Not long ago I was asked to write a blog post for the National Suicide Prevention Lifeline staff and volunteers. I was happy to do it.  Later, I wondered…, if you asked 100 Americans in the street what NSPL stood for, how many could translate the acronym?

My guess?

None.

They would get NSA, FAA, FBI, CDC, and hundreds more, but no one would get NSPL.

And yet, the NSPL is America’s default 24/7 mental health crisis service telephone system.  On a national basis, there is no other.  Many crisis centers answer the 1-800-SUICIDE number, but how the two systems are different and the same is a long story.

So, if you are down in your cups, depressed, just broke up with your lover, lost your job, and start to stumble into a downward spiral toward suicidal thinking, who is there for you after the bar closes at two in the morning?

Your primary care doctor?  Very doubtful.

Your therapist? Doubtful.

Your minister? Maybe.

The National Suicide Prevention Lifeline and its affiliate members? Always.

For 25 years I directed a 24/7 crisis line. Hired the staff.  Help train the volunteers. Tried to minister to the volunteers and staff impacted when someone we had tried to help killed themselves.

With almost perfect memory I can see the eyes of a young woman volunteer who was trying to help a suicidal man with a gun.  She, and the team, were doing all they could.  The call was being traced and the police were rolling.

Then she heard the shot.

Later, the officers on scene confirmed the man had died of gunshot wound to head.

What Winston Churchill once said of the fighter pilots who defended England during the Blitz in WWII also applies to these staff and volunteers, “Never was so much owed by so many to so few.”

During the Blitz, 40,000 English citizens were killed, or roughly the same number of Americans who will die this year by suicide.  While many work to prevent suicide, these few crisis line volunteers are the last line of defense, the last heart extended to those losing heart.

Because they will not be able to save them all, here is the post I wrote to those serving on the NSPL.

Research shows that the most feared clinical outcome for mental health professionals is the death of a patient by suicide. According to the National Violent Death Reporting System, roughly 35% of all suicidal people die while in the active care of a treatment professional.

As clinicians across the country go home for the day, many of them switch their calls over to you. Others see your number in any of a million places, and in those worst hours of suicidal pain, you get the call.

Courage is defined as overcoming fear, and crisis workers who help suicidal callers are nothing if not brave. While many professionals step out of their client’s crisis after hours, you step in.

Let’s be frank.  If client death by suicide is a professional’s number one fear, experiencing a caller suicide is, by definition, a major stress event. Death has come to your door and pounded on it. In the aftermath of learning a caller died by suicide you’d have to be a robot not to feel powerless, helpless, and a kind of overwhelming psychological paralysis.

While different people experience traumatic events differently, the loss of a caller to suicide is a 10 on a 10-point scale, and no one emerges from such an event unchanged.

Psychological trauma triggers changes in the brain, some temporary, some lasting. If severe enough, symptoms include hyper-reactivity (startle response), numbing, feeling not quite of one piece (dissociative state), disturbances in memory, and perhaps avoidant behavior – in this case difficulty getting back on the phones. These symptoms are the body’s way of saying, “Get down, you fool!  They’re shooting at us with live ammo!”

Following a caller’s death by suicide support by supervisors and peers is often enough to weather the ensuing emotional storm. And it is a storm.  But like all storms, it will eventually pass, and calm waters will return.

But just to be safe, be wise.

Consider that acute stress symptoms last for a few days to up a month. Max.  If these symptoms persist beyond a month, the event may have had a more significant impact than first imagined, and professional help may be warranted. 

It is good to remember that no matter how hard we try sometimes our very best is not enough and a suicidal caller dies. While we are all waiting for better research, better training, and better assessment, treatment, and management tools, if the worst happens, here are some keys to taking care of yourself:

• All your feelings are normal, so just accept them.
• Eat something. Yep, food is a comfort. Go for the mac-and-cheese or roast turkey sandwich. You can diet later.
• Take a hug, give a hug.
• You can’t fix what has happened, so don’t try.
• Lower your demands on yourself. Remember, start your own oxygen before trying to help others.
• Don’t judge the motives of the deceased; you can’t have known his or her life fully, and you will not feel better if you blame the victim for being weak, stupid, or selfish.
• Avoid alcohol. Sure, one drink may remove an edge, but three or four or more may tip you into a dark place.
• Sleep in.
• Accept that you will feel 110% responsible for this person’s death. Call it the “helper’s curse” – it is just the way empathic people are wired.
• Remember, the person called you, not the other way around.
• In the end, the choice was theirs, not yours.
• Expect to feel some guilt; you’d be a robot if you did not.
• Tears help, never hurt.
• You may even have thoughts of suicide yourself. This, too, is normal. Like a storm, these too shall pass.
• Find something to laugh about. Since they release natural feel-good chemicals into your brain, funny movies and stand up are therapy.

Here’s something to think about. Research shows that 1 in 4 Americans will experience an episode of mental illness in any given year. If your three best friends seem normal to you, then maybe it is your turn ☺ 

While clinical professionals are stepping out of their offices when their day ends and going home to dinner, you are stepping in. So it is good to remember that the purpose of crisis work is not to live well, but to care enough so that others might live at all.

Finally, the young woman who suffered the trauma of hearing a man shoot himself to death carried on.  We supported her, counseled her, and wrapped our arms around her.  She went on to complete her tour as a volunteer and then a degree in social work.  She is helping people today.

Dr. Paul

I wish to thank my dear friend Iris Bolton, author of My Son! My Son!, for originating this list of how to survive a suicide loss.

A few weeks ago I received a call from an intelligent, depressed and suicidal professor from a prestigious Eastern university who, after two attempts to find a therapist able to sit quietly and listen to her, found my free e-book (Suicide: the Forever Decision) on the web, and rang me up. As she put it, “You seemed like someone who could listen to the reasons I want to kill myself without butting in.”

Without butting in?  And here I thought all therapists were trained not to butt in.

“Are you accepting new patients?” she asked.

“Sorry,” I said, “I closed my practice some years ago. But I’m happy to hear you out and help you find someone if I can.”

So we talked; or rather she talked, and I tried not to butt in.

Selecting a psychotherapist is challenging, let alone finding one able to listen carefully to why people want to end their lives. In addition to the language barrier inherent in the subject of suicide, prospective patients must consider location, availability, qualifications, affordability, insurance coverage, cultural differences, and what sort of therapy is offered.  Psychoanalysis? Cognitive behaviorist therapy?  Family systems?  Or some spook therapy that oozed out of the bottom of a whisky tumbler and remains unencumbered by any scientific support.

On the public service side of things, the Substance Abuse and Mental Health Services Administration just published a survey report that found, “57 percent of all known U.S. mental health treatment facilities offer suicide prevention services.” I interpret this to mean that 43 percent don’t.  You can Google the SAMHSA full report for details, but if over 40 percent of the agencies that are supposed to employ the “go to” folks when you are suicidal say they are not in that business (of helping to combat our greatest public mental health threat), I beg to be enlightened about how they justify their funding.

Accounting for possible distortions in her interpretation of events, I was not surprised to learn that the lady I was listening to had seen both a psychiatrist and a psychologist.  One visit each.  With someone clearly in need, a one-visit length of stay is referred to in our business as a “drop out”  – someone who needed care but didn’t get it.

In this case, the psychiatrist interrupted her narrative to recommend medications. It seems the word suicide stimulated his reach for the prescription pad. This woman is a crack scientist and well versed in the pros and cons of antidepressant medications.  She said thank you and left before completing her story.

By her report, the psychologist became so visibly anxious during her suicide narrative that he changed the subject, not once, but twice.  Hardly bereft of interpersonal insight, our lady Ph.D. deduced that the poor therapist was far too frightened to be helpful.  Since he could not engage in a full-on existential discussion of suicidal ideation, its merits, threats, strengths, challenges, likely causes, and possible remedies, she politely closed the interview and did not reschedule. Had he be able to hear her out fully he would have learned what I did by simply keeping quiet: that she was suffering from a chronic circadian rhythm disorder triggered the year before by a traumatic event and had not had a full night’s sleep since the trauma.

Suicide talk makes therapists jumpy.  Losing a patient to suicide is their number one fear. Patients talking about suicide create a special terror deep in the hearts of therapists, and if there is anything more icky to talk about during a therapeutic hour than that a patient wishes to explore the option of ending his or her own life, I don’t know what it is.

In a recent issue of the journal Crisis, Rothes and colleagues titled their paper “Facing a Patient Who Seeks Help After a Suicide Attempt.” The authors explored the reactions of therapists to patients who were suicidal but who had not yet made an attempt, as well as those who had made an attempt. The most significant “difficulties” reported by clinicians to the authors were “emotional and relational” not technical, family, or logistical in nature

What interested me most in this report was this: “A very important and informative finding from our study is that although only 19% of health professionals reported specific training in suicide, 89% felt competent to assess suicide risk and 50% thought they had adequate suicide training.” In other words, 1 in 5 clinicians reported any training at all, yet 9 in10 felt they were competent to assess and treat suicidal patients.

Unless I am much mistaken, when the majority of clinicians report they have had no specific training in the problem they are about to treat (a suicidal patient), but feel perfectly competent to treat them anyway, back when I taught Psych 101 we called such false beliefs delusions – or, an idiosyncratic belief or impression that is firmly maintained despite being contradicted by the facts or reality.  As such, a delusion is a symptom of a mental disorder.

Now, I am not accusing the majority of clinicians of having a mental disorder when it comes to believing they are competent to assess, treat, and manage suicidal patients without training, but I am saying that any wrong beliefs about one’s abilities to care for suicidal patients creates three unacceptable outcomes, none of which are good for anyone.

First, suicidal patients deserve competent care by trained professionals. Millions need it, few get it. Our lady Ph.D. was just one. A suicide crisis is the mental equivalent of a heart attack and anything less that fully-informed care is unacceptable. Or the public should know why.

Second, any therapist providing care to suicidal patients without training is likely engaged in unethical practice, since the first requirement of all healers is to do no harm by attempting to fix a problem you don’t understand. How our graduate schools can continue to pass untrained professionals off on our communities in the face of a preventable public health problem that takes 2,700 lives a day around the world is beyond me.

Third, multiple studies have shown that the quality of the relationship and communication skills with a suicidal patient are essential to preventing further suicidal behavior. Thus, ignorant, fear-stricken therapists who lack self-awareness about their skills and competencies are not only no good to suicidal patients, they may actually make them worse.

Don’t think for a minute that our lady-in-search-of-a-therapist felt better after striking out her first two times at bat; in fact, she was scouring the web for reasons not to kill herself when she found my book.

The challenge for suicidal people and their loved ones is to find someone who won’t make them feel worse. I’ve little data to support this, but having interviewed lots of suicidal patients whose early ventures into psychotherapy were a bust, I’ll wager I am right.

Go ahead, imagine you are suicidal. Now go to your Yellow Pages and find a therapist who advertises, “Suicidal people welcome!”

HelpPro (http://www.helppro.com/) recently partnered with the National Suicide Prevention Lifeline and others to launch a search tool for those seeking suicide-prevention therapists. Prior to this, finding a suicide-savvy therapist has been next to impossible.

Even today, millions of untrained practitioners around the globe continue to treat suicidal patients they don’t even know are suicidal, or if they do know they are suicidal, remain stubbornly ignorant about what actually works to prevent suicide.  This is cough drops for throat cancer, and it is no wonder that according to the National Violent Death Reporting System, somewhere between 31 percent and 39 percent of suicidal patients die while in active care with a health professional. In some reports I’ve seen, the number is much higher.

Ha!  And just when you thought it was safe to call a therapist.

Twenty-odd years ago the leadership of the American Association of Suicidology asked me to serve as the chair of the Ethics Committee.  An unelected position without staff support, pay, or even other committee members, I took on the job because my predecessor, Dr. Jerome Motto, assured me that the only ethics committee in the world with less to do was the Wall Street Ethics Committee for the Protection of the Public, the last meeting of which was held in the early 1960s after its last member expired in situ at a small dusty conference table in an abandoned office building somewhere in Manhattan.

As a life-long consumer advocate, it is my view that suicidal people and their loved ones would benefit greatly if all the healthcare professionals to whom they turn in their times of trouble asked themselves this single ethical question:  “Since I have had no training in suicide risk assessment, treatment or management, is it still OK for me to take money from suicidal patients?”

I await their answer.

Dr. Paul

PS: Through my contacts with experts in the treatment of suicidal folks, I was able to find a fully qualified practitioner for the lady whose storied inspired this post.

I’ve been invited to give a keynote presentation to the Irish Association of Suicidology in October this year. Titled, “Why Can’t a Man be more like a Woman?” my remarks will focus on why men seem to do most of the dying by suicide and how we all need to rethink our social marketing approaches to the male of the species. Charles Darwin is my co-pilot.

I come by my interest in male psychology honestly. Back in the 1990s something of a men’s movement was afoot and as a psychologist, outdoor writer, and knowing something about suicide, I was invited to join a gentleman’s group in my community whose members thought we could do better as men.

In the first meeting we were asked to contribute money to offset emergent organizational costs, which donation would lead to our names being affixed to the masthead of the organization’s letterhead. I asked, “How much can I donate to keep my name off the list?”

I got a few laughs and as the evening progressed great plans were laid. Not exactly Lewis and Clark’s grand adventure up the Missouri, but we did have the poet Robert Bly in the intellectual lead boat.

When I got home that evening I attempted to explain to my newly-feminist wife that I had just signed up for a journey of discovery into the hinterlands of male psychology. A modern girl, she cracked, “If you ever have a meeting here, tell the boys to leave their drums on the porch.”

During that fitful but sometimes useful episode, I did publish an essay for a fledgling men’s magazine about men, women, and suicide. At the time, I was seeing a lot of suicidal men in my practice and trying to understand suicidal behavior within the dynamics of a relationship in crisis.

Having earned a reputation for my willingness to see suicidal patients, therapists all over town sent me their most scary cases: suicidal men. It was heaven; they knew why they were referred and I knew why they were there. My operating premise was that if you were suicidal and walked into my office, you still wanted to live; all that was left was to figure out how to do just that.

What I found again and again and again is that men cannot tolerate being left by a woman they want. Even the threat of abandonment makes them crazy. Most of men I saw were clinically depressed and didn’t know it, and their girlfriends and wives where leaving them precisely because their depressed behavior made them PMBs (diagnostic translation: poor miserable bastards).

As you know, men get pissed off, irritable, paranoid, angry, can’t sleep, and stop enjoying food, fun, football, and sex, but they DO NOT get depressed. Depression is what happens to economies, not men.

Here is that essay as originally published (minor edits only) in a now-defunct men’s magazine…

Some years ago I wrote a short story about a fly-fishing trip I took with my friend Al. It was supposed to be a quiet week in the mountains catching trout; it turned into a bloody mess. Because just as we started on the driveway, Al’s wife came out of the house, stopped the car, placed her hands on her hips, and said, “I’m done! I’ve found someone else and I won’t be here when you get back.”

Al stared at her for a long minute. Then he pointed to the gas pedal and said, “Hit it! I kind of thought this was coming.”

Rounding the first corner, he punched a fist-sized dent in my dashboard. “By God,” he groaned, “I hope the trout are biting.”

They were.

Thank God, they were.

Despite this opening scene, things didn’t turn out as badly as you might think. What with rising trout, tall mountains, campfires, and with the soft blessings of bright stars and dark whiskey, we got over the roughest patch in one piece, and I did not wake up one morning find Al floating face down in the river.

Instead, Al talked. I listened. As a highly-trained psychologist, I just shut up and listened. In my business, we call it “rapport” and are well paid for simply not butting in when people need to talk.

Later, when Al apologized for all the talk and tears and trouble, I said, “What are friends for?”

These many years later, my friend is alive and well, remarried, a book author, and a tenured professor, even if he still can’t cast a fly worth a damn.

Most men know you are supposed to mix God, death, sex and fly-fishing all together around the campfire and that no subject is off limits. Except killing yourself. Tell your best friend you want to do yourself in and the conversation sort of tenses up – which is why I decided to write this essay.

As a psychologist whose specialty is suicide prevention, I spend a lot of time with people who think about it, plan how to do it, and sometimes attempt to leave the planet before they really have to. I say “really have to” because the journey to suicide is generally undertaken for ordinary reasons; broken hearts, busted dreams, untreated clinical depressions, and is often the final price for the ravages of alcoholism and drug abuse.

Suicide is not an enterprise undertaken for extraordinary reasons, but rather ordinary ones. Except in combat to save your buddies, or to avoid terminal pain in the last stages of an expensive, final illness, all suicides are tragedy – plain and simple.

Just check your morning paper obits. Of the faces of men who died “unexpectedly” or “at home” with no cause provided, odds are they ended their own lives. Since men kill themselves at four times the rate of women, I ask myself “how come?” Is it in our genes? Do we have a crooked chromosome? Or can men just not take pain like women can? What gives?

The full answer would takes several books, but the short answer is, “who cares?” The fact is that men are killing themselves off in droves. Mature men, young men, gay men, straight men, men in blue jeans, men in three-piece suits and, most especially, old white guys. Alone, isolated, depressed and despairing, if you listen carefully you can hear the gunshots. But maybe we, all of us, just might be able to do something about it.

Here’s the drill. The most common dynamic for male suicide is this: woman leaves man; man leaves world. This has to stop. As I tell my male suicidal patients, “Women are wonderful, but they are not worth dying over.”

But since I can’t talk to all the men considering suicide as a final action plan following the real or threatened loss of the woman they believe they cannot live without, maybe you can help. Here’s how.

Too many men suffer from chronic loneliness. And I mean from other men. When they are dumped by the woman on whom they have been relying for food, sex, and emotional oxygen, and start teetering toward the edge where lethal loneliness pitches into the black, don’t just watch, do something.

Step in. Step up. Say something. Do whatever it takes to stop some guy from taking that terrifying plunge to oblivion. Simply being told, “this too will pass” is a priceless assurance that time, does in fact, heal all wounds.

Sure, some men hit the bars to find another woman. Any woman. And as quick as possible. A very few call shrinks like me or maybe even a crisis line. But most suffer alone and muddle in and out of whether or not to stop the pain themselves, hoping someone will care enough to lean into their misery and offer to listen – just listen.

Think about any male suicide you know. Was there a woman somewhere? Had she left him? Was she packing her bags? Had she found someone else and he’d just found out? If a gay guy, different gender, same questions.

We men may be depressed, angry, frustrated, embarrassed, broke, shamed, alcoholic or addicted – and own more firearms than James Bond – but these risks are all nothing compared to being left by the woman we love and believe we can’t live without.  Or so we believe at the moment we are undergoing open heart surgery without anesthetic.

Now, gents, please consider the possibility that the woman who once loved you now despises you. She may even want you dead.
Impossible?

Don’t be silly. To quote an old line from Congreve, “Heaven has no rage like love to hatred turned, Nor hell a fury like a woman scorned.”

For a modern update, here’s a recent telephone conversation I had with a “woman scorned.”

Wife: He just left with a pistol. I don’t care if he comes back.

Me: Where did he go?

Wife: Who cares? Let him kill himself. Don’t you get it?

Me: Just tell me where he went. I’m trying to save his life.

Wife: Screw him! If he blows his brains out, it’s his business. Besides he has it coming. It would solve a lot of problems.

Me: Just tell me where you think he went?

Wife: And spoil his plans?

Me: Just tell me.

She finally told me, but not until I convinced her dead men don’t pay alimony or child support.

We got to the guy before he ate his .38, and he’s alive these many years later.

Two quick points and I’m outta here.

If the woman leaving bothers to look back at our plight, it is seldom with goodwill. Some men, the way I read them, interpret this undiminished anger as a request to suicide, as in, “My life would be even better if you knocked yourself off.”

This is the one time, gentlemen, you do not say, “Yes, dear.”

Second, any man who threatens to kill himself if she leaves is setting himself up for murder in the 180th degree. Because if she’s mad enough she’ll call your bluff and, being an honorable chap who backs up his threats, you just have to go ahead and pull the trigger.

Free advice: You do not want to live with any female you have to blackmail to keep.

It’s easy to say we men shouldn’t be wired like this. But it seems we are. At least for now…

In this time and place a men’s movement may save a few of us, but the guys most likely to kill themselves are not likely to join a men group. Or call a hotline. Or walk into mental health centers or offices like mine. So we have to reach out to them. We have to show some compassion, some understanding, and that we actually give a damn.

It’s amazing how my friend Al festered and fumed and raged and cried about his breakup, and it is also amazing that just listening to him breakdown his life and put it back together into a coherent story was like ground fog struck by sunlight.

Trust me on this, it doesn’t take much to save a life from suicide. But it does take something, some action, and sometimes professional care.

In the throes of great emotional pain and loneliness, thinking of suicide is the symptom, the fever. What breaks the fever can be as little medicine as just one of us leaning into the other guy’s pain and asking, “You look pretty banged up, pal.  Anything I can do?  I got ears, you know.”

To be useful you don’t have to have a Ph.D. or understand even a fraction of the mysteries of life to redirect a suicidal man stumbling alone toward the abyss. All you have to do is lean in and listen; just shut up and listen.

Dr. Paul

Good news!

Like a California quake, the ground just moved under the suicide prevention movement.

The Golden Gate Bridge is going to get anti-suicide nets.

Some of us had given up on this decades-old recommendation. The vote to build the nets just goes to show that when it comes to preventing suicide, pessimism is a failed strategy, and persistence is a successful one.

On the Richter scale of social change, I put this shock at 7.5, maybe 8. The vote triggered a variety of public reactions: relief, joy, disbelief, bewilderment, and anger.

Here’s one in a letter-to-the-editor in my local paper:

“As I watched the news, I witnessed the most bizarre thing I’ve ever seen. San Francisco government approved spending $77 million to install nets on the Golden Gate Bridge to catch suicide jumpers. There are hundreds of other bridges and freeway overpasses, and on and on.

What is wrong with society? Giving the poor souls that decide to end their lives a $77 million net is just bizarre. Do we as an incredibly evolved race on this planet not see how many lives could be saved with $77 million for all the starving and ill children in Africa and other war-torn nations that die every day?”

The author goes on to state, “I pray one day we will actually understand what real evolution is, and it’s not putting up nets for the mentally ill.”

As something of an evolutionary psychologist myself, and after studying human beings for roughly 60 years, I’m pretty sure of two things: 1) some of us are less “incredibly evolved” than others, and 2) evolution produced the very thing that makes humans different from other species, namely, the capacity for empathy.

The author appears to have empathy for starving children in Africa – who doesn’t – but not for his neighbor. Or maybe he lacks empathy for suicidal people because it is simpler to disdain them than to understand them. Unburdened by thought or empathy, prejudice is fast and easy, otherwise it would not be such a popular occupation for we homo sapiens.

Question: Do the terms “jumpers” and “mentally ill” depersonalize the real people who die jumping from the Golden Gate? Do these “classifying terms” stereotype those who die and render empathy difficult for some, and impossible for others?

Evil is the absence of empathy, I believe actor Alec Baldwin said to the jury trying Nazis for the Holocaust in the remake of the film Judgment at Nuremberg. If true, is it not the presence of empathy that makes us good folk, if not honorable and admirable?

In a new study of brain activity and empathy, researchers found that feeling powerless boosted empathy with others in distress, whereas feeling powerful reduced subject’s capacity to “feel with” a person in distress. Hmmm….

There is an oft-told tale of a beggar boy who, upon asking for a small coin from a passing rich man, is asked by the powerful prince, “One of my eyes is glass, the other is real. If can tell me which is one is made of glass and which one is real, I will give you a coin.”

The boy quickly shouts, “Oh, sire! That is a simple matter. The left is your real one.”

“That’s correct!” cries the rich man. “How could you tell?”

The boy replied, “Easy, sire, the right one was full of empathy.”

The letter-to-the-editor author is not alone. Millions of people around the world believe as he does. Suicidal people – if they want to – should go ahead and kill themselves and not inconvenience the rest of us, or perhaps be fined or jailed if they do not die.

Few know, understand, or believe the science that this vote will actually save lives – which it will. Means restriction – the restricting of any method of suicide – actually works, but for reasons which are not apparent to most. Perhaps having never been clinically depressed themselves, strangers to utter hopelessness cannot imagine how the brain functions in extremis, and that when a suicide plan is thwarted, another does not emerge as it might in a healthy brain.

The vote is historic or it would never have made it to CNN. As an evolutionary psychologist, why couldn’t I speculate that San Franciscans have evolved to a higher order of human being? Other communities have done similar things, and for the same reasons, but $77 million? I can’t see this vote – or its attendant costs – happening in many places, including in my own county or state, but I would be delighted to be surprised.

Back to empathy. Empathy – and its boon companion, compassion – are the fuels that feed the engines of the suicide prevention movement. Without both, preventing suicidal self-directed violence in others simply cannot, and will not, happen. To stand and watch and label and blame the thousands of people who kill themselves somewhere in the world everyday only requires that the rest of us look away – say nothing, do nothing, and feel nothing for them and their loved ones.

The continuing public health menace of suicide is not just a crisis of preventable deaths, but an enduring reflection of our collective indifference. But no longer for those in the Bay Area who voted for the nets, God bless them every one.

Critics complain about the cost of the nets, about who we are trying to save – those useless mentally ill (about one fourth of us in any given year) – and about the how the beauty of the bridge will be forever ruined. Me thinks they miss the point.

The point of the nets is not about saving scores of lives, but about the larger meaning of the vote. Supporters voted this expense upon themselves to save strangers – people they will never meet, people they will never know, and people with whom they share but little genetic material.

While we are all out of Africa and share our genes with every other human, it is our collective expression of empathy for total strangers that makes us the grand species. The pro-net vote says, if you take your own life, we will all be diminished. The vote says, though we don’t know you, your life matters to us.

In my view, the nets is not just about discouraging desperate people to rethink their decision to end unbearable suffering, but about empathy, about love.

Love that says, we understand your pain, and we want you to live!

Love that says, we believe in science and that when you see the nets you will not go elsewhere to end your suffering but look for new ways to live.

Love that says, we believe you are more like us than unlike us, and that your pain today could our pain tomorrow.

Love that says, you think you have tried all doors, but we believe you have not tried all doors, so let us show you doors you may have overlooked.

Love that says, the net you see is not made of steel but of flesh and blood, of hands willing to catch you… hands willing share in your burden if you will but let us.

The message of the nets is at once powerful and far reaching. As an icon of America and its people, the Golden Gate Bridge nets say to the world, we are a kind, loving, and empathic people. We know those who die by suicide are ill and need help, not ridicule, not a cold eye, and not dismissal, but compassion, caring, and new hope.

The nets say, yes, we all have to die someday, but today is not that day… not like this, and not from this bridge.

The nets say, take my hand, step back, and we will get through this together.

To me the vote translates into the following subtext:

It is not about the millions we will spend to save you if you jump from our bridge, but that we wish the world to know that when it comes to understanding and preventing suicide, the time of ignorance, stigma, taboo, superstition, and fear are ending.

Dr. Paul

By all reports 22 American veterans will end their own lives today.

That’ll be another 22 tomorrow.

And another 22 the day after that, and the day after that.

Start in January this year, and by New Year 2015 it will 8,000-plus.

Unless we tackle this problem, by the end of the decade it will be more than 80,000.

I ask you, what country tolerates this horrific loss of life by those who served and defended it?

Where is the public outcry?

More importantly, where is the action?

Imagine that a commercial airplane fell out of the sky every five days with 100 Americans on board? What would we do?  Wring our hands?  I don’t think so.

Our National Alliance for Suicide Prevention  http://actionallianceforsuicideprevention.org/ has a plan and is working hard, but if you don’t belong, don’t support, don’t share and don’t push this agenda in your community, nothing much will happen.

If 22 soldiers a day were dying in firefights with an enemy somewhere, we would start a war to stop the dying. Planes, ships, tanks, drones, battalions, the works.  No holds barred, full bipartisan support.  We’d send the following warning: “Get low, get out, or get blown up” because here we come!

Americans soldiers don’t die cheap. Our enemies pay. Unless we kill ourselves. Then we’re just national a rounding error.

I say “we” because I am a veteran (US Army Security Agency, 1960-‘63, South Asia). My brothers, uncles and father were or are vets, and I know lots and lots of vets. I have a dog in this fight and he is pissed.

Our recent wars may have ended for civilians, but for veterans they never end. Soldiering changes you, and the changes are permanent. Some of them are good changes, some not so good. One of the “not so good things” is that after serving we are elevated risk for suicide. And that includes our women vets.

I know the Pentagon and the VA talk boldly about preventing suicide, and recently Congress passed a bill to provide more VA staff and better medical access for vets to the tune of 50 billion bucks.  This is significant, and it will count.  I only wish the bill had included a requirement that all those health care professionals vets will see outside of the VA (which has a strong focus on suicide prevention) will have had some training in suicide risk assessment, treatment and management, because without it, our vets won’t get the best service possible.

I know preventing suicide is hard, not easy. If it were easy, government would have done it by now.  We’d have a cure. But suicide is pernicious, like a virus on the soul.  Thoughts of suicide burrow into the psyche and eat away at hope.  At once corrosive and contagious, it takes strong medicine to counter it.  Our current death toll begs a massive public health funding research approach on par with the Manhattan Project. Given the burden of suffering, why do we putts around?

Every veteran life lost to suicide is a special affront to me.  It’s one thing to die in combat for your country; it is quite another thing to take your own life because your country doesn’t back you when the shooting stops.

Mind you, there are lots of good people out there helping vets, training others in how to identify those at risk, and carrying goodwill and the medicine of hope to this new psychological battle front. But every day I still hear things like, “troubled vets need to ask for help.”  Give it up folks, those vets most at risk for suicide are never going to ask for help. (See my note at the bottom to learn more about what I think we should be doing and why.)

Last week I gave a talk at a public meeting celebrating Flag Day. There was music, singing, a few of the last of the Pearl Harbor survivors in attendance, presentations about services for vets, and some paintings of veterans by my artist friend, John Thamm (http://jfthammstudios.com/).  I spoke briefly about my younger brother, Jim, who served in Vietnam during the 1968 Tet Offensive and saw a full year of combat, and then tried to explain what it was like for him to come home.

I tried to explain that as much times as it takes to turn a civilian into a soldier, it takes that much time and more to turn a soldier back into a civilian.

Jim was six days out of his last firefight in the jungles of Vietnam when he turned up on my doorstep in Washington State. I told him I would take him fishing in the morning. He said, “Don’t bang on the door to wake me up, I’ve been sleeping in the bush with a .45 for pillow and I’m still a little jumpy.”

Jim was “still a little jumpy” for about 20 years.

Toward the end of my remarks I ruined everything by bringing up the 22 veterans.  I said they would be dead today by sundown, and that unless I was much mistaken, no one but their families would know or care. I’d like to be wrong.

As an aside, I much admired Robert Gates, our Secretary of Defense, when he started writing personal letters to the families of those who died in combat, instead of sending form letters.  Who would write letters to the families of our vets who kill themselves? Our Commander in Chief?

A table had been set aside for me to talk with folks who might like to chat. Out of a fairly large crowd – maybe 150 – one chap came over and said he’d lost his son-in-law to suicide a week ago. Then he quickly hustled away. I waited 15 minutes, but the crowd never came my way.  I don’t think it was my deodorant.

I left the building concluding that suicide remains the unspeakable subject, and it occurred to me that until we can have an intelligent conversation about the 22, they will just keep dying.

People are trying, God bless them, and the ground is starting move, but until we reach a tipping point in public sentiment that cries “ENOUGH!” there will be no cascade of political leadership.  Politician only watch parades of public sentiment until they see which way the procession is headed, then they scamper around to the head of the line and shout, “Follow me!” 

Bring up suicide and people say, “Can’t we talk about something more pleasant?” Or they just smile and change the subject. Or, as one healthcare system CEO said in a community meeting about our county’s top health priorities – and where suicide had emerged at the top of the list from one small group of advocates – “Let’s fix something we know about…. like, say, diabetes.”  The majority followed his lead and stigma once again won the day.

Yes, I know, the majority of veterans are psychologically and physically doing just fine. But that doesn’t change the number 22. It is still 22.

A scientific article study published by my colleague Marc Kaplan and his colleagues in the Journal of Epidemiology and Community Health in June 2007 found that, “Veterans in the general U.S. population, whether or not they are affiliated with the VA, are at an elevated risk of suicide.”

When 22 vets a day die from preventable suicidal self-directed violence it boils up in me a great anger…, an anger directed at our collective failure to place the resources we know can save lives right into the hands of our veterans and their families. I mean manpower, mobile outreach, re-entry training – boot camp in reverse to become a civilian again – jobs, jobs, and more jobs, education, continuity of care, and especially family support and training in how to look after the safety of their loved ones.

It means requiring health care professionals to aim at zero suicides in those they serve, and to get over their causal attitudes about suicide prevention, and buckle down and show us they know what they are doing.  If sued successfully for suicide malpractice, and if the clinician could not show evidence of best-practice training in this area of clinical care, and if the deceased patient is a vet, juries should award triple damages to the survivors.

I know Michelle Obama and Jill Biden are supporting measures to help families, but so much more needs to be done. Waiting lists at VA hospitals? Need I say more?

And keep in mind, again, that the vast majority of suicidal veterans will never go to a VA hospital for care, nor to any outreach center. Most will go it alone, even over the rough patches ahead of them. Death in combat is not always avoidable, but suicide should be.  And even if we cannot entirely prove this to be true, we must believe it to be true, otherwise all is lost and tomorrow it will be another 22.

Lastly, I leave you with a poem written by Jim’s battle buddy from Viet Nam who, like Jim, made it through the war. There is a warning in this poem; one none can afford to ignore.

SO WE SHOT

We liked to shoot things. Boys being boys. We shot flying and

crawling things and swimming and walking things. We shot

birds and parrots and gulls and beautiful things we didn’t

know the names for. We shot monkeys and gibbons and

lemurs and deer and pigs and dogs and turtles. We shot oxen

and water buffalo in the rice paddies and bet how many M-16

rounds it would take to buckle one to its knees because it was

big and stupid. We shot tigers and elephants. Because we

rarely saw them, we rarely shot the enemy. We shot

Vietnamese women and children in their yellows and blacks

and a goodly number of old men. And if any of that were not

enough, we shot each other. Then we went home and shot

ourselves.

Edward Micus, From his book, “The Infirmary”

Dr. Paul

P.S. For my part, I have posted an online lecture describing our institute’s approach to preventing veteran suicide. It’s one. Using the QPR model, and understanding warrior psychology, and applying social network theory to suicide prevention, you might find it worth the 44 minutes to watch. See and share at: http://www.qprinstitute.com/vets.html.

When I started writing this blog, the country was still shaking from the shootings at UC Santa Barbara. Before I finished the first draft, the shooting at Seattle Pacific University had just ended. I am in rewrite today, one day after the tragedy in Las Vegas, and while writing this very sentence I learned of the shooting in Troutdale, Oregon.

Full stop!

America, we need to call a timeout, huddle up, and get an action plan going to stop the carnage.

To prevent the next mass murder-suicide we must, simply must, get upstream from these unfolding events and identify potential suicidal shooters before they purchase weapons, load up, and open fire. Yes, suicidal shooters, not homicidal ones.

I’ve covered this a bit in earlier posts, but bear with me. If suicide contagion is real (and it is), then so is murder-suicide contagion. See one, do one. Humans are highly imitative primates – and not just of good manners, but murder, means and mayhem.

For schools and colleges, one intervention recommended by some is to arm school employees, from teachers to school safety officers, and even students themselves. Armed resistance may reduce the number of persons killed and injured, but in my view it is too little too late. When bullets begin to fly, you’re into intervention, not prevention.

Stopping smoking is prevention; heart surgery is intervention. An armed employee or student can respond to an attack – if they are not killed first – but the homicidal-suicidal person who knows an armed target awaits him at his chosen location is likely to be attracted, not dissuaded, from action. His solution, after all, is to die in a hail of gunfire.

Mass murder-suicides (from Virginia Tech to Sandy Hook to UCSB to Las Vegas) are perpetrated by people who are suicidal first, homicidal second. Once the decision to die has been made – either by their own hand or by another’s – the second decision to seek “justice” for perceived wrongs provides only a final motivation.

These are not random acts of violence. Escapes are not planned. The shooter’s intention is to die, usually at the scene. Mass murder-suicides are premeditated, planned, and therefore preventable – if three things are done:

1. Train as many people as possible to recognize and respond to suicide warning signs. This is our collective responsibility to assure ourselves of a safe and sane society. On expert retrospective analysis of these events, suicide warning signs are inevitably present before the shooting begins. Suicide warning signs can be taught and acted upon to cause a formal threat assessment to be conducted, perhaps followed by voluntary or involuntary treatment or other risk mitigation interventions, e.g., denying access to firearms.

2. Train mental health professionals. Currently, few mental health professionals are well trained in how to conduct a comprehensive suicide/homicide risk assessment. More, too many do not routinely intervene with families to see to the removal or security of firearms available to potential suicidal or homicidal loved ones. Thus, even though a potential shooter is in treatment, there is no guarantee a competent risk assessment has been conducted or that all evidence-based risk mitigation strategies have been employed, including restricting access to firearms.

The training, by the way, is called Counseling Against Access to Lethal Means (CALM) and it is available free at: http://training.sprc.org/. It was developed by a dear colleague and friend and I cannot recommend it too highly. If you own a gun, you have a new duty: take CALM training.

3. Train law enforcement officers. Police officers are likewise not well trained to recognize and respond thoroughly to suicide warning signs. If they do detain a person for evaluation, they must rely on emergency room or mental health professionals to determine the level of risk and necessary action steps. But research shows that ED staffers know even less about suicide/homicide risk assessment than do mental health professionals. In the UCSB case, after a 10-minute welfare check, the sheriffs left a number and encouraged Elliot Rodger to call for help.

He didn’t.

Wake up, people…. suicidal males rarely ask for help, and homicidal-suicidal males never do. Or if they do, it is when taking the first steps down the trail to a tragedy for all.

This step might be taken in a therapist’s office, or in a conversation with a school counselor, or with someone who might, just might, be in a position to recognize that small but ominous cloud rising from a sea of mental anguish and torment “no bigger than a man’s hand.”

I am, admittedly, an impatient man. Waiting for troubled, angry, suicidal young men to ask for help before they start killing us is unacceptable. Enough with the waiting. If we have satellite spy cameras so powerful we can read a license plate from space, surely we are smart enough to figure out how to identify these people before they gain access to guns and start shooting.

(To my fellow Americans in the NSA reading this blog post: How about lending us all a hand here?  As tax payers, you work for us not the other way around, right?)

Back to the cops who, in this case, and in my view, might have tried the slick Lt. Colombo maneuver to get into the shooter’s house without a warrant, as in, “Oh, by the way… I wonder if it would be OK if we looked around just to make sure, etc. etc.” Stiff resistance to this polite request would raise the index of suspicion and perhaps trigger a deeper investigation.

If police officers cannot be trained to detect suicide risk, and then conduct suicide/homicide risk assessments in the field, then pair them with trained mental health professionals and create competent, quick-acting crisis response teams who understand that early identification and intervention may go unrewarded by the general public, but is still heroic. Mental health/law enforcement teams must be fully funded to respond to these threats and yet, currently, many communities are without them.

In the UCSB tragedy it is clear that the two groups of professionals who had contact with Mr. Rodger before he started killing people did not, or could not, communicate with each other about the risk that alarmed his parents and a roommate. The parents acted, but the roommate did not, later saying, “Why did I not say anything?”

The parents did say something, but we can only guess that the professionals involved may not have had the kind of training needed to a) recognize suicide/homicide warning signs, b) conduct a comprehensive suicide/threat assessment, and c) employ their collective civil authority to cause a change in the trajectory of the unfolding event, e.g., a voluntary or involuntary hospital hold to determine how much risk to self and others was present.

It’s a cheap shot for me to opine about this UCSB event while unencumbered by the facts, or the reality of actually having been there, but I have reviewed all of the other high-profile mass-murder suicides in recent history and the pattern is the same again and again and again. And as an old spy myself (retired), I have a pretty good idea of what’s missing. It’s called Intel.

From the 1955 Hoover Commission on American spy work, “Intelligence deals with all the things which should be known in advance of initiating a course of action.” Intelligence is used to prevent violence, and we cannot expect our mental health and law enforcement officers to initiate a course of action to avert violence without better intelligence. The dots are there; they are just not being connected.

But what about confidentiality?

What confidentiality? When lives are at stake, confidentiality is moot.

Too often confidentiality is the screen behind which mental health professionals stand to protect themselves from extra work, like talking to parents or family members when conducting a youth suicide risk assessment. Yes, they don’t get paid for intelligence gathering beyond that provided by their patients, but they should, and this can be fixed with a stroke of the regulatory pen.

Any clinician who relies solely on the statements made by a suicidal and possibly homicidal patient to assess and manage potential risk for violence is either untrained or naive. (Sometime I will share my Top 10 Reasons to Lie to Your Therapist if You Are Suicidal).

When I directed a large emergency service for 25 years and had the authority to invoke involuntary detention to determine if treatment was indicated for anyone suicidal or homicidal or both, people sometimes threatened to sue us over their loss of privacy. None did. But if they had, I was fully prepared to make the case for a temporary suspension of a person’s civil rights in the name of safety for all.
Some say these mass murder-suicides are unpredictable and therefore cannot be prevented. I disagree.  The dots are all there. Through training, education, better intelligence gathering, better intelligence sharing, and better communication among observers, we’ve shown we can greatly reduce American battlefield causalities. Now all we have to do is apply what we already know how do in our own back yards.

Dr. Paul

Except in a dream, I didn’t really have a meeting with the pope. But in my dream I was terrific. I helped Pope Francis launch the Vatican’s new suicide prevention program and thus changed the course Western civilization. Then I woke up.

The pope’s response to the pedophile priest problem is all over the news. Associated Press headline: “UN scolds Vatican on abuse.” AP headline: “Pope Criticized for Lack of Action on Sex Abuse.” Last week he apologized to still-living victims, and this week the UN committee is testing the Vatican on whether sexual abuse is torture.

Not a great time to be pope.

The apology to victims is fine, but it won’t be enough. When the true downstream results of childhood sexual assault are revealed, even successful lawsuits can’t right all the wrongs.

Why? Because even the pope can’t apologize to the dead. On this side of the veil, nobody can. But he could make amends to the families. And he could step up to the suicide prevention movement.

Here’s why. Multiple research studies show that early childhood sexual abuse and its associated adverse psychological trauma are leading risk factors for eventual death by suicide.

The impact of child sexual abuse on psychological wellbeing and suicidal behavior is clear. In 2005 Dr. Finklehor and his colleagues from the University of New Hampshire’s Crimes Against Children Research Center reported victims experienced fear, anxiety, depression, anger and hostility, aggression, and sexually inappropriate behavior, as well self-destructive behavior, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, a tendency toward re-victimization, substance abuse, and sexual maladjustment. These researchers added, “the kinds of abuse that appear to be most damaging are experiences involving father figures.” (Emphasis mine.)

Father figures? As in Father Murphy, Father John, Father What’s-His-Name?

Consider new research published on the contributing causes of suicide conducted by the U.S. Marine Corps and the Canadian Army. Both found that childhood sexual abuse was the single greatest risk factor among soldiers who were otherwise physically healthy, brave, and proud to serve. This sexual “torture” tripled their lifetime risk.

In a 10-year follow-up of Marine recruits researchers found that, yes, boot camp was tough; yes, advanced combat training was tough; yes combat was tougher still; and yes, managing relationships and deployments were tough. But among the five types of childhood trauma victims experienced by these Marines, sexual abuse emerged as the signature root cause for eventual suicidal self-directed violence.

In both the Canadian and the U.S. studies, it seems childhood sexual trauma creates a chink in these soldiers’ otherwise bullet-proof psychological armor. We call these early life traumas “distal events” which can create life-long vulnerabilities. Just imagine these early-wounded warriors trying to find safe havens when passing rough times later in life. Where do they turn for comfort?

To Father What’s-His-Name? Not likely.

Suicidal people are in a desperate search for buffers against death, reasons to live, and compassionate others who understand them. They need powerful arguments to keep living, and while multiple studies have shown that faith communities provide all of these and can serve as a kind a protective shield against suicide, I am unaware of any research on what happens when a victim has been taught to believe that suicide is a mortal sin – as the Catholic church has taught for centuries.

Seems to me that for victims of a pedophile priest, the road to the rescue and recovery is twice blocked; once by betrayal and once by doctrine.

I had one suicidal Catholic patient explain it to me thus… “In the end, I figured that Jesus, if not my church, would forgive me if I killed myself.” On this fine point, he and his church agree.

Question: How many sex abuse victims have killed themselves?

Answer: GOK (God only knows).

Consider one small dot on the great Catholic global map. The church recently acknowledged its contribution to the suffering of as many as 20,000 children in Dutch Catholic institutions over the past 65 years.

To my knowledge, the church has yet to link its sexual abuse of victims to any deaths by suicide. I could have missed this confession, and if I did, I’d be delighted to be corrected.

But in the meantime this appears to be the church’s stand on suicide from the current edition of the Catholic Digest – “The Church teaches that suicide is wrong; is contrary to the Fifth Commandment. It is an action that runs counter to the proper love of self, as well as love for God, the giver of life. We are stewards of our lives, not owners. The person who takes his or her own life also wrongs others – those who remain experience loss, bewilderment, and grief. You won’t find anything in that teaching about going to hell.”
The quote goes on to say of those who end their own lives, “Pity, not condemnation, is the response of the church. Prayers are offered for the deceased. Mass is celebrated. Burial with dignity, in consecrated ground, is provided for one who dies this way. Not that long ago, Christian burial was denied to those who took their own lives.”

Burial in consecrated ground now? Let’s see, the practice of punishing suicide victims and their families by burying them any old place except next to good Christians started in 4th century and continued until, let’s see, 1997.

By my calculations, that’s 17 centuries. I don’t like it, but I can accept the barbaric treatment of suicidal people since the time of St. Augustine, but not now.

I have no idea how many of these otherwise wonderful souls ended up in unhallowed ground over these eons, but it must run into the hundreds of thousands, if not millions.

I also found this Catholic Digest quote from Father Bryon about suicide particularly disturbing, “It seems to me that there has to be some mysterious insulation enveloping those who commit suicide. Tragically, their minds cannot be read by those around them, nor can they reach out and ask for help.”

“Mysterious insulation?” “Commit suicide?” “Can’t reach out and ask for help?”

Mysterious insulation suggests fundamental ignorance about the published research from the brain sciences, modern psychiatry, and suicidology.

Commit suicide perpetuates the stigma and Medieval dictum that suicide is a crime.

Can’t reach out and ask for help suggests a help-seeking deficit in the tortured.

Let me translate. The full line… Their minds cannot be read by those around them, nor can they reach out and ask for help completes the blame-the-victim dodge and can be redrafted as, “How can you expect us to do anything to prevent suicide since we can’t read their frigging minds and they won’t ask for help?”

Question: if such exists, what about the state of the immortal Christian souls who ended their own lives? Where did they go?
The current view – as I read it – is that suicide is still wrong (I think “wrong” is pretty close to “sin”), and that after they have killed themselves, God sorts them out, sending some to heaven and some to, well, wherever pedophile priests go.

My guess is we will all wait a long time to celebrate either of these headlines:

1. The Vatican Acknowledges the Role of Sexual Torture as a Leading Cause of Suicide

2. Pope Francis Appoints Committee to Explore the Church’s Emerging Role in Suicide Prevention.

I like the new pope. Who doesn’t?

So I wish I could feel sorry for him. But I don’t. Which is why I’m piling on right now. Because every second that immediate action to remove pedophile priests is delayed, suicide risk is added to lives of living victims, and if there is anything those of us working to prevent suicide cannot tolerate, it is inaction.

 

Some years ago after conducting a suicide prevention training in a Christian church, a little 90-year-old lady waited for me at the door after everyone had left. The pastor was with me when she stopped us.

“I need to ask you both a question, ” she began. “My only son killed himself when he was 15. I was an unmarried mother and when I asked my priest what would become of him, I was told that because he had committed a mortal sin he would burn in hell forever. I have been living with this pain for 60 years. Can either of you tell me it isn’t so?”

Fortunately, I had on the wrong kind the collar and redirected her question to the pastor (not a priest). A good soul, the pastor assured the woman her son was not in hell, but in the embrace of Jesus and always had been.

I don’t know if her son was sexually abused by a priest, and I don’t care. Enough damage was done with the explanation of Catholic policy on suicide. Mind you, I love the work of the Church has done and have long admired its many great contributions. But when I drive by cemeteries I look to the edges, just beyond the formal boundaries.

Why? Because that’s where those who took their own lives were buried by otherwise good Christians. The dead-by-suicide are not among the neat community-like rows of headstones that stand beside the old churches. No, the suicide victims of child sexual abuse were buried alone; in the very psychological state they most feared.

If there is redemption for the church in this matter, it lies in correcting its catechisms and embracing the science of trauma-caused psychological injury and trauma-informed care. You didn’t ask, but here are my modest proposals for a fix:

1. Acknowledge that historical church attitudes toward suicidal people and their families have been hurtful and have contributed to the problem of suicide, not helped prevent it.

2. Review the records of known victims of those abused, and for those who died by suicide, and publically apologize to their families.

3. Search church records for those who died by suicide (you will never know if they were sex abuse victims, but then you don’t need to), find the ground they are buried in, and consecrate that ground as “hallowed.” If Mormons can baptize the dead and give them a second chance, surely the Catholic church can release all these souls from the hell it condemned them to.

4. Instruct your clergy worldwide to study the scientific literature on suicide and its prevention and oblige them to take training in how to prevent suicide. Terms like “mysterious insulation” just don’t cut it. The church began to back scientific learning after Galileo caused all that trouble, and it helped get us to the moon, so this is an excellent time to open a journal and start reading.

5. Step up and join local, state, national and international groups trying to prevent suicide. (I’ve been going to meetings for 30 years, and I can count the number of Catholic priests who attended these meetings on one hand with three fingers left over.)

While I would never presume to suggest Christian clergy re-read the Holy Bible with an eye to early scripture and suicide, I would suggest they read, What Does the Bible Say about Suicide? by my now deceased friend and colleague, Reverend James T Clemons. Ignorance of your own scriptures is no blessing.

Finally, Pope Francis, you have great power. Whatever else you do with it, do not embarrass the church further by showing up with too little too late or making a nickel payment on million dollar debt. Suicide is a monstrous and crushing public health problem, and for the thousands of Catholics and Christians who will end their own lives this year, you can either get in the way, get out of the way, or show us the way.

Your choice.

Dr. Paul
References:
– Impact of child sexual abuse: A review of the research. Browne, Angela; Finkelhor, David. Psychological Bulletin, Vol. 99(1), 66-77. 1986,
– Relation between traumatic events in suicide attempts and Canadian military personnel. Belick, et. al., Canadian Journal of Psychiatry, 54, 93–104. 2009
– Suicide Attempts and Suicide among Marines: a Decade of Follow-up. Gradus, et. al., Suicide and Life-Threatening Behavior, 43 (1) 2013.

When my oldest son was 16 he developed Hashimoto’s disease and required a delicate thyroid operation. The boy was terrified. “They’re going to cut my throat, right?” he asked, as he lay waiting to be rolled into surgery.

The surgeon stopped by, “Well, Jeff, do you have any last questions for me?”

“Yes,” said Jeff, “What kind of grades did you get in surgery?”

The surgeon smiled. “Straight As.”

In my experience, patients about to enter treatment for suicidal thoughts, feelings, and nonfatal suicide attempts never ask such questions. But if they did, how would we mental health types respond?

“No worries, they covered this in a lecture as I recall.”

“Ah… let me think …”

“I’m pretty sure I had a seminar on that topic…”

Only a handful of mental health professionals ever actually take a course with the word “suicide” in the title, so it is something of a stretch for most of us to reassure suicidal people we can fix what’s wrong with them. While several good treatments for suicidal behaviors actually exist, on exams I’ve given (and I’ve given thousands), less than half of licensed clinicians can name them.

Imagine how much better a suicidal patient would feel if in response to the competency question, the answer was, “Yes, it was a tough course, but I passed the final at 100 percent.”

Would that not be an injection of 2ccs of hope?

With suicide prevention on the move, new training programs are emerging. Some are evidence-based, peer-reviewed, well-evaluated, and specifically designed to improve attitudes, knowledge, and skills in suicide care. To meet emergent demand others are being made up on the fly.

This is where the hard-ass comes in.

I’ve been a part-time college professor and clinical training director forever. According to some of my students I’m a hard-ass. I like my students the same as my martinis – shaken, not stirred. I don’t want my students relaxed. I don’t want them mellow. I don’t want them for friends. I don’t care if they like me and almost prefer they didn’t. Rather, I want them to learn. While I made learning fun, my students were not in class to be entertained, but rather to be trained.

If a student in my class slouched casually in the back of the room while playing with a cell phone, guess who I crushed with a question Einstein couldn’t answer? When a student arrived late to class, my standard line was, “Thank God you’re here! We thought you were killed in a crash!” No one came to class late twice, and some never returned at all. Oh well.

Being a hard-ass means I failed students. When I saw incompetence in clinical care, I fired people. And not just a few. Because her attitude toward suicidal patients was, “If they really want to kill themselves, we can’t stop them,” I fired one of my senior psychiatrists.

Why?

Because in good faith I could not safely place a suicidal patient in her care or count on to her to inspire hope in our clinical teams.  If a patient thinks he’s going to die, you don’t want the clinician treating him to agree. The last thing suicidal patients need are therapists more hopeless about their future than they are.

For the firings? No apologies.

Which brings me back to the question my son asked.  Only a well-trained health care professional can exude the kind of competence and confidence that gives hopeless suicidal patients hope, which is why I believe our training programs in assessment, treatment, and management should be rigorous.

Currently, we do have what are called registered best practice training programs in how to conduct a suicide risk assessment and then manage the assessed risk. These have been peer reviewed and have passed minimum standards as educational training programs in this area of clinical practice.  Right now, and as near as we can tell, they are best we have.

To see training recommendations made by an expert panel go to: http://www.sprc.org/bpr/section-II/preventing-suicide-through-improved-training-suicide-risk-assessment-and-care. To see a listing of the training programs go to: http://www.sprc.org/bpr/section-iii-adherence-standards. Not all of the programs listed cover suicide risk assessment, but you can find them by reading the descriptions, one of which is offered by the QPR Institute.

Like others in the field, I’m pushing for high training standards. I want clinicians to not only know something, but show something.

As part of my internship in clinical psychology, I was trained in a hospital-based psychiatry residency program. The director – another hard-ass – didn’t care about how you talked about therapy or assessment, you had to show him.

When your turn came, you went to the ward, brought your patient to an exam room in which six or seven of your peers and other doctors were seated with pens poised over notepads. Your work was about to be carefully examined, as every word you and the patient spoke were written down, together with notes on your body language. Some of your peers grinned at what would be a 45-minute roast; others simply drooled at the prospect.

After you introduced your patient to the group, you conducted your interview. Live. Everyone took furious notes.

At the end of 30 minutes you thanked your patient and escorted him or her back to the ward. Then you returned to the exam room to face – how shall I say this – a pack of ravenous wolves dressed just like doctors.

The critiques were tough. Some were brutal. Residents were known to throw up. Anxiety attacks left pools of sweat on the floor. But you learned. In the end, and if you survived, you felt oddly strong, not unlike graduating from Army boot camp. Even more important was the internal sense of confidence and competence you felt and radiated – just the medicine our suicidal patients need to restore hope.

This medical school rigor was not drive-by training. This was not slouch-and-listen training. This was blood-on-the-floor training. If you didn’t have a four alarm panic attack, the training director felt he’d failed.

And yet it was the best clinical training I ever got. Thank you, Dr. Spiro!

So as we roll out new clinical training programs to help suicidal patients, my vote is for rigorous training. Demanding training. Don’t tell me you do a great job assessing risk in suicidal folks; pass a knowledge exam, demonstrate the National Suicide Prevention Lifeline core skill competencies in a 360-degree peer review role-play, and have your risk stratification decisions supported by experts. Then put your written work in the medical record so your supervisor can review it to external standards.

Did I say lives are literally at stake?

As these programs emerge, and as cell phones populate the classroom, here’s how I rate classroom-only clinical training:
– Attendance only = D
– Attendance and 70% correct on post-training knowledge exam = C
– Attendance and 100% on post-training knowledge exam = B
– Attendance, 100% on the exam, and scored skill demonstration = A

What do I think of video content streamed into your computer?

Did I say D-?

Finally, I have aided and abetted suicide malpractice lawyers on how to disembowel clinical psychologists like me when they are on the witness stand trying to defend their training after losing a patient to suicide.

I have said to them, “Here are five questions that I guarantee will cause little beads of sweat to pop out on their foreheads. Nausea guaranteed. And all will look negligent to the jury.”

I’d tell you what those five questions are, but then I’d have to turn in my hard-ass badge. So, ready or not, here come the training programs. The public thinks we educators know what we’re doing.

Let’s not disappoint them.

Dr. Paul

The Governor of Idaho has signed Senate Bill 1254 into law, the bill to allow people with Idaho’s enhanced concealed carry permit to bring guns on Idaho public college and university campuses. This may be a Second Amendment win, but I’m not sure any suicide prevention experts testified on the additional risk ready access to firearms represents.
Mind you, I’m a defender of Second Amendment rights. But I hope not an uninformed one. In case Idaho voters were not aware, here are few well-established facts about firearms and suicidal people.
First, firearms are the leading method of suicide in Idaho and the United States. Second, access to firearms is associated with increased risk for suicide by that method. Third, suicide by firearm is preventable.
Global studies have confirmed that reducing ready access to the means of suicide lowers suicide rates, e.g., removing carbon monoxide from coal gas in England, anti-jumping screens on tall buildings and high bridges, and removing human-lethal pesticides in Sri Lanka.
To reduce suicides among 18-21 year old soldiers, in 2006 the Israeli Defense Force disseminated suicide prevention information and ordered soldiers to leave their firearms on base, rather than take them home over the weekend. This simple intervention reduced suicide rates by 40%.
Now that the Idaho bill has become law everyone concerned about preventing suicidal self-directed violence, including suicide-motivated violence toward others, needs to address how to mitigate the additional risk soon to be introduced to college life in Idaho. (For an excellent read on suicide-driven violence toward others, read The Perversion of Virtue: Understanding Murder-Suicide, by Dr. Thomas Joiner.)
Facts to consider in going forward:

1. Gun owners are no more mentally ill than non-gun owners. But the vast majority of people (95%+) who take their own lives are suffering from an untreated or under-treated mental illness. In the case of college students this illness is typically anxiety, depression, or both, and often complicated by substance abuse. Thought disorders also emerge in college years. Sadly, depression, anxiety and substance abuse disorders are not rare, and the typical onset of these illnesses is in young adults, and may be accompanied by suicidal ideation.
2. College health risk surveys show that approximately 10% of students report seriously thinking about suicide over the past 12 months. This figure does not include staff and faculty.

3. With some exceptions, college and university counseling departments are sorely understaffed and have very little time for marketing to, and recruitment of, those students at risk of suicide. Most departments can barely deal with their waiting lists, and very few have psychiatrists available for assessment and medication consultation. Thus, most suicidal college students go untreated.
4. Suicide is preventable, including by firearm. Reduce access to the means of suicide and you reduce suicide.
5. Prevent suicide and you prevent murder-suicides.

Debating gun control produces mostly heat, not light. Gun safety is another matter. Excellent “light” on the subject of gun safety and eans restriction can be found at http://www.meansmatter.org – Harvard University’s School of Public Health’s web site.
So what can we do now that some students will carry firearms on campus in Idaho?
If you are a parent and if your child gets into trouble emotionally, make sure he or she is safe. Visit them. Question them. Bring them home. If they have a firearm – or access to a roommate’s firearm – do whatever it takes to make sure you child does not have access to any weapon when they are in personal crisis.
Do not assume they will voluntarily get the care they need. If your child is male, you can pretty much be assured he will ignore social marketing efforts that ask him to ask for help if he is troubled. And don’t assume your daughter will either.
Suicidal people of either gender typically never ask for help during the early onset of a depression and, as time passes, the odds they will seek help and ask for it can decrease. We call it the “help negation effect” – which basically translates hopelessness into inaction as in, “I’m so hopeless no one and nothing can help me, so there’s no sense in trying.”
Or, if they do seek help they often stop at the slightest obstacle, e.g., “I don’t know where the counseling center is.” Bottom line: Assume nothing, and never choose to wait-and-see when you can act.
Family members, faculty, staff, and fellow students can be trained to recognize distress signals and how to safely intervene. Some Idaho schools are doing this now, and hundreds of other campuses all over the country are stepping up with programs.
If it was up to me – and if they’d just let me rule the world for a few minutes – suicide prevention training would be mandatory for all college freshman during orientation week, AND all faculty and employees, with annual refresher training to assure ongoing competence.
Do the math. You have 10,000 students. If 10% are going to consider suicide in one school year, that’s 1,000 students. Count up your counseling center treatment staff and divide this number into 1,000 and then give each student 10 sessions of cognitive behavioral therapy.
Guess what? You are long on students and short on staff. Way short.
I did this math with an unnamed major university with 40,000 students. They’d had five recent student suicides. When asked, I was told they had five counseling staff. Five staff for 4,000 potentially suicidal students each year.
This was not like trying to build bricks without straw, but trying to build bricks without mud or water, and I said as much in my keynote. I was later told that some in leadership positions where “disturbed” by my remarks. I said, “Good! Then my work here is done!” They later hired a platoon of new therapists.
Back to guns.
Every gun owner needs to practice the 11th Commandment of responsible firearm ownership: “Keep firearms from persons in distress.”
This means that if you are gun owner and you know someone is in crisis, you don’t loan them your weapon. You keep it locked up. If you are a college student with a firearm on campus, you never let that weapon get into the hands of someone whose life, studies, or relationships are not going well. A friend never lends a weapon to a troubled friend.

And, if you are a mental health professional – or any health professional – take a little time to learn how to counsel clients on restricting access to the means of suicide. Called “Counseling on Access top Lethal Means” the program was developed by my friend and colleague, Elaine Frank at Dartmouth. The training is free and can be found at http://training.sprc.org/course/description.php#course3. Every college counselor in Idaho should take it now!
Here’s another fact that can be leveraged to prevent suicide. Suicidal people planning to use a firearm don’t easily switch to a different method, and frustrating access to a gun often produces relief, e.g., “Someone cares that I live and is willing to frustrate me to prove it.”
Reducing access, even for a few minutes, hours, days, or weeks buys precious time for a crisis to pass.
Consider that when President Lincoln was a depressed young man and actively suicidal his friends removed all his knives and pistols and kept a careful watch over him, thus preventing a suicide attempt. A great read on this is: Lincoln’s Melancholy, by Joshua Wolf Shenk, Houghton-Mifflin Company.
Now that the Idaho guns-on-campus law has passed, we should learn all we can about constitutionally-appropriate, politically-neutral, and community-based suicide interventions available now for immediate implementation. There are some that actually work, and others are in research and development.
Watch this space.
Dr. Paul

It’s been one year since Sandy Hook and we are as ignorant about why it happened today as we were in the immediate aftermath.
In recent weeks the Connecticut Attorney General’s final Sandy Hook Report has been released, and the New Yorker magazine just published an interview with Peter Lanza, Adam Lanza’s father. This interview filled in the last missing piece of this puzzle for me. I’ll explain in a few.

I read every word of both the AG’s report and the father’s interview.

The report and the press claim “no motive” was found for this tragedy.

No motive?

Really?

Unless I missed something, I understand that no comprehensive psychological autopsy was conducted to help explain Adam Lanza’s suicidal-homicidal state of mind and his possible motive. However, that does not mean that we have learned all we need to know about this horrific mass murder-suicide, or that understanding what happened became impossible with the death of of the last victim – and in the wreckage of his hard drive.

Nothing more to be learned? No motive? No way to predict this kind of behavior so we can prevent it in the future?

Puzzle with me awhile.

Imagine for few minutes that you are a college sophomore psychology major. You’ve had a few courses, including abnormal psychology. While you are not trained to conduct a forensic psychological autopsy, you are nobody’s fool. You understand the word “motive,” and you read somewhere that a combined Secret Service and FBI report found that 75% of all school shooters are unequivocally suicidal before the shooting begins. Which means most mass murderers are suicidal first, homicidal second.

With no escape attempt planned or made, Adam Lanza arrived on the Sandy Hook campus a dead man walking. Was he suicidal before he started shooting or after?

Begin your investigation by reviewing some AG’s conclusions.

Do any of items selected from the AG’s report below suggest to you that, in fact, something like a “motive” might be discernible? As a thinking frame, consider that the investigators reported the exact weight of munitions, but not what weighed on the mind of this young man.

From the report itself: “The obvious question that remains is: ‘Why did the shooter murder twenty-seven people, including twenty children?’”

The investigators did ask not why Lanza killed himself.

More from the report: “Unfortunately, that question may never be answered conclusively, despite the collection of extensive background information on the shooter through a multitude of interviews and other sources. The evidence clearly shows that the shooter planned his actions, including the taking of his own life, but there is no clear indication why he did so, or why he targeted Sandy Hook Elementary School.'”

I don’t mean to be stupid here, but really? There was no “indication why he did so?”

Consider that there is no murder without motive, and there are no meaningless suicides. The focus of the report fails to address the prime cause for this entire tragedy: suicide.

But like the drunk searching for his keys under a street lamp, not because that was where he dropped them, but because that’s where the light was better, by failing to explore Adam Lanza’s state of mind the investigators never considered the probable chain of events that fueled Lanza’s suicidal-homicidal plan.

Consider their focus: “The purpose of this report is to identify the person or persons criminally responsible for the twenty-seven homicides that occurred in Newtown, Connecticut, on the morning of December 14, 2012, to determine what crimes were committed, and to indicate if there will be any state prosecutions as a result of the incident.”

If you are a prosecutor, the light is excellent around crime scenes but dim when trying to explore the state of mind of the perpetrator. The lost keys for this event were dropped back in the shadows of Adam Lanza’s history, remote and recent.

As a college sophomore sleuth, you may have learned something about what motivates suicidal behavior, e.g., untreated depression, mental anguish and unbearable psychic pain, and the growing belief that relief from suffering can only come through death. Couple this state of mind with a perceived inability to escape your unbearable circumstances, or a conviction that death by suicide is the only way to avoid some pending unendurable change or requirement. With these conditions in place, you now have the mental crucible in which the sparks of suicide begin smolder and smoke.

Imagine, also, that you have learned how to recognize a few warning signs of a pending suicide attempt. In a word, the subject’s behavior telegraphs what is about to happen, which gives you time to act – provided you know what to do.

Now, do you see any warning signs in the “facts” that might help you see what is coming? Is there anything here to help you understand the motive for this mass murder-suicide?

Quotes from the report of items found in Adam Lanza’s room:

“A Christmas check from the mother to the shooter to purchase a CZ 83 firearm”

“A New York Times article from February 18, 2008, regarding the school shooting at Northern Illinois University.”

“Three photographs of what appear to be a dead human, covered in blood and wrapped in plastic.”

“Photocopied newspaper articles from 1891 pertaining to the shooting of school children. While the vast majority of persons interviewed had no explanation for the shooter’s actions, a review of electronic evidence or digital media that appeared to belong to the shooter, revealed that the shooter had a preoccupation with mass shootings, in particular the Columbine shootings.”

“For example, there was a spreadsheet with mass murders over the years listing information about each shooting.”

“Two videos showing suicide by gunshot.”

“Commercial movies depicting mass shootings”

“The computer game titled “School Shooting” where the player controls a character who enters a school and shoots at students”

“Images of the shooter holding a handgun to his head”

“Images of the shooter holding a rifle to his head”

“Five-second video (dramatization) depicting children being shot”

“Images of shooter with a rifle, shotgun and numerous magazines in his pockets”

“A document written showing the prerequisites for a mass murder spreadsheet”

“A spreadsheet listing mass murders by name and information about the incident”

“Large amount of materials relating to Columbine shootings and documents on mass murders”

Any thoughts yet? See any possible clues? Any suicide warning signs here or should we just move along?

Does it bother you that all the school shooters listed by Adam Lanza died by suicide at the scene of the shootings?

Don’t strain for an answer here…, just let it come to you.

Is there a final spark that ignites the crisis and sets in motion this  chain of events?

From the report:

“As of December 14, 2012, the shooter and his mother lived at 36 Yogananda Street. This had been the family home for years, although only the shooter and his mother had resided in the house for an extended time. Both the shooter’s and his mother’s bedrooms were on the second floor; the mother occupied the master bedroom. In November 2012, the mother sought to buy the shooter another computer or parts for a computer for the shooter to build one himself. She was concerned about him and said that he hadn’t gone anywhere in three months and would only communicate with her by e-mail, though they were living in the same house. The mother never expressed fear of the shooter, for her own safety or that of anyone else.

“The mother said that she had plans to sell her home in Newtown and move to either Washington state or North Carolina. She reportedly had told the shooter of this plan and he apparently stated that he wanted to move to Washington. The intention was for the shooter to go to a special school in Washington or get a computer job in North Carolina. In order to effectuate the move, the mother planned to purchase a recreational vehicle (RV) to facilitate the showing and sale of the house and the eventual move to another state. The RV would provide the shooter with a place to sleep as he would not sleep in a hotel. In fact, during Hurricane Sandy in October 2012, with no power in the house, the shooter refused to leave the home and go to a hotel.”

A few more facts from the report…

1. “At the time of death he was six feet tall and weighed 112 pounds.”

2. “Both the shooter’s mother and father indicated that the shooter was bullied growing up.”

3. “There were a number of people who knew the mother over the years, some fairly well, who had never met the shooter – although were aware of his existence – and had never been inside her residence.”

4. “Over the years from the late 1990s and into the 2000s, the shooter had evaluations of various types, some of which were available to the investigators. In the late 1990s he was described as having speech and language needs. At that time he was also being followed medically for seizure activities. In preschool his conduct included repetitive behaviors, temper tantrums, smelling things that were not there, excessive hand washing and eating idiosyncrasies.”

Now pull on your Sherlock Homes deerstalker…

As a young investigator, it is common to put yourself in the shoes of the criminal to try to see the world from the perpetrator’s perspective. Why, you ask, would someone do something as horrible as this? What would drive them to such extreme action?

If you were this young man, and given your history, current symptoms, almost complete isolation from family and a few acquaintances – and whatever else burdened your mind – what would be your reaction to being forced out of the only sanctuary you ever had? Remember that during a dangerous storm – perhaps fearing unbearable anxiety and psychic suffering – you refused to leave your room to go to a hotel for your own safety.

With the house on the market, would strange people enter your sanctuary?

Would potential buyers want to see your room?

What would they find there?

Would your refusal to show your room ruin a sale for your mother?

If the house sold, what would be required to do?

Who is forcing you to move?

Consider also – as the missing puzzle piece I mentioned at the outset – that his father reported in the New Yorker interview that when Adam began middle school he was required to change classrooms each period rather than sit in the same room all day. Moving from classroom to classroom so upset and overwhelmed him that he stopped most normal activities, experienced panic attacks, and developed a host of acute symptoms that led to a psychiatric evaluation and eventual diagnosis that he was suffering from a serious mental illness.

In sum, the requirement to move from one room to another during the school day exacerbated his developing mental illness and required his mother to begin home schooling him, thus leading to even more isolation.

Now, with your only safe hiding place in the entire world up for sale your mother announces that she is about to move you not only out of your room, but out of your house, and even out of your state.

Confronted with this unavoidable consequence put into motion by your mother – and already believing women are selfish and insensitive – how on earth do you avoid being forced out into a world you not only dread, but cannot imagine existing in?

Is it at possible a “no-escape-but-death” option could have entered your mind?

Take your time.

Now note that a Danish study of 4,000 children ages 11 to 17 published in the June 2009 Archives of General Psychiatry (Vol. 66, No.6) found that those children whose families moved three to five times during their young lives were twice as likely to attempt suicide compared to children who had never been moved. Teens required to move more than 10 times were four times as likely to attempt suicide.

So what do we know? We know that we have an untreated serious mental illness or two (Adam refused medications), possible weight loss from depression (a 32 fold risk factor for suicide), almost complete isolation, inescapable suffering on the immediate horizon if the house sold with no way to escape, access to firearms, and a long-standing fascination with mass murderers who all die by suicide at the scene of the crime….. We also know that, given his diagnosis, he lacks basic empathy for others… just one of the serious symptoms of his illness.

Compared to all other known risk factors for suicide, I’ve conjectured that the one we most frequently underestimate in our assessment of unfolding risk is that looming, unbearable circumstance we know is coming and that we also know we cannot possibly endure or avoid. Or, to borrow from Winston Churchill, suicide becomes the only escape from a pending unavoidable adverse event up with which we will not put.

My colleague, Dr. Thomas Joiner, recently published a book on murder-suicide, and I just finished it. Kudos, Thomas! Titled, The Perversion of Virtue: Understanding Murder-Suicide, it deserves a wide audience. Just Google it and read a sample. Among its valuable lessons, one point is this: Murder and violence toward others can be prevented by helping suicidal people. For our own safety and that of others – including the children to die in the next Sandy Hook – we ignore suicidal people not only at their peril, but at our own.

Even as a college sophomore I think you can provide a superior explanation of motive for this mass murder-suicide than the experts.

From the AG’s report: “The evidence clearly shows that the shooter planned his actions, including the taking of his own life, but there is no clear indication why he did so”

No clear indication why he did so?

Really?

Dr. Paul

For an earlier piece on this tragedy, you can read my first response at: http://www.qprinstitute.com/pdfs/Newtown.pdf.