Compelled to Comment - Part 3: Towards a Better Understanding and Prevention

       What we aspire to know, to gain advantage: As I emphasized in Part 2, while assiduous research into the critical subject of suicide is ongoing (which will certainly lead to improved models of prediction, mitigation, and prevention), intellectual honesty once again compels us to acknowledge that a foolproof algorithm does not yet exist. We do know there are certain 'risk factors' that heighten the possibility of suicidal ideation, planning, and attempts (all very important in intervention), such as: family history of depression/suicides, early maltreatment in family setting, previous attempt(s), history of mental illness (especially depression, which is frequently 'masked' in men by surface/manifest anger), and history of alcoholism and/or substance abuse. We have also become more aware of certain 'protective' factors (i.e., those that moderate the degree of risk when present): availability of effective clinical care, family and social supports, skills in problem solving/coping, and cultural/religious orientations that discourage self destruction and conversely support self-preservation (what I many times refer to as 'spiritual warfare').                                                                                                                                               It is highly critical for me to point out here that no one or combination of risk factors (including the stressors associated with the current pandemic) cause suicide, no more than the noted protective factors prevent suicide or guarantee the development of resilience (a highly sought after characteristic which may insulate us from self-destruction, still a frontier of study in our field). If anyone had a reason to say "goodbye cruel world" it was Sybil, who endured the torture of a raging psychotic mother coupled with a passive, frequently feckless father. Yet she chose life (albeit after prolonged psychoanalysis). Then there is the well documented experiences of Viktor Frankl ("Man's Search for Meaning") who, observing the equally emaciated men in his proximity in the WW II concentration camp, could identify those who were more likely to die first, as they did not find purpose/meaning that day, even in the most meager of tasks such as improvising shoe laces (his repeating theme: "Life does not owe me but I owe life...I have to find the purpose...despite not because of what I am enduring".). About a year after surviving the concentration camp, Dr. Frankl gave a talk "Say Yes to Life, In Spite of Everything".                                                               Confounding our current understanding of suicide are such variables as an individual's willingness to confide suicidal thoughts/intentions (regardless of how approachable we are), as well as the level of honesty when doing so. We still are trying to discriminate (through sophisticated statistical analyses) between those who don't confide, who seem to be living an otherwise normal, even idyllic life but who still attempt or complete a suicide (e.g., even Olympic gold medalists are not immune), and those that make multiple threats and don't ever act on them. Further, there are those who 'survive' an attempt and embrace the second chance, whereas others repeatedly attempt and finally 'succeed'. Finally, there are numerous cases of people whose deaths are deemed suicides but we believe they may have been making a 'cry for help' and 'accidentally' overdosed, for example. 

       What are we to do? While we continue to search for both understanding and improved methodologies of prevention, we do possess effective tools for mitigation, including: active treatment (studies have demonstrated those in active mental health treatment commit suicide less than those who never seek or receive any form of treatment) which addresses feelings of helplessness, hopelessness, and powerlessness; possible medication in the case of a diagnosed mood disorder; and ample engagement of social supports (including but not exclusive to family). In addition to these measures, on this day designated as World Suicide Prevention Day, I share with you a Socratic method I employ, which includes a series of questions as to whether the respective individual has in fact ever talked to anyone who completed a suicide ("Of course not Dr. Irving...") and what that (deceased) person is in fact experiencing, along with a discussion as to whether anyone has ever come back to tell us what God, Heaven or, for that matter, Hades, looks like (of course not and no one of us can account for these any better than the six year-old who drew a picture of what she believes God and Heaven resembles on the first day of school). The discussion eventuates (by design) to a specific acknowledgement that even people who profess to be of great faith, are taking a 'Leap of Faith' when considering the afterlife. No one I know (including many devout Muslims I have interviewed) believe the suicide bombers from 9/11 are in the 'Paradise' they were promised. The discussion usually ends by further active contemplation on just what the individual believes they will accomplish (e.g., "I'll be rid of this pain..."), and at least a counter argument that suicide is NOT an option, NOT a resolution. While I have no hard empirical evidence on the efficacy of this approach (again in addition to not in replacement of other strategies), those I have encountered tell me it was at least somewhat transformative. I can only hope that if you ever find yourself in dire circumstances that lead you to contemplating the act of taking your own life (or you are in audience with someone who is), you will actively contemplate such questions as well; I trust you, too, will "Say Yes to Life In Spite of Everything".