Putnam points out that our belief that everyone in revolutionary times were members of church is a fallacy.  The curve of church membership and attendance seemed to follow the broader societal changes which led to a greater sense of “we” in the middle of periods of “I.”

One of the complicating factors is that one of the drivers for church attendance and membership is forming a family and having kids.  Young adults are delaying both marriage (see Anatomy of Love) and having children.  These delays appear to be further impacting church membership and attendance.

Replicating Asch

It’s a famous experiment where Solomon Asch was able to demonstrate the power of peer pressure on our perceptions.  He engaged collaborators to incorrectly select a second line of equal length to the first.  The result was that the actual participant seemed to change their mind to conform with the group, even though there was no doubt that the lines weren’t the same length.  Subsequent research with the aid of brain scanning seemed to indicate that the person didn’t have conflict, they really saw the answer the others gave as the answer.  It had warped their perception.  (See Unthink and The Data Detective for more.)

However, other, more recent work has seemed to show lower levels of influence indicating that Asch’s ability to influence perception was a side effect of high levels of conformity during the 1950s when he was running his experiments.

Narcissism

Thomas Gilovich explains, in How We Know What Isn’t So, our propensity to believe things that cannot be true.  Whether evaluating professors or students, more than 50% of us believe we’re better than average – which isn’t statistically possible.  We’re wrong, but we’re able to keep our beliefs.  Putnam uses the answer to a single statement, “I am a very important person,” to highlight the change in perceptions.  In 1950, only 12 percent of people identified with that statement; by 1990, 80% of people identified with the statement.  In the space of 40 years, most of us had decided that we were, indeed, important.  Some of this may reflect generational differences (see America’s Generations), but the change is striking.  While we may not be narcissistic, we are moving in that direction.

The Cycle

In the end, we should recognize that this I-We-I represents just a part of a cycle where we oscillate between our need for individuality and our need to be in the community.  We hope we’re at the bottom of the cycle and we can start The Upswing.

The post Book Review-The Upswing: How America Came Together a Century Ago and How We Can Do It Again first appeared on Thor Projects.

Statistics

Atkinson was equally critical of the inferences made by statistics.  Building on the work of others, he points out that the statistical foundation upon which some assertions rested were untenably fragile.  We can’t go back too long before we discover that the registration of deaths wasn’t required at all.  The degree of expertise necessary in coroners was highly variable, and the key indicating factor for suicide is intent – which is difficult to assess postmortem.  (See also Postmortem.)

He suggests that, rather than relying on such unreliable sources, we needed to begin with more contemporary studies – and allow for similar distortions of the data.

A General Theory

Atkinson even criticizes the idea that there could be a single theory of suicide by using an example: “to construct a general theory to explain why people dig holes would be to put one’s judgement severely in question.”  He explains that, like suicide, the reasons for digging holes varies widely.  Because of that, no single theory could suffice.

Scholars after him would struggle to find unifying theories of action.  Today, we struggle to have theories of suicide that are broad enough to encompass all suicide attempts and narrow enough to be useful.

Indicators

Atkinson, while acknowledging the difficulties, still sought indicators.  In the case of a drowning in the river, he’d look for whether the clothes of the person were neatly folded on the shore or simply tossed in a pile.  He believed that neatly folded indicated suicidal intent.  I, however, think it indicates some level of need for order.

Other examples, like an overdose taken in the middle of the woods, are a slightly more generalizable and potentially reliable indicator.  Except in cases where the person became disoriented, it’s more likely that the preparation of going someplace secluded indicated a degree of planning.  That planning seems to have little other purpose than to ensure that they’re not interrupted.

There are no easy answers to explain the phenomenon of suicide.  Atkinson offers solid critical approaches to the research being done.  Discovering Suicide doesn’t have answers, but its criticisms of the field are useful.

The post Book Review-Discovering Suicide: Studies in the Social Organization of Sudden Death first appeared on Thor Projects.

The Promise

The goal is clear: we want to identify those at risk for suicide and provide care for them.  However, Shea states, “It has always been hoped that risk factors, if studied collectively in a specific client, would also serve as reliable risk predictors alerting the clinician to an immediate danger of suicide.  Such is not the case.”  Later, Shea identifies the core challenge: “We do not know for certain what is going on in our client’s mind.  We never will.”

While there are things to be learned from improving the assessment of patients for suicidal risk, we cannot fool ourselves into thinking that the process is foolproof – or in some sense ever will be.

Chronological Assessment of Suicide Events (CASE)

The core of the book is explaining the CASE approach, which involves a structured interview.  That is, there are a series of areas, phases, or questions that are intended to be asked.  It’s a framework designed to help a clinician ensure they’re not missing anything.  Much like The Ethnographic Interview approach that is recommended for anthropologists, it has no forms to fill out and recognizes the dynamic unfolding of conversations.

The use or non-use of forms is problematic.  Shea makes the point that without forms, you can focus on the client.  However, without forms, it’s also almost impossible to not drop something.  Approaches like CAMS, explained in Managing Suicidal Risk, explicitly use a joint form that the patient and clinician work together on to ensure fidelity, accuracy, and collaboration.  It’s my strong belief that this is a much better approach than having the clinician do an interview without the support of a memory, documentation, and understanding confirmation aid.

Stage 1: Setting the platform

In the show before the show, Shea recommends preparing for the CASE part of the interview by building rapport and setting expectations.  It’s called therapeutic alliance or therapeutic environment.  A more detailed understanding of this concept is in Motivational Interviewing, and support for the efficacy can be found in The Heart and Soul of Change.

Stage 2: The CASE Approach

The CASE approach itself has four regions.  They are intended to be addressed sequentially.

Region 1: Presenting Events

The patient’s current condition, including their suicidal feelings, death wishes, ideations, plans, intent, and actions.

Region 2: Recent Events

The items that preceded the presenting events, including immediate or imminent danger in the patient’s method of choice, time spent contemplating the method of choice, and actions taken on the method of choice.

Region 3: Past Events

A review of a patient’s past suicide attempts.

Region 4: Immediate Events

This region captures the patient’s thoughts and intentions concerning suicide that come up during the interview itself.

Ideation to Death

There’s a general belief in the suicide prevention space in an ideation to action framework.  This framework says that first people think about it, then they do it.  Shea states, “Roughly less than one percent of people who have had suicidal ideation go on to kill themselves.  This is an extraordinarily important number.  It is a measure of hope.”  Shea vastly overestimates the percentage of people who die by suicide as a ratio of those who have suicidal thoughts.  If we assume that 1/3 of the population considers suicide (which is conservative based on the research), it’s easy to see that the number who go on to die cannot be 1%, because the base rate is roughly 14 per 100,000.  At 1%, those only considering suicide would be 3,333:100,000.  Clearly, it’s substantially less than 1% of people who have suicidal thoughts die by suicide.

Causes

Consistent with the fluid vulnerability theory of suicide, Shea believes that suicide is triggered by external stressors, internal conflict, and neurobiological disfunction.  (See BCBT-SP for the fluid vulnerability theory of suicide.)  Despite the coherence, it’s difficult to understand the mechanisms of internal conflict – and therefore hard to predict the probability of suicide.

Fear of Suffering

There is a fear of death that is inherent to humans.  (See The Denial of Death and The Worm at the Core.)  However, as The Top Five Regrets of the Dying implies, death isn’t the largest fear.  Shea recounts the testimony of an elderly person who answers whether he fears death.  “No. I fear suffering. The older one gets, the greater the likelihood that one will be kept alive without purpose.”  This is one of the reasons why people want the option of suicide – even if they don’t intend to use it.  (See Undoing Suicidism.)

Making Your Way in the World Today Takes Everything You Got

The opening song to Cheers contains the lyrics, “Making your way in the world today takes everything you got, taking a break from all your worries sure would help a lot.”  That’s the way that some people with suicidal ideation think.  Shea says, “Consequently, the common vicissitudes of daily living may present these clients with a bewildering array of unbearable pains.”  He insists, “Most people do not kill themselves in response to a single, catastrophic stressor. It is the stress of living with oneself that more often leads to despair.”

I don’t agree here.  While there are too many lives lost after a long period of pain, there are also those whose journey to suicide is very short.  (See Myth: Suicide is Never Decided Suddenly.)

Swing of Suicidal Ideation

While defining the art of prediction of suicide, Shea also argues against its efficacy.  “Within the span of five minutes, Anna went from feeling wonderful to feeling suicidal. That’s how quickly such a descent into a suicidal maelstrom can occur when fed by a borderline rage created from a bevy of cognitive distortions.”  This statement is supported by research that demonstrates that suicidal ideation intensity can vary quickly and rapidly.

Involuntary Commitment

The greatest fear in disclosure of suicidal ideation is the fear of institutionalization.  There are good reasons for this fear.  Shea exposes the validity of this fear with, “In this type of questioning, besides determining lethality, the clinician is searching for information that would fulfill involuntary commitment criteria.”  As innocuous as it may sound, it’s problematic.  It subtly signals to the patient that the clinician isn’t necessarily looking out for their best interests – they may be protecting themselves from a future lawsuit.

This is particularly challenging when we look at the evidence (or lack of evidence) on the inpatient commitment process.  (See Myth: Inpatient hospitalization is best for people with suicidal ideation.)

Environmental Factors

Shea explains why we need to look beyond the individual for risk: “Suicide is often an interpersonal phenomenon. As we saw with Jimmy, an evaluation of suicide risk involves not only consideration of the identified client but also assessment of the people surrounding the identified client.”  He’s right that some people have environments around them that protect them and help them to avoid suicide attempts.  Other environments are not so friendly.

The environments that people find themselves in can be a huge factor for whether they’re at risk or not.

Indicators

Looking for indicators of risk is good – but expecting them is not.  Consider Shea’s comment, “Perhaps the most important indicator that Kell is probably not imminently suicidal is the fact that she denies current suicidal intent and has no organized plan to harm herself.”  The missing piece of this is “that she has disclosed.”  As mentioned earlier, you cannot know what is in the mind of a client.  We cannot know what they are or are not thinking.

Relying on a few indicators to be present – and shared – means that many people will slip by.

Suicidal Risk Is Messy

Shea admits that clinicians are wary of asking about suicidal intent, saying, “If we uncover serious suicidal intent, we are potentially creating a mess for ourselves.”  The “mess” is, of course, the additional work to assess their imminent risk – requiring institutionalization, enhanced documentation, and the time necessary to stabilize the patient if inpatient hospitalization isn’t called for.

While it’s appropriate to recognize the extra work, people are worth it.

Documentation

Shea recommends seven principles for suicide assessment documentation to keep clinicians out of trouble.  They are reproduced here:

1. Good clinical documentation is the primary shield against malpractice litigation.
2. There can be no good clinical documentation, unless there has first been good clinical care.
3. Even if good clinical care has been provided, if there is poor documentation then the risk of malpractice litigation rises steeply.
4. There are two types of poor documentation:
   • The clinician didn’t document the assessment.
   • The clinician did document the assessment, but documented it poorly.
5. The first legal purpose of a sound written document is to keep the clinician out of court.
6. The second legal purpose of a sound written document is to effectively defend the clinician if the case goes to court.
7. The most important reason to write a sound written document is to convey information to other professionals that may help the care of the client or may serve as a quality assurance checklist for the clinician which, if done effectively, will also result in a sound legal document.

In the end, the right thing for a clinician to do is to create appropriate documentation.  It’s the best defense against a lawsuit and a judgement.  This is true even given the limitations in The Practical Art of Suicide Assessment.

The post Book Review-The Practical Art of Suicide Assessment first appeared on Thor Projects.

Misunderstanding Suicide

“Suicide may be one of the most misunderstood acts, and subjects, on the planet.”  It’s certainly very misunderstood.  They claim that they want juries to deliver verdicts on fact, not myth.  I agree.  It’s a small part of the reason we developed https://SuicideMyths.org.  We wanted a place where people could get the truth in a way that is sufficiently authoritative that people may stop believing the lies that are costing lives.

Ample Warning

A place that I’ll disagree with the author and Skip is that “nearly every person who commits suicide provides ample warning about his or her intention.”  I think those are the kinds of cases that they get involved with – but I don’t think that’s true of every suicide death.  Consider that roughly half of all deaths by suicide weren’t engaged with the mental health system.  Given their role of suing mental health providers, it makes sense that there’s a whole other grouping of suicidal people they’ll never (or rarely) see.

Minor Tragedy

“There’s usually a lot more behind a suicide than some minor event. If a high school or college student commits suicide after getting a poor test grade, chances are that his or her decision was just the final straw of a rather hefty set of problems he or she was facing.”  The tricky part here is that “usually” is probably right.  However, this doesn’t eliminate the possibility that someone was thinking in a cognitively constricted way and made a hasty decision.  (See The Suicidal Mind and Capture.)

The Copout

Responding to the author in an interview, Skip said, “That can be a copout. Most suicides can be prevented, and a caring, compassionate individual is going to do everything in his or her power to stop people from killing themselves.”  The issue at stake is whether you can save someone else from suicide.  The answer – as a technical matter – is no.  No set of constraints that anyone can put on another will prevent them from dying by suicide.  They can, if they’re determined, find a way.

That being said, Skip has a point.  We should work towards preventing suicide in others where we can.

Foreseeability

Skip clarifies that the issue at stake in legal terms is foreseeability, not predictability.  Foreseeability is about whether the consequences of an action or inaction could reasonably have been anticipated.  In clinical settings, the key consideration is whether the clinician can predict the behavior of a patient which is a higher and more important standard.

Skip’s statement, “Professionals, who properly assess for suicide do, however, have enough knowledge to foresee a likelihood that someone will commit suicide in the near future,” can be troubling.  It’s troubling, because when viewed from the prediction lens, this is incorrect.  Research routinely characterizes our ability to predict short term risk as low.  This applies both to screening tools and to clinician assessments.

The gap is that Skip is speaking of foreseeability.  In tort law, if the harm was foreseeable and the person did not take reasonable steps to prevent it, they could be held liable for negligence.  What are reasonable steps?  The quip I’d expect from my attorney friends is, “Whatever the jury says.”  In practical terms, it’s more complicated than that.

“Reasonable” is determined – in part – by the standard of care.  That means that the standards brought forward by the National Action Alliance for Suicide Prevention’s recommended standard care matters.  So, too, do the recommendations of The Joint Commission – an accreditation organization for health care organizations.

“Reasonable” can be as small as having considered the short-term risk and ruled it out based on a set of reasons that are written into the patient’s record.  According to the colleague who introduced me to Skip, this is more than most do.

Proper Assessment, Diagnosis, and Treatment

Skip appropriately criticizes the mental health industry for failing to train clinicians on suicide risks.  However, there are some overreaches in terms of the capacities of the assessment and diagnosis components.  In addition to the assessment issue addressed above, diagnosis – using the standard DSM-V – is notoriously fickle between clinicians.  There are criteria, but they’re broadly written and interpreted in ways that lead to poor reliability.

The good news is that Skip’s spot-on with regards to treatment.  We have clinically validated treatment approaches (DBT, BCBT-SP, and CAMS) that are appropriate for those clinicians working with patients with suicidal ideation or attempts.  I don’t agree with Skip’s statement, “Psychiatric treatments can be just as effective as those for other illnesses, if the clinician is competent.”  We’ve got a long way to go to get to those levels of clinical efficacy.

Safer Cars

Skip says, “Why do we have safer cars today? I’ll answer that…one of the main reasons is because of trial lawyers. It was trial lawyers who forced automakers to design safer cars.”  I’m relatively certain that Ralph Nader would disagree.  In Unsafe at Any Speed and in his other advocacy work, he and others transformed public perception.  As much as it pains me to say it, the claims made against carmakers were written into a cost of doing business rather than taken as an imperative to change their way of business.  Do I think trial lawyers help to encourage accountability? Yes.  Do I believe it stops there?  No.

Firearms

When it comes to firearms in the United States, people can get sensitive.  However, the facts aren’t equivocal.  More than 50% of suicides in the US are completed with a firearm.  However, like most things in suicide, it’s not that simple.  It’s not as simple as saying that access to firearms causes suicide deaths.  Skip explains, “Firearms account for more than 55 percent of suicides. However, guns are easily obtained in Texas, and it ranked 39th in per capita suicides.”

In the US, there’s probably not a more sensitive topic.  Folks like John Lott write books like Gun Control Myths to combat what they feel like is excessive gun control.  It’s a response to sometimes inflammatory writing, like Gun Country, which blames unrestricted capitalism for the explosion of guns and the resulting problems.  More balanced approaches to the challenges of the topic, like Guns in America and America’s Gun Wars, are often drowned out in the competition for headspace.

Ultimately, I’m less concerned about ownership of guns (because that ship has sailed).  I’m more concerned about making sure that guns are safely (or securely) stored.  That means when not on one’s person, they should be locked.  (See Guns and Suicide for a more nuanced conversation.)  If we could just get everyone to store their guns safely, we might find that we don’t need as much from The Suicide Lawyers.

The post Book Review-The Suicide Lawyers first appeared on Thor Projects.

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 accounts 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.

The post Book Review-November of the Soul: The Enigma of Suicide first appeared on Thor Projects.

Birth and Death Control

We have no control of our birth (or our conception, for that matter).  Szasz argues that “the state” insists that we die that way.  His arguments are similar to those made in Undoing Suicidism, but the arguments are more pointed.  He speaks of our work to prevent death row inmates from dying by suicide and then executing them.

With the recent US Supreme Court decision overturning Roe v. Wade, the state governments have moved in to seize greater control of birth rights from mothers.  Szasz’ argument is that governments want control of things that should rightfully belong to individuals.

We have a set of rules that apply to suicide that apply to no other condition, argues Szasz.  Police officers can detain a person against their will on the suspicion that they’re a harm to themselves or others.  Consider a hypothetical situation where an officer is 80% convinced of harm to self or others.  The result is – effectively – imprisonment.  (Detention against will.)  No other condition except suicide carries the same consequences.  There’s no officer detaining someone on the 80% chance that they might want to drive drunk.

Doctor–Patient Relationship

The foundation of any relationship is trust.  (See The Righteous Mind, Trust, and The Science of Trust as a start.)  The doctor–patient relationship has protections to allow patients to be able to share openly.  However, suicide, for too many doctors, isn’t safe.  It’s not something that everyone believes can be discussed, so they directly avoid patients talking about it.  They intentionally ask screening questions in ways that lead the patient to know how to answer.

For those patients that push through and speak about suicide openly anyway, they find that they often are involuntarily detained as a risk to themselves.  Instead of listening and understanding the life concerns that lead to suicidal thoughts, the doctor moves to deprive them of their freedom.  These are, unfortunately, not isolated cases.

Even mental health professionals sometimes move in ways that shame patients.  No-suicide contracts ask patients to commit to contact when symptoms worsen.  The outcome is clearly institutionalization (loss of freedom), but patients are compelled to sign these contracts, because if they don’t, the providers will refuse to treat them.

I pause here for a moment to recognize how counter this is to everything we know about good mental health.  We know that the best indicator of outcomes is therapeutic alliance – how the patient and provider relate – and this signals a complete breakdown.  (See The Heart and Soul of Change.)

Carl Rogers implored therapists to treat their patients with “unconditional positive regard” and to acknowledge that they are the experts in their lives.  (See A Way of Being.)  Both David Jobes in Managing Suicidal Risk and Marsha Linehan in Cognitive-Behavioral Treatment of Borderline Personality Disorder explain that clinicians should work with their patients to support them – not to lord over them.

Mental Illness and Suicide

It’s odd.  90+% of people who die by suicide have a mental illness.  95% of people who have a mental illness won’t die by suicide.  The reason both of these statistics can be true is because the number of people with mental illness is large – and the number of suicides (relatively speaking) is small.  There’s another problem with these statistics: the number of people in the general population that qualify as having a mental illness.  20% or more of adults in the US admit to having had mental illness in the preceding year.  That likely doesn’t include others who would be included if substance use disorder and alcohol use disorder were added in.

The problem is that mental illness and suicide have become tightly coupled in the minds of the public – and both have stigmas attached to them.  Suicide has a long history with stigmatization, the escape from which was to claim mental illness.  (See Stay and A Sadly Troubled History for more.)  The result is that there’s little chance that a person suffering with suicidal ideation will be treated with compassion, should they reveal this fact.

Szasz highlights the missteps by President Bill Clinton on June 7, 1999, when he said, “As we’ve heard again today, mental illness can be accurately diagnosed, successfully treated, just as physical illness.”  The problem when a public official makes outlandish claims is that the public trusts less of the truth – not more.  The truth – despite what some may believe – is that we can’t get reliability of therapists diagnosing with the same condition much less agree on treatment.  The DSM outlines the criteria for various conditions, but the criteria themselves leave so much room that it’s often hard for clinicians to make decisions.  Twenty-five years after Clinton’s claim, we still can’t meet the idealistic standard that he proposed.

Prediction

Perhaps the hardest truth is that we still cannot accurately predict which individual will make a suicide attempt and who will not.  There are some cases when we’re clear that someone is at risk – for instance, if they directly tell us.  However, in most cases, we just don’t know.  We know what leads to increased risk, but not which people will be responsible for the next iteration of those risk statistics.  While we’ve not learned how to predict it, we have learned what won’t work to reduce suicide rates – Suicide Prohibition.

The post Book Review-Suicide Prohibition: The Shame of Medicine first appeared on Thor Projects.

Suicide Connection

I need to pause and explain that the reason for the interest in DBT is because it’s an effective treatment for people who have suicidal ideation or a history of previous attempts.  The connection isn’t obvious until you realize that patients with borderline personality disorder (BPD) are prone to “self-injurious acts.”  Linehan quotes the rate at 70-75% of BPD patients based on other studies.  It’s not surprising that she and her colleagues encountered suicidal ideation, attempts, and death by suicide during their careers.

Manipulation

One of the commonly lobbed labels for suicidal patients is that they’re being manipulative.  Too often, we hear, “They’re not really serious.”  The belief that patients who attempt suicide are not serious is pervasive.  Farberow and Shneidman wrote (edited) The Cry for Help, which demonstrates how little the perspective has changed since 1965.  In my review of The Suicidal Person, I shared the stark difference between the healthcare provider perspective of manipulation compared to attempter.  Healthcare providers perceive manipulation where there is none.

However, for the moment, let’s accept the assertion that it is manipulative, and pause before we accept the pejorative judgement about it.  We’re manipulated every day.  We wear seatbelts because of laws and peer pressure.  We buy one brand over the other because of the manipulation of price discounts and sales.  Why is manipulation even a problem?

The problem, as expressed in Compelled to Control, is that everyone wants to be in control, and no one wants to be controlled.  The sense that we’re manipulated means that someone else is controlling us.  That sense is unacceptable to most of us.  (Work Redesign makes it clear there are some people exist who do want to be controlled – probably through conditioning.)

Healthcare professionals resent the sense that others are manipulating them – but at some level, we have to accept that the behaviors are because their lives are unacceptable.  There’s too much uncertainty, pain, or suffering, and they want to find a way out.  Who among us wouldn’t try to find ways to escape unimaginable pain?

Abuse

Another staggering statistic is that up to 76% of women meeting criteria for BPD are victims of sexual abuse during childhood.  It’s the tragedy pointed to in The Assault on Truth.  The human race is reticent to admit that there are such horrors being perpetrated on our children.  We’d rather turn a blind eye to the problems than confront our failure to protect them.

Synthesis

It’s convenient, but incorrect, to view the world as static and unchanging.  We see things as fixed rather than flux, because it’s easier for us to process.  The truth, however, is that things are constantly in a state of flux.  They’re constantly changing in both predictable and unpredictable ways.  It’s easier to see things as independent parts, but it’s harder to see them as parts of a broader whole.

From the universe with galaxies pulling on one another, to the orbit of planets around a star, down to even the atoms that make up our bodies, what we perceive as safe, solid, and stable are actually arrays of predictable forces and motions.  Most of the space that atoms fill up are actually space, as the electrons form shells around their nuclei.

When we view people as fundamentally stable and fail to accept the times when they’re not how or what we expect them to be, we fundamentally misunderstand reality.

Validation and Change

The fundamental tension in DBT is the tension between the absolute necessity to validate the person so that they know they are seen and understood and the need to support and encourage their change.  In the context of either counseling or considering suicide, something isn’t right, and it needs to change.  Since we only ever have control of ourselves, we need to find ways for us to change.  (See Compelled to Control for more about our inability to control and therefore change others.)

It’s too easy to invalidate.  It’s too easy to say that the world really isn’t that way.  It didn’t happen that way.  It’s hard to start from the perspective of “I can understand and accept that you experienced it that way.”  This invites the challenge of whose perception is “right” but opens the possibility that there are multiple ways to experience something.  It’s difficult to navigate from here to a place of mutual understanding where every experience is acceptable.  It is, in fact, the way the event was processed.  However, there is the need to be open to alternative views.

The real gift is in understanding how to give feedback – and how to help people receive it.  Thanks for the Feedback councils people on how to receive feedback better, including how to identify the triggers that might prevent them from reacting well.  Books like Crucial Conversations and Difficult Conversations offer additional advice about ensuring the transition from acceptance to change is managed well.

Distress Tolerance

Though much of what Mischel found in The Marshmallow Test hasn’t been replicated, there’s an interesting core to the work.  What is the impact of learning to tolerate short-term discomfort for long-term rewards?  Mischel’s answer was a better life.  Einstein’s perspective was, “Compound interest is the 8^th wonder of the world.”  Invest, rather than spend today and harness, its power for your good.  Spend more than you earn, and you’ll suffer needlessly.

Teaching distress tolerance is a key piece of DBT.  Effectively, the tools that are taught in DBT aren’t that different than the tools used by the children in Stanford’s child care center.  Distraction and removing focus from the pain are the key starting points.  Admittedly, DBT does add mindfulness and practices that a child looking for a marshmallow wouldn’t have.  They also attempt to engage in a better appraisal of long-term implications.  If there is value to the pain, they try to find it.  Nietzsche said, “He who has a why to live for can bear almost any how.”

Emotional States

For too many, emotions are scary, uncharted territory.  It’s a place where they dare not go.  When they find themselves feeling or expressing emotion, they’re embarrassed.  Too many were raised in homes where emotional expression wasn’t acceptable.  To be a good child, an acceptable child, there could be no expression of emotion.  When emotions were expressed, they were sent away or, worse, told “If you keep crying, I’ll give you a reason.”  The result of this constraint of emotions is that when they flow, people are confused and overwhelmed.

Imagine a child who is taught that all anger is bad.  They’re taught if they get angry, they’re bad.  The result is that when they get angry, they also feel guilt and shame.  Instead of processing one emotion, they’re overwhelmed by two or three.  Anger is an important and necessary emotion.  Aristotle said, “Anybody can become angry – that is easy.  But to be angry with the right person and to the right degree and at the right time and for the right purpose, and in the right way – that is not within everybody’s power and is not easy.”  Here, Aristotle is implying the universal nature of anger – and both the power and difficulty of harnessing it. Because anger isn’t acceptable, people never learn to interact with it in a way that allows them to find ways to harness it.

Another emotion that is stifled is the sense of sadness, including loss and grief.  Borderline personality disorder patients think, “If I do cry, I’ll never stop.”  They’re afraid that once they let the “monster” out of its cage, they’ll never be able to put it back.  The research on emotion doesn’t matter.  To them what is real is the threat that emotions are things that can overwhelm and overpower reason.  At some level, this is truth.  After all, as Jonathan Haidt explains in his elephant-rider-path model, it’s the emotional elephant, not the rational rider, that is in control.  (See The Happiness Hypothesis and Switch.)  However, at another level, we know that emotions cannot maintain control of us over the long term.

We know that emotions, once expressed appropriately, tend to fade.  (See How Emotions Are Made, Emotion and Adaptation, and Emotional Awareness for more on expressing emotion and the relationship to moods.)  The safest thing to do with emotions is to let them out and let them pass.  Dan Richo in How to Be an Adult in Relationships encourages acceptance and allowing.  Buddhist philosophy suggests detachment and mindfulness, where emotions are acknowledged and then set free.

Inaccessible Territories

We like to believe that our minds are reliable processors of information, but we know through research that this isn’t truth.  We know from Kurt Lewin’s work that there are psychological states, and that the transition between states requires energy.  The path between states may be mediated by other states, and it can be that we perceive that there is no path from where we are to the place we want to be.  For instance, in moments of intense grief, it’s impossible to see how to be happy again.

We also know that our frame of mind dramatically shapes our responses.  Judges grant more pardons after lunch than before.  It makes no sense, but blood sugar and hunger shape our decisions in ways that cannot be seen.  (See Willpower.)  We know that priming people with safety words makes them more likely to take risks.  (See Thinking, Fast and Slow.)  Capture explains how we can get into self-reinforcing states – that end badly.

After the Mistake

Mistakes are, in life, a fact.  It’s not if you’re going to make a mistake but when.  As a result, it’s not that informative when a mistake happens.  What’s really informative is how we respond to mistakes.  Do we apologize?  (See Anatomy of an Apology for how to apologize well.)  Do we make it right?  Or do we hope that the mistake isn’t noticed?  John Gottman in The Science of Trust explains that repair attempts are a vital part of our relationship health.

Don’t Feel

When someone is ashamed of their emotions, they’ll sometimes tell themselves not to feel.  They try to will their way away from their current emotion by overpowering it.  However, this strategy is doomed to fail.  As mentioned above, it’s the emotional elephant that is really in charge.  More than that, we know that cognitively this doesn’t work.

In White Bears and Other Unwanted Thoughts, Daniel Wegner explains how we cannot not think about something without first thinking about it.  This paradoxical situation means that the more we try to actively avoid thoughts, the more consuming they become.

The only working strategy is to allow feelings to run their normal course.

Fear of Getting Better

One of the challenges of therapy is that people may decide they enjoy the process so much that they’d rather stay in the process than recover.  It sounds odd, but one of the barriers to successful completion of therapy is that sometimes the person wants to stay in therapy.  As explained in Immunity to Change, there are sometimes these hidden barriers that stop people from making the change you want them to make.

In the context of therapy, the greatest loss is the relational loss with the therapist.  If they get better, then they will no longer have a reason to stay in the relationship.  Of course, this is a barrier to them getting better – whether they’re conscious of it or not.

Responsible for What You Become

The tragic reality is that most people will encounter a trauma in their life.  It’s a part of the human condition, which very few will escape.  While trauma is inevitable, continued suffering is not.  We’re often not responsible for the trauma that happened to us, but we are responsible for how we respond to it.  (See also Hurtful, Hurt, Hurting for a similar concept.)

What You Cannot Do

There is a misalignment of image that can occur between the person themselves and the therapist – or other caring person.  Internally, a person may be consumed by self-hate.  (See Compassion and Self-Hate for more on self-hate.)  One’s self-image may be such that even if there is no self-hate, there is also no opportunity for pride or positive feelings.  There may be no opportunity for self-esteem or self-agency.  This can come in stark contrast to the perception of others.

When the therapist (or other person) suggests that there is capability and possibility, it may be met with the retort, “If you knew me, you wouldn’t ask me to do what I cannot do.”  For that person, they literally cannot accept the possibility that they can do what is being asked – even if they’ve done it before or demonstrated the behavior.

This can become a problem for the therapist as well.  Once someone has demonstrated a behavior, they expect it can be replicated, while the person may steadfastly insist that it’s not possible.

The opportunity here is to help the person see that they are capable – but this can take time.

Threat Response

One of the dysfunctional power dynamics that sometimes happens is that the patient exerts control over the therapist, often by threatening suicide.  There are numerous techniques that are described that refocus the power of the relationship such that the patient isn’t manipulating the therapist.  One of the ways that this is done is by “extending.”   This is, in essence, taking the patient more seriously than they take themselves.  If they say something like, “If I can’t get an appointment next week, I’ll kill myself.”  An artful response might be, “How can we talk about a mundane topic like scheduling when your life is in danger?”

Arbitrary Change

One of the challenges in change is connecting the change with reasons and theories of operation, so that the change made isn’t arbitrary but, instead, is relevant and powerful.  Of course, the real challenge when working with people is identifying which changes are relevant.  Without a clear understanding of the factors driving people – either in the specific or in general – it becomes hard to identify what influences what – and therefore what small thing may be capable of making a large change in the back end.

As the therapist improves their understanding of the person, including their history, perspectives, and values, they’re better positioned to develop or adapt working theories to accommodate the person and the change that’s being proposed.

When Praise is Invalidation

It seems like praise should be a good thing.  The person being praised should experience it as a positive – but that’s not always the case.  Sometimes, when you’re receiving praise, you recognize that the other person’s sense of you and the situation are very far from your sense.  It can feel as if they don’t understand.  This lack of understanding can be invalidating.  As a result, praise often needs to be strong enough to move the person’s self-esteem and sense of personal agency forward, but not so far ahead of them that they feel as if you don’t understand.

One approach is to start by recognizing that there were possibilities for improvement – which the person is likely focused on – but that the overall experience or activity was good.  By allowing for imperfection, you make it easier for someone to accept the praise.

Another fear associated with praise is that the person who is doing the praising will withdraw support.  The historic experience is that, after the praise, support is withdrawn, and therefore praise is associated with a new sense of vulnerability – one that is quite often unwelcome.  In these cases, it’s useful to reinforce continued support with the praise.  “You’ve done a good job of managing the relationship with your mom.  I’ll continue to be here if you need me.”

Forming the Chains

Too often, we can’t connect the things that we do and the outcomes that we get.  We take actions, and the results are so erratic, inconsistent, and delayed that we can’t make the connection.  Instead of seeing how things connect to one another, we perceive them as completely random or beyond our control.  In some cases, the sense of randomness is real – but in other cases, our behaviors have a real and measurable impact on the outcome.

It’s possible to discover previously unseen relationships between behaviors and outcomes with careful analysis – but this isn’t natural, and patients can resist the process of determining the connections between behaviors and outcomes.  DBT calls this “chain analysis.”  When worked backwards, this is often called “root cause analysis.”

The idea is that, given an outcome, we can identify the one root cause of that outcome.  I prefer a slightly broader definition, where it’s not a single root cause but rather are a cluster of conditions that led to the outcome.  Some of those conditions are the behaviors of the actors in the system.

Consider a situation where a family doesn’t have much savings, and they suddenly need to fix the car – but they don’t have money to pay for it and to feed the family.  What is the root cause of the problem?  Is it the failure of the car – or the failure to put aside an emergency fund?  What additional conditions must be present?  For instance, not having family members willing to help lend money.  What happened that family members aren’t willing or able to lend money?

Threats to Way of Being

Sometimes the criticisms we receive aren’t perceived as being about some situation or behavior but rather as a threat to our very way of being.  Rather than being an isolated case, it’s seen as a fundamental condemnation of the way that we think and act.  This perception can incite anger or despair depending on whether the response is directed outwardly or inwardly.

Unfortunately, we view our identities from an unconscious and multifaceted lens.  It’s not always possible to identify what another person would consider a threat to their way of being.  That makes it important to be prepared to recover if you accidentally trip over something that someone feels is core to their identity.

You Don’t Know What I’m Going Through

A familiar trap that people, whether clinicians or not, fall into is saying to the other person, “I know what you’re going through.”  The problem is this statement is false.  We don’t know exactly what they’re going through.  We didn’t grow up with their family of origin.  We don’t know all the pressures on them at the current moment.  A better response is, “I can understand some of that,” or perhaps indicating what aspects you believe you can understand.  We can’t assume that we know what someone is feeling completely.  Our experiences may be similar, but they are not the same.

Irreverent Communications

Sometimes a conversation is headed down a bad path.  Irreverent communications can be sufficiently disruptive that he helps the other person “jump a track.”  In other words, if the path the conversation is going down seems stuck, irreverent comments can break the pattern to allow a new pattern to emerge.  It’s a strong driver for change, sometimes with hidden costs.

Too much irreverent communications, and the other person will believe you’re not taking them seriously.  Not enough, and you may be stuck in patterns of communications that don’t lead to results.

Who Is on the Case?

It’s typical now for healthcare to include a case manager.  This is a person whose job it is to help ensure that the patient is getting what they need.  While this has been shown to be clinically effective in many cases, it may not be the best choice for BPD patients.  DBT emphasizes patient agency.  There’s extra value in having the patient take ownership of their care that case management or overly paternal approaches from the therapist can rob them of.

In general, the goal is for patients to speak up for themselves and only have healthcare workers (case managers or therapists) step in when the patient isn’t capable of supporting their own care – and only until this can be resolved.  Every patient should be capable of advocating for themselves, they just need to be shown how to do it.

Friends and Family

Virginia Satir in The New Peoplemaking and The Satir Model explains the family systems that can keep someone stuck in a dysfunctional pattern.  Rather than focusing on one person’s behavior, the model encourages us to look to how the system reinforces certain behaviors and discourages others.  (See also Thinking in Systems for a primer on systems.)  This highlights the powerful allies – or saboteurs – that friends and family can be when someone is making changes.

Change or Die points out that many successful substance use change programs intentionally change the environment that surrounds the addict to encourage positive behaviors.  Kurt Lewin said that behavior is a function of both person and environment.  While you’re working to change the person, you can change the environment.  (For more of Lewin’s work, see A Dynamic Theory of Personality and Principles of Topological Psychology.)

Hospitalization

The sad reality of hospitalization is that it isn’t for the patient.  It’s for the provider.  They get to pass the buck and make someone else responsible should a patient die.  The problem is that no one has ever shown that inpatient hospitalization is effective.  On the contrary, we know that the period of greatest suicide risk is immediately after being discharged from an inpatient program.  So why do many providers still subject patients to hospitalization?

The risk of suicide becomes too great, and they panic.  They decide that they’re not throwing away their career because they can’t be certain a patient won’t attempt suicide.  As a result, they give up.  They decide that they’re not capable of helping the patient through Cognitive Behavioral Treatment of Borderline Personality Disorder.

The post Book Review-Cognitive Behavioral Treatment of Borderline Personality Disorder first appeared on Thor Projects.

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.

The post Book Review-The Suicidal Person: A New Look at a Human Phenomenon first appeared on Thor Projects.