The list of warning factors for suicide reads, in part, like a catalog of everyday modern ills: lagging self-esteem, depression, loss of relationships or economic security, insomnia.
"When you look at those lists," says Eric Beeson, core faculty member at Northwestern University's Counseling@Northwestern, "it almost seems like who's not a candidate for suicide?" And yet, in the wake of highly publicized deaths by suicide like that of fashion designer Kate Spade and television personality Anthony Bourdain, our scrutiny of the act centers on a need to quickly settle on a cause and, on some level, to distance ourselves from it.
Spade's longtime friend Elyce Arons told The New York Times that when the subject of celebrity suicides came up in their discussions about Spade's depression, her friend assured her, "'I would never do that. I would never do that. I would never do that.' And I believed her."
"At some point in everyone's life," says Beeson, "they have said they would never do that. But I believe we are all just a few life events away from considering it. So for me, we're all on that continuum."
National Institute of Mental Health data show that, in 2016, 1 million U.S. adults made plans for death and attempted suicide. Yet most of us lack even the most basic understanding of what leads to these deaths, beyond those well-known risk-factor lists. The picture is much more complicated, says Beeson, and it might be time to take a more nuanced view.
Suicide risk is not as simple as a list of risk factors. "We talk about suicide as this one thing," says Beeson, "but suicide is really this spectrum of behaviors. You always ask, 'Are they suicidal?' and for me that's really a limiting question." In assessing whether people might kill themselves, Beeson looks at "key variables that seem to be more related to death." Those are:
Perceived burdensomeness, "this idea that my death is more valuable than my life."
Thwarted belongingness, "meaning I try to make meaningful connections, and they just don't work out."
Hopelessness, "OK, I have this, and it's never going to get better."
Acquired capability, the ability to set aside normal psychological and physical constraints and perform an act that may be painful or horrifying.
With the first two factors, Beeson says, people begin to have ideas about suicide. Adding hopelessness can bring on planning of a suicide. But the final factor is the hardest to discern.
Clinicians like Beeson look for clues that the person might have become more inured to pain, shame or guilt. Past histories of abuse, substance abuse disorders, assaults or even professions such as medicine that make contact with death part of the everyday can constitute a slow wearing away of the mental and physical barriers to self-harm.
"People work along that continuum until they start to overcome the pain, the shame and the guilt," he says, "and then the value of suicide starts to outweigh the pain, shame and guilt."
Suicide is not typically an impulsive act. "People talk about it being selfish; people talk about it being irrational," says Beeson, "but actually I think a lot of suicides are very well-thought out, very well-contemplated. And generally not impulsive.
Generally, this is a long process for an individual that started with a faint idea that gradually took hold as those risk factors mounted and as the capability came into their purview." Leaving behind a note, as Kate Spade reportedly did, can be interpreted as evidence of the contemplation suicide often entails—it may be an attempt to remove the last psychological barriers to death.
"Some people might say that it's a last way to cope with some of the guilt," says Beeson. "The guilt can be a protective factor in a certain way, so some people might say that's a way to reduce that. There's something about this that the person is still not OK with, so they are trying to address that."
The philosophical debate on suicide is more present than ever. In ancient societies, suicide was sometimes interpreted as an available and even noble choice. Today, in countries like Switzerland, where there are euthanasia clinics, assisted suicide is accepted. And five U.S. states and the District of Columbia have "Death With Dignity" laws that allow assisted suicide in cases of terminal illness.
"That gets us into the discussion of whether it is ever OK and under what circumstances," Beeson says. "Some people would argue that if I have a chronic mental health condition that interferes with my quality of life, is that any different than a fatal medical condition? And that's a really really hard discussion to have."
To shift your perspective on suicide, think back to the events of 9/11 and how you felt about the people who chose to jump from the Twin Towers before the burning buildings collapsed. "That analogy is not too different from someone who has a depressive disorder," says Beeson. "It's not true flames, but it's the flames of something.
It's easier for us to look at the 9/11 example and say, 'Yeah, I'm not going to judge that person,' but what if it's flipped around and these are not real flames, but it's something that's very real to that person?" Given any of these circumstances—the burning building, the terminal cancer or the extreme, persistent mood disorder—Beeson points out, none of us really know what we would choose to do.
Condemning suicide might hinder prevention. "I think we run the risk of looking at it as a black and white thing," says Beeson, "and that's just not the way it is. I really do view suicide as a continuum and frankly we are all on it in some way. Some of us are just much farther from it than others."
There is a movement aimed at destigmatizing suicide, including changing the ways in which we talk about it—committed suicide" conjures an image of committing a crime, while more straightforward language—died by suicide" or "killed himself" avoid those punishing overtones. Willingness to view suicide as a part of human behavior, without judgment, may be difficult. But, Beeson says, it can be the key to helping someone who is considering killing herself.
"If we view ourselves as too separate from people and we think that we'll never be there, then it's really hard to connect with people in a meaningful way." Before talking to someone who might be contemplating suicide, he suggests, think about where you're coming from.
"Have the hard dialogue with yourself: 'Am I so far removed from this?' and if I am, I'm probably going to be perceived as coming from a judgmental place. That's going to make it harder to connect with someone and catch it sooner, if you will.
You want people to be able to be open enough to share with you before it gets to the point where they've made the plan, they're set on this and it's going to happen." The goal? To get past the suicidal thoughts and offer an alternative. "We try to find out what they are trying to achieve with this choice," says Beeson, "and then show them another way to get there."
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