I'll be speaking in Lewiston Idaho next week at the St. Joseph's Region Medical Center's annual Rural Mental Health Symposium. I know from IP addresses that we have readers in the Northwest. If any are in the Lewiston area, please come.
The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:
...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents. (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)
I am not expert enough in public awareness and mass media approaches to prevention to comment or speculate about how effective this video might be in preventing suicide in the Army. But I would like to comment on some intersections between the approach this video takes and some ideas about clinical practice.
To me, one of the most powerful aspects of this video is the way in which it leads the soldier-viewer to see him/herself as potentially at risk for suicide. The video gives the message "If you don't get help, your life could be in danger." Since the video is interactive, the viewer can actually make decisions (like keeping the distress or suicidal thoughts secret) that eventually lead to death.
From a clinical perspective, I have found that putting in front of a person--sometimes in a dramatic way--the danger he or she is in can actually help to kick in the person's survival instinct. It sounds strange to warn someone of danger when the danger is from oneself. But a question like this one can be sobering: "If there were nothing we could do to move life be more livable, how likely would you be to die?" I worked with someone who could not name a single reason why life could have worth or meaning and who could identify no chance for things to get better, but who, when asked that question, started talking about his son and two other people he wouldn't want to leave behind. Recently, I was pleased to hear a similar question encouraged in the ASIST approach to suicide prevention and intervention. An advanced variation of this question might even embed the prospect of hope within the danger question: "If there were nothing we could to help life be more livable--I think there are things, but let's say we didn't pursue them--If things continue like this, how likely would you be to die?"
It is strange and surprising to some clinicans that most people who are suicidal (and I would venture to say some who actually kill themselves) don't want to die. Many people who have survived near lethal suicide attempts have reported that. A participant in a workshop I gave several months ago illustrated this for me in a compelling way. This participant had, at an earlier point in her life, attempted suicide. She had since recovered and pursued education in the mental health field. In sharing her subjective experience of the suicidal wish, she said, "I never wanted to kill myself. I just wanted to kill the pain." What a gift. Clinicians should be aware of this and look for ways to simultaneously connect with the suffering and activate the part of every person that desires life.
Other related post(s): Reminder from the bridge: Suicidal individuals are full of ambivalence
The Urge To End It, by Scott Anderson, is a stunning piece. Well-written, and well-researched, it challenges the stereotype that suicide is always well thought out, carefully planned, and the result of a conscious and un-ambivalent decision. He focuses on the impulsivity and momentary desperation involved in many suicide attempts, and raises awareness about means restriction as a potent intervention.
For clinicians, there are several important take-home points and cautions:
- Expressed suicidal ideation is only one part of an assessment of risk for suicide; impulsivity, high intensity stressors, and agitated emotional pain signal as much about risk as suicidal ideation.
- We need to ask about available means and seek to disable lethal means whenever possible.
- We need to advocate for public policy that promotes means restriction--this may save the life of someone in our care (or in our lives).
- Ambivelance runs deep. Even in the moment of jumping, survivors report feeling regret, not wanting to die. We are built for living, and those who help distressed individuals have a powerful force on our side.
- We need to ask about how bad the pain is and how intense the desire for escape, even (especially) with individuals who have not previously expressed suicidal ideation.
There are probably other lessons from Anderson's excellent article, including understanding more about the subjective experience of someone who attempts suicide. The article is not short, but you'll be rewarded for the time spent to read it all the way through.
I recently became aware of a project called Newsmap, which takes a traditional news feed (Google News) and maps it so that you can see the news landscape in a different way. The program purports to "to divide information into quickly recognizable bands which, when presented together, reveal underlying patterns in news reporting across cultures and within news segments in constant change around the globe." In the quick scans I've done, I've been impressed with how much information can be presented this way, and with how much more context one apprehends from this visual view.
For clinicians assessing and managing suicide risk, the fact that phones installed on a bridge have been used by individuals who went on to live is testimony to just how much ambivalence remains, even in people who have gone very far toward resolved plans and preparatory behavior.
Understanding that ambivalence is key to clinical work with suicidal individuals. When I train clinicians about assessment and response to suicide risk, I often get questions about whether it is useful or even right to assess suicide risk. I'm also asked, "What about people who have good reasons for killing themselves or who rationally decide they want to end their lives?" My answer goes something like this:
Thankfully, for health care professionals there is no practical dilemma here. If you find out about a person's suicidal thinking, then there is some degree of ambivalence. Everyone knows that psychotherapy or primary care are about health...that is life. We're not about suicide and death. So if someone is coming to us, at least some small part of them is aligned in that direction. And it's our job to understand that ambivalence and work toward health and life until such time as the ambivalence is resolved in one direction or the other.
That line of thinking can apply to any person, really--not just healthcare professionals. Except in some rare circumstance that you'd have to work hard to construct, the fact that someone is still alive and letting someone know by words or action about suicidality reflects ambivalence.
The fact that people read signs and use phones on bridges also discourages a fatalistic stance on the part of clinicians. We can't simplify the matter by saying "If someone really wants to kill themselves they will, so what's the point of screening or assessing?" That question misses the point. We assess because people don't want to kill themselves. Some just don't see options for life and, under the wrong circumstances (like under the influence of substances or after a particularly deep emotional wound), they overcome their ambivalence just long enough to do the unthinkable. We need to have deep compassion for the amount of pain that must be, and nurture the life-embracing side of the ambivalence until the person can see options again.