We are in the midst of a public health crisis of suicide, yet our understanding of why it happens and how to prevent it remains frustratingly limited. Our widespread cultural perceptions about it — that there are clearcut depressive red flags before, that there's a lengthy note left behind — only represent one kind of scenario. But not all suicides follow a Kurt Cobain narrative. And treating the problem as if they do that doesn't do much to ameliorate all the other possibilities.
Author Craig J. Bryan is trying to shake up our limited understanding. His "Rethinking Suicide: Why Prevention Fails, and How We Can Do Better" is a powerful, eye-opening examination of research shows about why suicide happens, and the actions that could prevent many of them. While traditional mental health support has an important place, for example, it's not enough. We need to be looking at circumstances and opportunity. Consider, for example, one of the most astonishing revelations of the book: "Whereas adolescents with a mental illness living in a household with a firearm are 3 times more likely to die by suicide, adolescents without a mental illness are 12 times more likely to die by suicide." Our presumptions about the warning signs are not enough. So what does work?
Salon spoke to Bryan, a clinical psychologist and the Stress, Trauma, and Resilience (STAR) Professor of Psychiatry and Behavioral Health at The Ohio State University Wexner Medical Center, about what we get wrong about suicide, and what we need to know to tackle one of our most pressing "wicked problems."
This conversation has been edited and condensed for clarity.
One of the first phrases you use in the book I had not heard before. What is a wicked problem, and how do we approach one in the context of suicide?
The term "wicked problem" was developed to really capture the notion that there are some types of problems that are highly complex and cannot be readily solved through traditional, solution-focused, linear thinking. A lot of the typical examples of wicked problems are these big societal problems. Right now that might be global warming, or poverty, or homelessness, where there really isn't a clear single solution. You really can't think about wicked problems in terms of solutions, especially in terms of right and wrong strategies. You have to think in terms of better or worse. Some strategies might be better than others, some strategies might be worse, but there's no right answer or single solution.
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It's definitely the case with suicide. One of the arguments that I'm making in the book is that we tend to approach it from that solution focused angle, and the predominant solution that has been proposed and that's been adopted, definitely here in the U.S., arguably globally as well, is "mental health problems, mental health treatment." That if we could just get everybody into mental health, if we could identify them earlier, get them into treatment, then we could solve, theoretically, this problem of suicide.
That's not a terrible start, raising awareness of mental health and mental health treatment. But the problem, as you lay out, is that this is not always just a clearcut mental health issue. You talk about confirmation bias and you also talk about survival bias, and the fact that a lot of what we know about suicide comes from people who survive attempts.
On top of that, the people who survive attempts oftentimes are interviewed, they're surveyed, we collect data from them in clinical settings. They survive a suicide attempt so they come to the emergency department, receive medical care. They might be admitted to a psychiatric inpatient unit, they're referred for mental health treatment. So we largely have based our assumptions about suicide from this subgroup that is convenient for mental health researchers to access. The voices that we are missing, of course, are those who don't survive their first suicide attempt, those who don't come in for mental health treatment. They could potentially have a very different pathway towards suicide. Some of what I explore in the book is that the data would seem to suggest that's very probable that they are following a different course and we are largely missing them because their data, their information is totally invisible to us. In essence getting it wrong.
The thing that is extremely important, that is terrifying, but also maybe hopeful because it starts pointing us in the right direction, is how much of suicidality can be down to impulsivity.
What's interesting is over the past, maybe decade, if not less time, that notion of impulsivity has become fairly controversial among suicide researchers. There are many who I think have argued very effectively that suicide is not impulsive. Or maybe a better way of saying it is that impulsive people do not necessarily attempt suicide.
What it reflects on is this notion of what we even mean by impulsivity. Impulsivity is actually a pretty nonspecific term. We use it to refer to lots and lots of different things. There are good data saying that the whole notion of trait impulsivity as a characteristic of who you are as a person doesn't really seem to be strongly correlated with suicidal behaviors.
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Nonetheless, there is a large subgroup of people who attempt suicide very suddenly. The question becomes well, is that impulsive? Things that happen quickly don't necessarily mean the person's impulsive. It just means that it was a rapid shift. The language that we have used gets very mixed up, such that it's hard for us to fully understand this issue of suicide when we're using verbal constructs in very imprecise ways.
It's an imperfect correlation, but it made me think of that French phrase, l'appel du vide, the call of the void. There is some feeling that is not rational that comes over you. And that can be that tipping point. There's something here that is so important to discuss, and that is the timeline of decision making for people. What does that look like for a lot of people?
If you look at some of the studies that have been published, when we interview those who have survived a suicide attempt and ask them, "How long did you think about it before you actually made the attempt?" What you see is something like a quarter of them will say five minutes or less.
A quarter. A quarter.
One in four will say it's just, boom. It was within a few minutes.
I just want to tamp on that because that is so urgent.
It's very rapid. Even if you extend the timeline a little bit, you go out to, "So I acted within an hour of my first thought or first impulse," in some studies that's up to about 75 percent of those who attempt. Now, there's a lot of debate about this. There are a lot of researchers who argue, well, these are people who have thought about suicide in the past, and it's episodic and it comes and goes. There's a lot of good evidence, our research shows that as well. Then there are some researchers who say it's impossible to attempt suicide or to engage in suicidal behavior without this sort of forethought. Yet what we see in our studies consistently is that there's a good number, maybe like 10 to 15 percent, who are saying, "I didn't have any thoughts about suicide at all before I attempted." You can expand it to say, "I mean, I thought about suicide, but it happened at about the same time, or within an hour of attempting." So it was the sudden transition.
We've largely dismissed that and said, it's kind of a demeaning term, but, they're bad historians. That these people have reasons to not disclose their true experience, or they're incapable because they're so upset. That might be true sometimes, but by and large, I don't know that that many patients would be deliberately concealing or deliberately trying to lead us astray. The alternative explanation is, maybe people are actually describing what they experienced, and we should perhaps listen to that and think about suicide in a different way, abandon some of our notions about suicide and recognize that there are some who very rapidly move from a low risk state to a high risk state. What that means is that a lot of our classic prevention methods, like the whole notion of warning signs, they're going to be pretty limited.
I give the example in the book of a gymnast. When I do presentations and talks, I show a video of a gymnast who's doing this amazing routine and then just very all of a sudden, they fall off the balance beam. They lose their balance and fall. It just happens so quickly. In retrospect, there were warning signs. You saw her leg shoot out. You saw her trying to catch her balance. But it happened so quickly that you couldn't even process it until after she had fallen off of the balance beam. I think the same thing happens with suicide. There's a lot of people where, by the time we can even make sense out of a possible warning sign, the behavior has already occurred. If that's true, then that means we really need to seriously rethink how we prevent suicide.
One of the things you talk about that must be very controversial to say, is that not having easy access to a gun in your house can make a huge difference.
I would argue if we really want to bend the curve on suicides in the United States, where we should probably put a lot of our time and effort is related to firearm availability. It is controversial. It's the third rail of suicide prevention. We do a lot of work now. A huge part of our research is focused on firearms suicide. What we've found is that when you sit down with gun-owning communities, — we go to gun shops, we go to shooting ranges, we go to gun shows — we recruit gun owners and say, "Would you answer some questions for us?" We really have reached out to them. It's predicated on the notion that there are actually sort of multiple ways that we can prevent suicide. The first and the classic is stop people from trying to kill themselves. That's everything that we do in suicide prevention. The idea is, if you don't try to kill yourself, then you can't die as a result.
But there's actually a second way to prevent suicide, and that's to help people survive their suicide attempts. It's really based on this notion that I think we will not be able to prevent every suicide attempt from ever happening. If we accept that as a truth, which is not a popular opinion, but it's reality, then what we need to do is everything we can to maximize the likelihood that someone gets a second chance after a suicide attempt. We need to reduce the lethality of suicidal behaviors. One of the surest ways to do that is to make it difficult to die as a result of suicidal behavior.
In some cases that would be complete removal of firearms from the home. But in other cases, for firearm-owning households in the U.S., it's using locking devices and other storage practices that can get in the way of your kid finding or having access to a loaded weapon during a breakup or some other momentary period of distress. It's also relevant for adults. It's not just for the kids. Even those few seconds that it takes to unlock the gun, to load it, things like that, sometimes is enough for that urge to pass and for a person to survive.
You're talking about that ebb and flow.
One of the important lessons we've learned over the past several years as we do more and more research on firearms suicide is that one of unintended consequences of this heavy focus on the mental illness model of suicide is that it really has created a wedge between the suicide prevention community and the gun-owning community. It's to the point that a lot of times when we bring this up with gun owners, they say, "I've taught my kids to respect guns, this has nothing to do with suicide prevention, that's a mental health issue." Things like that. We have to overcome those barriers to reconceptualize suicide from more of an injury prevention model. Once we start talking about things like, "You buckle your seatbelt even though you don't plan to get into a car accident. I know you're a great driver, but you buckle up anyway because everybody else is a dangerous driver, right? And you lock up the chemicals and cleaning supplies in your home so your kids don't get hold of them."
Once we take that perspective, we find that then gun owners are much more open and they think about it in a different way. They say, "I never thought of it that way before, maybe this is something that could be beneficial to me and my family."
You talk about dialectical behavioral therapy and "the life worth living," which is a huge concept. Tell me what that is, and how that can head off suicidal behavior in a way that other types of treatment and other types of therapy don't necessarily do.
The status quo approach with suicide prevention is to prevent people from dying. So we put them in hospitals, we call the police, things like that. The whole idea is keep them alive. But what that fails to consider is that oftentimes to the suicidal person, life is unlivable. It's very painful, there's a lot of suffering. There may not be a lot of desire to continue living. So to many suicidal individuals, it's like you're just, prolonging my suffering by keeping me alive. I think being able to recognize that and then say, the alternative to dying is living, it's sort of a subtle shift. I like to say living because it really captures that it's a process. It takes lots of little things, not only for the person, but also the community around all of us, to impact the desire to live and to make living worthwhile.
How we treat each other, how we construct our environments and communities, how we think and how we behave, can help us to find purpose, to find meaning, to find even positive outcomes or positive situations even in our darkest moments. What we think is, at the neural level, when a person's making that decision, "Am I going to live, am I going to die?" if they can harness or tap into these positive emotional states, like having that sense of purpose and meaning, it hits as a braking system. It's like, just hang on. Hold on just a second. Don't act now. And it helps to get them through that urge.
My appreciation for this came with all the work that I did with suicidal individuals who said after our treatments, "I still get stressed out, I still have problems, I'm still depressed. But now I realize that there are good things in life. That people care about me." What they were telling us was that in that moment of despair, being able to hit the brakes and say, here are the positive things in my life, that was to them the most impactful and most useful parts of going through treatments like DBT or cognitive behavioral therapy.
It shifted my thinking because initially, myself and I think others, really see treatment as, we get rid of the bad stuff. We get rid of the hopelessness and the depression and the anxiety. But what seems to actually be making a difference is strengthening those positive things. Helping people to remember what is worth living form which for some people is reconnecting with reasons for living that you've lost or that you've forgotten about. But there are others for whom we create new meaning in life that didn't exist before.
I use with my patients a lot the notion of lost keys. Most people have lost their car keys at some point in their lives. I will ask my patient, "How did you find them?" They're like, "I retraced my steps, I went back to where I last had them, I asked other people to help me find them." The lesson that is really important is that when you lose your car keys, it's not that they cease to exist. It's just that you don't know where they're at. And there are these strategies we can employ to find them. Worst case scenario, maybe you never find those car again, but you can always get a locksmith to create a new lock and a new key set. That's in many ways what a part of the meaning-making process is all about, sometimes finding what you've lost, other times creating something new that maybe wasn't there before.
There's a show that I like on Hulu called "This Way Up," and there's a character who has survived a suicide attempt. In one episode, she says, "If I could helicopter back to myself that day that was so bad, I'd have felt like it was going to last 20 years. But actually it was just a day. I'd say to myself that while it might not even be the worst day yet, it's still just one of hundreds of days that might be great, and those are some really good odds. So keep going."
I think there are these expectations, because that whole notion comes up all the time in therapy. I have patients who say, "Every time something good happens in life, then it all falls apart." I'll be like, "Have you also noticed that every time things fall apart, they start to get better afterwards?" We'll draw it out on a board, like this up and down. When you're up there's probably going to be a down. But when you're down, there's probably going to be an up. Being able to take a step back and look at the bigger picture is often what we forget because we get locked into that tunnel vision and that moment of despair. Being able to hit the brakes, and take a step back and say, "It probably won't always be this way, although right now feels like it's never going to end."
To anyone who's going to read this book, what would you say is the biggest thing you really want us to understand about suicide so that we can help each other?
Suicide prevention is about the environments that we create. It's about quality of life. I think we've gone so far down the spectrum of focusing on individual problems. It's like a thing inside of us, or inside of people. We've got to find them and we've got to screen for them, and we've got to get rid of those bad things through treatment. That's hard to do. The reality is that there's a lot that we could be doing to create meaningful lives for all of us on a day-to-day basis. Some of which are related to political action. But some of which is just within our communities and how we treat each other. You know, treating each other with dignity and respect, expressing gratitude and appreciation, creating communities that foster hope and growth and positive emotional states, and surrounding ourselves with other people who model positive emotional states.
Those are the little things that we take for granted. I think sometimes they even seem kind of like cliché or almost pop psychology-esque. But if you really think about it in your own lives, how many times have we had a job that we were miserable at, or that was really stressful, but we loved the people that we worked with? That gives a great sort of example of how we can build community and support one another and create lives that are worth living. That goes beyond all of the traditional mental health approaches that right now I think have a major monopoly on suicide prevention.
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