Dispelling the silence and shame around suicide

Suicide: saving lives, comforting survivors

Dear Reader,

All health issues are personal, but this month’s is intensely so. Death by one’s own hand is at record levels in the United States. It doesn’t matter if it’s a celebrity or a family member: death by suicide sends ripples of sorrow and shame — and yes, frustration and anger too — that wash over everyone who knew the victim even a little bit.

Can we spot them before it’s too late? Can we intervene in a positive way to help those around us who might be thinking of killing themselves? The answers are yes, not always but often enough that it’s worth knowing more about.

And when it does happen, is there anything we can do that will help the deceased person’s loved ones and that  won’t inadvertently deepen their pain?  The answer again is yes. How we say it can be just as important as what we say.

Real facts about suicide too often are shrouded by destructive myths

Here are some myths and facts about suicide:

Myth: People bent on killing themselves will figure out a way, and there’s nothing the rest of us can do to stop them.

Fact: This is an especially bad myth, because it’s not only wrong on the facts, but it’s so fatalistic and almost cynical. The fact is that most people who kill themselves yield to a sudden impulse in the midst of a personal crisis. If we can help them through the crisis, the risk will subside. And if we can help them past the impulse, the risk will also subside even if the crisis hasn’t.

There are both personal and societal implications from this big fact. On the societal level, we know that suicide barriers work. That fact has finally sunk into the overseers of the Golden Gate Bridge, the No. 1 suicide magnet in the world. They started planning to put up netting in 2013 and now are scheduled to complete their barrier in January 2021. Better late than never for a bridge that made self-execution, in the words of one would-be victim who was a rare survivor of a jump, “ridiculously easy” with its four-foot railing and nothing below to break the fall to the frigid water of the San Francisco bay 220 feet below. I recommend a moving piece by Tad Friend published in the New Yorker in 2003 and still fresh.

The concept doesn’t just apply to bridge barriers. Anything we can do to make suicide impulses less easy to carry out can be life-saving. That includes keeping guns away from depressed people. It’s no coincidence that states with high rates of gun ownership, like Wyoming and Montana, have the highest per capita suicide rates.

Myth: People who kill themselves have simply made a choice that life is not worth living, and we should respect that and leave them alone. 

Fact: There may be a few people out there for whom suicide seems like a logical exit strategy. Hitler comes to mind, not that you have to be evil to fit this logic. And it might also seem somewhat logical for people in the final stages of a fatal and painful disease, particularly if they have outlived other family members. But for the vast, vast majority, suicide is a product of disordered thinking. A voice whispers: “You’re worthless, you’re a burden,” and so someone who is eminently worthy does himself in: Robin Williams, David Foster Wallace, Anthony Bourdain, Kate Spade, Sylvia Plath. All were creative, vibrant souls who brought joy and laughter and delight to many.

And, of course, there are many more, not household names but we’ve all known someone like this, whose lives had connections and meaning and real accomplishments, and then we learn one day that they’re dead by their own hand.  And the long lines of bereaved survivors stand in mute refutation of the idea that the victim had no one to live for.

So, I reject the idea that there is a logic to suicide that we should stand aside for.

Myth: Suicide is nearly always the product of depression or another mental illness. 

Fact: The statement actually becomes a true fact if you strike “nearly always” and substitute “sometimes.” People in the dark night of depression can develop a profound hopelessness that amplifies the physical manifestations of this common disorder. William Styron wrote movingly in his memoir Darkness Visible: 

“In depression this faith in deliverance, in ultimate restoration, is absent. The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come—not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul.”

And of the physical side of depression, he wrote:

“It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero. Ultimately, the body is affected and feels sapped, drained.”

On the other hand, the angst that drives some to suicide isn’t always or necessarily related to a mental illness. That’s why I said that “disordered thinking” captured the concept better for me.

The eternal question: What makes life worth living?

Some suicidal people aren’t really depressed at all. (Or perhaps they hide it extremely well, but I don’t think so.) Instead, these individuals have lost the life-long struggle for hope and meaning. Anthony Bourdain may fit this mold.

Here’s an extended quotation from a recent piece by Caroline D’Agati that I thought captured some deep truth:

“Every human being must at some time confront the same disease that claimed Anthony, Kate, Robin, and every other person who takes his or her life: meaninglessness. Why are we here and is this life worth living? It’s a sobering thought. Friedrich Nietzsche — another struggler — said that anyone with a ‘why’ to live could endure almost any how. These wealthy, accomplished people had some of the most marvelous ‘hows’ anyone could imagine. Yet none of it could make up for the lack of ‘why.’

“There is a reason trauma victims, combat survivors, and celebrities are so vulnerable to suicide. Victims of abuse and witnesses to war are exposed to a depth of humanity that many of us never get to. The lowest lows show us just how depraved and hopeless this world can be.

“Those with everything are often no different. The highest highs show us that, no matter what we achieve or acquire, the hopelessness doesn’t go away. Both the king and the pauper stare life in the face and see that it’s merely ‘vanity of vanities, all is vanity.’ ”

Ms. D’Agati’s antidote is to seek meaning in the One who created us. But the gift of faith in God and faith in eternal life is just that, a gift. It can be soothing and protective for those who were touched by the gift, but to others, religion seems like utter nonsense.  I’m more in the believer camp, but a struggling believer. I do know that life’s meaning is a worthy subject for deep contemplation, with no final answers.

A key first step: Spotting someone at risk

Few readers of this newsletter are mental health professionals. But suicide is everyone’s business, because the harmful effects are so vast and lasting, not just for those who end or try to end their own lives, but for all their family and friends and acquaintances.

The first task is to spot someone at risk.

Here’s a mnemonic of suicide warning signs from the American Association of Suicidology:

IS PATH WARM?

 I  Ideation
S  Substance Abuse

P  Purposelessness
A  Anxiety
T  Trapped
H  Hopelessness

W  Withdrawal
A  Anger
R  Recklessness
M  Mood Changes

Ideation means threats or talk or actions (seeking guns, pills or other weapons) aimed at hurting or killing one’s self. The rest of the list is pretty self-explanatory. You don’t have to have all of them to qualify: just some worrying combination that makes bystanders wonder if this person might try something drastic.

Some of us worry that if we ask, “Are you thinking about hurting yourself?” we might be planting a seed. It’s better  by far, I think, to work at a way to break through the silence and shame that surround thinking disorders like this and just pop the question. Of course it’s also totally acceptable to call in a trained professional. Or call the national help line: 1-800-273-TALK (8255).

The only thing unacceptable is doing nothing and remaining silent. That can deepen and reinforce the at-risk person’s sense of withdrawal and hopelessness.

The prevention paths are especially key, by the way, in curbing the also rising and scary incidences of young people taking their lives. The young often lack the maturity and experience to bolster the resilience they might need to battle suicide or its attempt. Research suggests that the brain itself grows and changes in the young, notably so they gain greater impulse control. Maturation of so key an aspect of life may make a difference when youths in despair make the flash decision to end their lives.

The young, as much as any, also need a good ear and grown-up presence to assure them that life gets better, bullies (in cyber space and in person) can be overcome, and today’s dramas won’t matter in just a bit, if teens can wait. It’s an important sentiment and concern captured in the vernacular by an anti-suicide campaign targeted at high schoolers entitled: “U Ok?”

Soothing survivors by just being there

This is really hard, but really important. Survivors of a recent suicide victim need their friends and family nearby. You won’t know what to say. You may be literally speechless. That’s okay. What’s not okay is being absent.

There are a few things you should avoid saying, because they’re hurtful without meaning to hurt. For example: “I know what you’re going through.”

No, you don’t know. A survivor will likely have a swirling, complex mix of emotions: the usual grief at any sudden death, mixed with anger, guilt and other strong feelings. Pretending you understand all that can look like you’re trivializing an unimaginable tragedy.

A few other things not to say, because they also tend to minimize what happened

• “He’s in a better place.”
• “You’ll get over it.”
• “Everything happens for a reason.”
• “God never gives us more than we can handle.”

These are all standard bits we tend to say at an ordinary death. They just don’t work with suicide.

So what should you say?

You can start with the honest truth: “This is so hard. I don’t know what to say. But I want to be here for you.”

Feel free to say how much you loved, enjoyed, liked being around the deceased person. Anything that is natural and genuine works well.  Reminiscing with the survivor is a good thing.

Offer some specific bit of help to the survivor. This is much better than the empty cliché, “Please call me if you need anything.” Better to say: “Is it okay if I bring over dinner tomorrow night?” And if you see a specific need, fill it. So if the refrigerator is empty, go to the store for them.

If the house is already overflowing with food and you cannot think of something concrete you can do to help, just be there.  Sit with them, walk with them, watch TV with them.

Keep checking in with them. There’s no lonelier time than the weeks just after a funeral. This can actually be the hardest time, after all the out-of-town relatives have gone home and the house is empty and echoing with the ghost of the suicide victim. The survivors need you then more than ever.

The lessons for the rest of us from physician suicides

It’s an old cliché, and a bitter one in this context: “Physician, heal thyself.” Because there are clearly many health care providers who cannot heal themselves and succumb to depression and even suicide.

Some grim numbers (from the American Foundation for Suicide Prevention): Doctors have the highest suicide rate of any profession in the United States; male doctors kill themselves 1.4 times more often than the general male population, female doctors 2.3 times higher than the general female population. One doctor commits suicide every day.

The reason this matters for the rest of us non-doctors is that there are some factors pushing up the suicide rate among doctors that shed light on the overall suicide crisis.

For example, many doctors feel pressure to avoid seeking professional help for mental health issues. They worry about the fallout for their licensing, and in fact some state licensing boards are unusually aggressive in hounding applicants about mental health histories. Hospitals considering bringing a doctor on staff also can demand mental health treatment information, and the consequences to a doctor applicant, especially a young one on the outset of a career, can be huge. Ditto for malpractice insurance carriers whose application forms are intrusive.

There are other reasons for not getting professional help: a reluctance to cross the line from doctor to patient, or to admit “weakness.” Whatever the reason and whatever the objective reality behind it, not seeking professional help for suicidal feelings can be fatal.

Another issue important to physician suicide is the shame and silence that surrounds it. There has been a spate of young doctors jumping from high buildings to their deaths in New York. You wouldn’t hear about it, except for the dedicated work of a family doctor named Pamela Wible, who has made it her mission to chronicle and bring into the open physician suicides, for learning lessons and preventing tragedies. Here is one of her many moving pieces on the subject, this one on KevinMD.

The lesson for the rest of us is that we need to move past the stigma, reach out to friends who are hurting, and show them that they are loved and needed.

Helpful resources abound

Here are select resources on suicide prevention (please click on the hyperlinks to access):

• The issue isn’t new and has only worsened over time. USA Today reported a series in 2014, with lots of good information.
• The new report on suicide as a public health crisis from the federal Centers for Disease Control and Prevention and its periodic publication, Vital Signs, includes excellent material.
• The CDC has posted a “technical package,” a deep dive for policy makers and public health officials on suicide prevention.
• The National Suicide Prevention Hotline has its online information cache for help.
• The American Foundation for Prevention of Suicide offers resources, though it’s worth noting this group has its own controversies over its taking of money from the gun lobby and its subsequent refusal to take a strong stand on keeping guns from depressed people.
• It’s worth checking out the trove of suicide research and prevention materials from the charitable, nonprofit American Association of Suicidology.
• The National Institute of Mental Health has information posted online about suicide and its prevention.
• Suicide prevention has been a focus for researchers at RAND, especially self-inflicted deaths that skyrocketed with US armed forces’ deployments in Afghanistan, Mideast. The US government poured more than $200 million into efforts to reduce military suicides, also with hope that learnings could be used by civilians.
• The federal Substance Abuse and Mental Health Services Administration has issued a tool-kit to assist high schools with suicide and its prevention. Those focused on young people and the problem also may wish to view the national “U Ok?” youth prevention campaign.
• The New York Times’  coverage has included reports on: cognitive behavior therapy and suicide prevention; telling experiences of therapists and counselors; risks of copy cat outbreaks; the importance of sustained help, especially because repeat attempts are common.
• Firearms play a terrible and undeniable role in suicide, which is why it’s worth reading research on the topic from the Brady campaign against gun violence and from Harvard’s public health school.
• Because depression is the psychiatric diagnosis and condition most linked to suicide, information information worth exploring may be of interest from UC Santa Barbara, the CDC, or the National Institute of Mental Health.
• The suicide crisis serves to underscore the dire need in this country for increased mental health services, which too often are under-funded, inaccessible due to cost, insurance, and practical causes, and subject to persistent stigma that needs to be overcome.​

HERE’S TO OUR HEALTH FOR THE REST OF 2018!

Sincerely,

Patrick Malone
Patrick Malone & Associates