It’s been just over six years since I wrote my last article on suicide. The first suicide piece discussed my family’s experience with suicide and the horrible question that so many survivors ask. The second entry described how someone’s suicide feels like a nuclear bomb went off in your life and the suicide domino theory. The third post went over how almost every survivor asks “why did they do it?” and how there is never a satisfactory answer. It also dives into another terrible yet common survivor’s thought, “how come I didn’t see it?”
So many new things happened in those six years: I returned from my Army deployment; COVID impacted everyone in the world; my play was published, I created a bi-weekly Veterans group and a bi-monthly therapist group; my father died in my arms in Belize; I hiked every 4000 foot mountain in the Northeast; I’ve watched in horror on the assault of American laws; I spent a fortune on a series of massive home repairs; my Uncle died; I experienced two loving romantic relationships; and the Dodgers won three World Series.
Throughout those positive and negative events, I continued to give speeches and conduct trainings on suicide for the US Army, the New York State Police, several dozen labor unions, a variety of treatment programs and over 20 conferences.
I often counsel and speak on grief. It’s a tough subject for almost everyone. People don’t know what to say, so they often say nothing. Planet pretend. Which is awful. The best thing one can do when someone dies is to write about them.
Some grief is a bit more complex, as there can be some regret, guilt, anger, confusion or unresolved issues sprinkled in. Suicide often causes brutal complex grief in the survivors. When my close friend took his life, I experienced a deep sadness, occasional fits of anger towards him, misplaced guilt and confusion about why he did it. The best way to deal with complex grief after suicide is a combination of individual therapy, writing, group therapy and getting out in the world.
When I rejoined the Army in 2014, I was told by a few Colonels that the Army was highly motivated to reduce the high suicide rates of soldiers and Veterans. I told them that the Army would have to address its culture around alcohol, reduce the stigma of seeing a counselor and increase the number of Army counselors tenfold. The Colonels were incredulous and I told them they we should change their wording from highly motivated to slightly motivated.
Over the years, families, the media, public officials, schools, universities and therapists have all asked about or offered plans on how to prevent suicide. There was a pretty good article in the New York Times this past November that discussed the problems that therapists face:
Suicide rates continue to rise; it is now the third leading cause of death worldwide among those 15 to 29. But despite decades of research into suicide prevention, it is still very difficult to know whether someone will try to die by suicide. The most common method of assessing suicidal risk involves asking patients directly if they plan to harm themselves. While this is an essential question, some clinicians, including Dr. Galynker, say it is inadequate for predicting imminent suicidal behavior. A better solution, they say, is to identify and treat the symptoms that lead to a suicidal state of mind: a condition they call suicide crisis syndrome, or S.C.S.
Dr. Galynker, the director of the Suicide Prevention Research Lab at Mount Sinai in New York City, has said that relying on mentally ill people to disclose suicidal intent is “absurd.” Some patients may not be cognizant of their own mental state, he said, while others are determined to die and don’t want to tell anyone.
Schools of social work, counseling and psychology seem to love pushing the Columbia Suicide Severity Rating Scale. I believe it can be helpful in determining the depth of someone’s despair and their immediate and intermediate risk of attempt. However, I do not think it is a good way to assess if someone is having thoughts of suicide.
In 2010, I did a bit of a dive into Victor Frankl and I’ve been asking my clients about their purpose and community ever since. I found those that lack one or the other to be much more likely to be anxious or depressed or to engage in process disorders (alcohol, drugs, gambling, sex, food, shopping, video games, social media). Those lacking both were more likely to have some passing thoughts of suicide.
And yet, plenty of people without purpose or community are not suicidal. A vast majority of them, in fact. They aren’t happy and are operating at a sub-optimal level but they aren’t thinking about killing themselves. They unexcitedly drudge on through life, often to the exasperation of those that love them. A good therapist (or athletic coach or mentor or religious figure or teacher or wise older relative) might nudge them towards purpose or suggest a few communities.
Back to the suicidal people. A history of trauma is a risk factor. I have trained my students, interns and supervisees to use the Adult Trauma Checklist and the Stressful Life Events Screening Questionnaire to help explore a client’s background [To be clear, I do not want nervous mothers or concerned friends or frightened lovers to be using these psychological screening tools on those they are worried about. If you fit into any of those categories in the previous sentence, get that person to a therapist who understands trauma. And if you are a therapist, get them to see someone who isn’t you].
So, if someone lacks purpose and community and has a history of trauma, that’s a red flag. One side effect of trauma though, is that it can negatively effect one’s sense of self and therefore, their purpose and community. It’s a real chicken and the egg conundrum.
Everything I’ve written so far has been prelude to this: I ask three questions that can help address suicidality a little more [Again, to be clear, while I am writing this for everyone, I don’t want lay people asking these questions and then washing their hands of the situation].
Who do you care about in this world?
The more people named, the better. The more intense the level of care, the better. Pets are great. I treated a guy back in 2005, who, when he was arrested, thought about killing himself but didn’t because he didn’t know who would take care of his dog.
What kind of things do you like to do?
Sports. Books. Movies. TV. Video games. Travel. Eating. Museums. Plays. Parties. Painting. Swimming. Hiking. Puzzles. Comics. Shakespeare. Civil War Battlefields. Yoga. Biking. Pottery. Croquet. Gardening. Fixing cars. The more activities they like, the better. The higher the intensity, the better. The more expertise, the better. If they do these things with other people, the better.
What would you like to do in the future?
Do they want to watch their team win a Super Bowl one day? Do they want to travel to the South Pacific? Do they want to see their kid graduate from high school? Are they waiting for the next Radiohead tour? The more stuff they are looking forward to, the better. If they have stuff they want to do that’s a ways off in the future, the better.
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When someone can’t name anyone they care about, don’t have any activities that they enjoy and have no future plans, that is an alarming situation. I’m not going to hospitalize them or ship them off to rehab just on those answers, but it helps me get a much better grasp on the situation.
These questions aren’t foolproof. My friend who took his life in 2018 had lots of people he cared about (and cared about him), had loads of things he enjoyed and had a bunch of future plans. And he took his life anyway, to everyone’s surprise. Was it unresolved trauma that bubbled up to the surface one morning and overwhelmed him? Was he determined to die for a few weeks and was cagey about it? We’ll never know. That’s the horror of suicide. We can improve our screenings and treatments, but we will never get to zero suicides. We can try though. And we should.