Suicide among men—and the myth of impulsive acts

The recent death of chef and documentarian Anthony Bourdain sparked widespread media attention and a broader cultural discussion about depression and impulsive suicide, especially among middle-aged men. With the nation marking National Suicide Prevention Week this week, the conversation seems more relevant than ever, considering that men account for a staggering 80 percent of suicides, according to the American Foundation for Suicide Prevention. What's more, the highest rates of suicide in recent years have been among those who are 45 to 54 years old.

Clinical social worker Susan Lindau is an adjunct professor at the USC Suzanne Dworak-Peck School of Social Work in its Department of Adult Mental Health and Wellness. She spoke about the cultural stigma that may correlate to higher suicidality among men, offering techniques for helping at-risk individuals in times of crisis.

Can you tell us about your professional background?

My path to social work has been unique: First I pursued an MSW, which I received in 1972. Then, because I was not sure I wanted to be a social worker, I did everything from running a catering business to attending film school. I returned to social work in 1995 and I've been teaching at USC since 2006.

As a therapist, I specialize in working with individuals who have borderline personality disorder, depression and anxiety. The treatment that I provide is known as Dialectical Behavior Therapy. I enjoy using DBT because it recognizes the struggles that come with facing change. Sometimes we can only tolerate inches of change, rather than massive leaps—and that's OK. I often tell clients: Change is inevitable, growth is optional.

What is your approach to working with depressed patients and what factors do you believe may contribute to a higher rate of suicidality among men?

I believe that Western cultures place particular pressure on men to perform socially and financially in ways that prevent them from expressing vulnerability. Society expects men to be strong, unemotional and conventionally "successful."

When they reach middle age, many people face thoughts along the lines of, "I should have …" or "I wish I had …" If he hasn't reached a certain fabricated benchmark of "success" that his culture dictates he should have reached, he may feel like a failure. When societal norms don't grant men the permission to be vulnerable or express the need for help, these perceived shortcomings can lead to depression. I don't discount the commensurate pressure that women endure, but statistics do indicate that men may suffer higher rates of suicidality due, at least in part, to an inability to cope with these stressors in a healthy way. Sadly, the number of women attempting suicide is also on the rise.

Other hardships that characterize this period of life may also contribute. Marriages and friendships may not feel as effortless as they may once were—and if these relationships aren't allowed the flexibility to evolve as the individuals within them evolve, this may feel like another failure. Too often, these perceived failures are endured in silence due to the fear of reaching out for help. I hope that the tragedy of individuals taking their own lives may force us to examine the stigma we place on emotional vulnerability in our culture.

Is there a difference between impulsive and premeditated suicide?

A lot of research is currently being conducted on the role of impulsivity in suicide. However, I believe that suicide cannot be deemed absolutely impulsive unless it's drug-induced or the victim is already a fairly impulsive person.

Those who choose to take their own lives are often experiencing excruciating sadness and isolation and may have difficulty expressing that vulnerability. Outwardly successful individuals—especially men such as Robin Williams or Anthony Bourdain—may feel especially unable to express their pain. Again, this is compounded by the pressure to demonstrate their masculine strength within certain boundaries defined by our culture.

What are some methods for addressing an apparent impulse toward suicide?

Research shows that when individuals make the decision to attempt suicide, nearly half of people will attempt it within 20 minutes. That's why I begin many of my coaching phone calls with clients by saying, "What actions can we take to get through the next 20 minutes?"

DBT methods for mitigating suicidality in the moment come from the module defined as "Distress Tolerance." The idea is to help the client take an action that makes it possible to think of almost anything except harming himself. Together the client and I discuss an action that he feels comfortable doing. If it is during the day, I might suggest a long, hard run and ask the client to describe the route he will take. If it is late at night, I might suggest taking a long, hot shower.

The tool is identified as TIP: Abruptly change the Temperature, perform Intense exercise, and Paced breathing. Temperature refers to the act of dipping your hands or face in ice water, which can initiate shock that breaks the chain of impulsive thought. Intense exercise such as running or swimming creates a flow of endorphins that can mediate the sensation of intense pain or impulsivity. Finally, paced breathing is a meditative strategy of inhaling and exhaling in measures of four counts to relax the mind and body. Each of these actions forces the client to think about something other than his pain.

How can individuals help family members or friends who may be struggling with depression or suicidal thoughts?

The most important thing that we can do is create the space for our friends and family to feel safe expressing vulnerability. We have to have the courage to step up and say, "Let me help you find the resources you need." Those who are struggling may initially reject help, but it's important to reach out and be persistent. Often the person who is feeling terrible doesn't know what to say when you ask: "What can I do to help?" We must be willing to validate our friend our family member who is feeling horrible and offer a specific action: "I can see you're feeling awful. Can we talk?" Or, "let's go for a walk."

I'm optimistic about the future because I believe millennials and Gen Z value vulnerability and emotional expression more than previous generations. Clients in their 20s to mid-30s come to me feeling less ashamed to say, "I'm feeling depressed." The conversation about mental health is finally happening, and people are learning the values of practicing mindfulness—which can promote better physical and mental health. These trends make me hopeful about reducing suicide rates in future generations.