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.


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


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.

Is a Shoot-Out Coming to a Campus Near You?

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

My Meeting with the Pope

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
– 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.


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

Packing Heat to Study Hall…. Idaho’s New Gun Law

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

Newtown One Year Later

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?


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?


Dr. Paul

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



There is a crack in everything. That’s how the light gets in.

Thank you for the lyric, Leonard Cohen.

There’s a crack in Washington state, and the light is pouring in. 

History was made in Washington this week.  Big, memorable, Wikipedia-quality news.  While working on a blog about how the Catholic church helps shove suicide victims and their families down into the black pits of hell (post coming soon), the Washington State Legislature just helped to pull them out and into a new light.

Here’s what happened.

Thanks to a small, fierce, and determined group of suicide prevention advocates, the Washington State Legislature turned its back on lobbyists from the Washington State Psychiatric Association, the Washington State Medical Association, and the Washington State Nursing Association, and others and voted its conscience. 

To remain licensed to practice, all 148,000 doctors and nurses in Washington will be required to complete one six-hour training session in suicide risk assessment, treatment and management.  In so doing, the legislature changed the face of suicide prevention in America and the world.  More, they helped unravel the fabric of stigma, shame, and ignorance that has cloaked suicidal self-directed violence for centuries. I trust that Gov. Jay Inslee will have the good sense and the heart to sign the bill into law.

Blog followers will recall my recent posts about legislative activity in the state of Washington. While the bill to require training  of primary care providers passed the Democratic House, most of us figured the chances of getting past the heavily-lobbied Republican Senate were less than 50-50. 

 We were wrong.  Yes, the opposition was backed by thousands of voters with money and paid lobbyists – while we had fewer than 100 without money or a lobbyist, but we won.  We showed up.  We told stories about lives lost or nearly lost to suicide. We corrected distorted facts and stepped up to testify with passion and courage. The opposition sent lobbyists.  Turns out passion and courage won. The Senate vote?  49 in favor, zero against.

We wanted the mandate to require six hours of training every 8 years.  We didn’t get it (that was the compromise to get the bill out of committee), but I’m satisfied with a one-time training provided – and this is a big one – their professional rules committees don’t so water down the requirement that it will fail to have the desired impact on quality of care for suicidal patients. 

From the top of one of the organizations resisting the bill the following line in an email was mistakenly routed to me: “Bad news.  It looks like we will need to do a couple of one-time suicide seminars, as we did with the HIV CME requirements.”

Bad news?  Really?  Did you not see “Dallas Buyers Club” or “Philadelphia” or have a relative or someone you know die of AIDS?

The risk for a least-possible-effort approach to the required training lies in our penchant for quick-and-dirty drive-by seminars.  Attendees need do nothing more than be a warm-body-physically-present to pick up a “Certificate of Attendance.”  While passively listening to the facts roll by “trainees” can watch a Seahawks football game on a smart phone or text with the office to stay on the “real job.”

Ignorance is not relieved by indifference.  You can’t learn a skill by watching a video. A passive educational approach to “assessment, treatment, and management” will not reduce avoidable clinical errors, and half-measures only create more risk for patients.   As one of my staff said about working with suicidal patients, “You have to be willing to pull on your hip waders and get down there in the muck of existential despair if you hope to really help people planning to kill themselves.”

You only mandate training when there is a crying need to fix a problem that is causing avoidable morbidity and mortality.  You only mandate training when willful ignorance has been winning.  And willful ignorance has been winning for far too long. 

Yes, we currently lack a deep battery of proven suicide prevention interventions, but we have some that actually work to save lives, and to not learn these amounts to willful ignorance.  Besides, there is a reason for our confessed lack of evidence about what works to prevent suicide.

Just look at the National Institute of Health’s per-person research budget by cause of death. For each death by HIV-AIDS, we spend $15,665 on research; for each heart disease death, $6,664; for each breast cancer death, $3,875; for each prostate cancer death, $1,635, etc..  How much do we spend to understand and prevent suicide and life-threatening behavior per death? A lousy $254 dollars.  Compared to all other major causes of death, research funding for suicide prevention is a rounding error.

Consider this quote from the widely-ignored 2002 report from the Institute of Medicine, titled Reducing Suicide: A National Imperative, “There is every reason to expect that a national consensus to declare war on suicide and to fund research and prevention at a level commensurate with the severity of the problem will be successful, and will lead to highly significant discoveries as have the wars on cancer, Alzheimer’s disease, and AIDS.”

This is the same Institute of Medicine that, more than 10 years ago, strongly recommended the very training required of health professionals in the new Washington State ESHB 2315. For those medical professionals who think being asked to learn something new about how to save lives is “bad news,” I say get over it or get out of medicine.

My prediction is that once medicine realizes its role in how we can all work together to slow this terrible and avoidable carnage, doctors and nurses will move quickly to take the lead. And if they do, then they can help the rest of us pry open the crack that lets the light in.

Finally, it is helpful to realize that since St. Augustine’s determination that suicide was a mortal sin, which then became a capital crime (yes, suicide attempters were once hanged by the state),  our collective understanding of suicidal behavior has remained in the Dark Ages.  With few exceptions, we have brought no light, no understanding, no compassion, and but a little science to better comprehend our fellow travelers whose experience of life is so unbearably painful that only death promises relief. 

While I am as jaundiced as the next American about the democratic process in the other Washington, I am reborn this week to believe things can and do change in this Washington. With the push and passion-fueled actions of a few, a moral victory can be won, and one was won right here in my backyard.

The Washington State Legislature has thrown open a window to let the light pour in.  It is bright and hurts the eyes, but it is light, light, light.

 I say, celebrate!

 I say, rejoice!

I say,  dance and sing!

And now that we have found the crack in the bell where the light comes in, pass these laws in your state!

Dr. Paul

Note: There are too many heroes to thank for what just happened.  But you know who you are.  Good on you!

For a review of the bill and how it all happened go to: http://opb.washington.edu/billtracker/

Change Can Be a Beautiful Thing

If you have been following this blog you know that I’ve been trying to make the moral, scientific, and humanitarian case that providers of healthcare services ought to be better trained in suicide prevention. From primary care providers, resistance to mandated training has been stiff. Change, it seems, is only desirable if your diapers are dirty.


Well, good news!  Change happens.


The Washington state House of Representatives just passed House Bill 2315 by a vote of 94-3!


HB 2315 would oblige primary care providers (PCPs) to complete the same kind of training now required of mental health professionals in my state (HB 2366 passed into law in 2011 and training is underway).


Briefly, PCPs would have to learn something about suicide risk assessment, treatment, and management to keep their licenses, and the mental health problems that motivate suicidal behaviors.  The mandate would impact chiropractors, naturopaths, all nurses, osteopathic physicians and surgeons, physical therapists, physicians assistants and physicians.


The bill now goes to the Senate and you can read it at: http://www.leg.wa.gov/pub/billinfo/2013-14/Htm/Bills/House%20Bills/2315.htm. The bill does a couple of other good things, but the training mandate is key to real change.


For a rock solid rationale on why the bill is needed, I invite you to read the bullet points in the opening of the bill following “The legislature finds that…”  My House testimony on this bill is posted in an earlier blog (Oh Doctor, Where Art Thou?).


Remember, this bill does not require additional continuing education training hours, or additional costs, but rather a retargeting of existing required CE hours with an aim to mitigate a major public health problem.  To any who have lost a loved one to suicide, and given the scope of impact a death by suicide has on every aspect of our society, this requirement hardly seems an imposition. 


When a cause of death is at once knowable and avoidable through education and training, only four questions need answers.  And to each of these, we can now say yes. Is the training:

·       Affordable?

·       Available?

·       Accessible?

·       Adequate?


Richly-funded modern medicine leaps forward on every path to extend life but one: preventing death by suicide.  Learning how to interact and talk with suicidal patients is not neurosurgery or spinal manipulation, and it only costs only a few dollars to learn how.  Yes, the interviews will slow the processing of X many patients per hour, but the payment mechanisms and integration of behavioral care into primary care under the Affordable Care Act are going to make these conversations much more possible for everyone, patient and provider alike.  It is very difficult to have a deep, existential conversation about life and death in 9 minutes, which is what we have been asking PCPs to do and, to boot, not get paid for.    


HB 2315 passing the house is real change, and this is good.  Many in the public sector wonder why it hasn’t happened before.  Just off the phone with a reporter, I explained to him the scope of the problem and the recommended fix (six hours of training every few years), to which he said, “That seems like a pretty low bar.”  I did not disagree, but I will take a low bar to a no bar every time.


It sometimes helps me to think like the tax payer I am. For example, unless I am much mistaken, my tax dollars helped support the medical educations of the folks targeted in HB 2315. Having helped fund their training, do I have any right to ask that – since their medical schools overlooked the topic – they now spend a few hours fixing this gap in their education?  I think not.


Being suicidal is not like having high blood pressure or trying your first cigarette. That first cigarette can lead to life-long addiction, perhaps emphysema, and even cancer, but a first suicide attempt can lead to death, and too often does.  In the case of helping people lose weight or stop smoking you have time; in the case of dissuading an acutely suicidal patient from attempting suicide, you don’t.  


Many of us here in the real Washington will be contacting Sen. Randi Becker, chair of the Senate Health Care committee to request that she schedule the HB 2315 for a public hearing.  In case you live in Washington, or know someone who does, take minute to act.


Change only happens when people act – not talk, think, consider, or pee down both legs while contemplating what might happen if, some day, soon perhaps, I stopped tossing around ideas about what I might do and, just, you know, do it! 


Nike made a fortune and changed the athletic activity of an entire nation with the slogan “Just do it!”


My work here is done.


Sen. Becker can be reached at randi.becker@leg.wa.gov or 360-786-7602.


Quote for the day: Preventing suicide may be easier than overcoming our fear to try.

Dr. Paul

Ernest, We Hardly Knew You

Every now and then some ignoramus will announce that, because he killed himself, Ernest Hemingway was a coward. This view of why Papa ended his own life begs a better answer. A modern one. An enlightened one. An explanation that does not subtract from who the man was.

Among the three men who ignited my spirit to fish, the first was my grandfather, the second was my father, and the third was Ernest Hemingway.  His short story, “A Big Two-Hearted River,” gave a compass to my life.  For his sake and mine, and because I’ve learned something about suicide since I was a young fisher boy, I’d like to set the record straight about what really killed Ernest Hemingway.

First, Papa did not die only of – as we say in my line of work – “a GSW to the head.”  In this dismal field, a “GSW” stands for gunshot wound. Yes, this was the manner of death, but the cause is much more complex. Suicidology (the study of suicide) is what I do when I’m not fishing. Since Ernest Hemingway ended his life by suicide, a better understanding of his death is part of my business.

I deal with death by suicide pretty much on daily basis, and called our county medical examiner by his first name because we have that much truck between us. So I know – without seeing it – what the coroner’s report said about Ernest Hemingway’s suicide. In determining manner of death and later rating the seriousness of a self-inflicted wound, shotguns top the list, even ahead of .44 magnum pistols. Death by pills, slashed wrists, and hanging are no less deadly, but it takes an extra special something to terminate consciousness with a shotgun.  Shotguns are forever.

As a suicidologist, the first thing I know about Ernest Hemingway’s death was that his decision to die was premeditated. The older folks get, the better they plan. At Papa’s age – 62 – pulling that final trigger was no impulse. Thoroughly familiar with firearms and their deadly force, he had no intention of being rescued, saved by a crack 911 crew, or somehow surviving a carefully-placed blast to the skull.

As a side note, not everyone dies from a GSW to the head. One young fellow I evaluated years ago had placed a 7mm magnum rifle to his forehead while sitting in the front seat of his pickup with the windows rolled up.  When he pulled the trigger he blew a gaping hole in his scalp, but the bullet ricocheted off his hard Irish skull.  A year later he was combing his hair down over the sutures and smiled easily when I asked him how it felt to not die. “It’s great,” he said, “but I don’t hear so well anymore.” We both laughed.

The second thing we know about Hemingway’s suicide is that his decision appears to have been unequivocal. We will never know if he had last minute thoughts about signing off, but his plan did not include a chance to be interrupted. Others may have tried to dissuade him from his decision in the days and weeks before, but we can assume that in the final moments his actions were on automatic.

The third thing we know is that this final decision was made with an impaired brain. Research has shown that persons who die by suicide using very violent methods have often conducted careful post-death scenario planning as regards how things will unfold after they are dead.

This analysis includes the selection of lethal means, timing, place, and who will find the body. We call these preparations “deadly planning.” Of note, on physical autopsy of brain tissue after a suicide there are often only trace amounts of essential neurotransmitters in the brain. If serotonin and dopamine are the neurotransmitters that make us happy, cheerful, and full of goodwill toward strangers, they also help our frontal lobes solve problems quickly and well. Absent these necessary neuro-juices to float our noodle in, our brains become like a dry socket after a tooth extraction – a mass of pain-emitting, raw nerve-endings.

Some in our field call this mental pain “psych-ache.” Research confirms it is real, measureable, and one of the most serious drivers of suicidal behavior. People experiencing this ache explain that only death seems to offer any hope of relief – thus does hope spring even from the minds of those praying for their suffering to end.

It’s important to understand that bench science on the suicidal brain is underway, and that much more is needed. For now, what we know is that the neurochemistry of suicidal brains is so out of kilter that, more often than not, the person cannot think properly, let alone make life-and-death decisions. Just as a Cadillac won’t run long and well without sufficient oil in the engine pan, neither will a human brain run long and well without sufficient neurotransmitters in the brain pan.

Lesson four. Serious thinking about death and suicide are symptoms of a medical illness, most commonly an untreated mood disorder.  These illnesses are, now and thankfully, quite treatable.  Some are resistant to treatment, yes, but most are not. As it turns out when Ernest Hemingway died many of the effective treatments for mood disorders we have today were not available to him. Had they been available to the physicians trying to help him during his illness, he might well have lived to fish and hunt again, and to write well again.

Lesson five. Most people do not understand that serious clinical depression is a potentially fatal disease. I’m pretty sure Ernest Hemingway considered depression a character flaw, or a personal failure of some kind. Maybe he thought of himself as “weak” because he could not kick his depression in the ass or knock it down the stairs. Add alcohol to depression and you have a remedy for disaster.  People suffering from bi-polar disorder (formerly called manic-depression), have a one-in-five chance of dying by suicide if they do not receive competent medical care.

Lesson six. Had Hemingway survived his suicide crisis without making what proved a fatal attempt, we don’t know if, one day, he would have responded to a new medication, or an emergent new treatment.  With a successful intervention, we have every reason to believe that he would have re-embraced life and relished it as few others know how.

Having spent 35 years treating suicidal people, and having known dozens who did not die as the result of a serious suicide attempt, I can tell you almost all of them went on to live a full and merry life. Yes, some had relapses of depression (it is a recurrent condition for many), but research shows that most people who seriously consider, and even attempt suicide, don’t die by suicide in the decades that follow.  And once the crisis is behind them, they never become suicidal again. Because they learned greatly from this deep existential experience – unlike most of us suicide attempt survivors have looked death in the eye and death blinked. Many go on to achieve great things. Abraham Lincoln, Buckminster Fuller, Martin Luther King, Jr., and J.K. Rowling come to mind.

Lesson seven. Many people think Hemingway died of a gunshot wound to the head, and that suicide is the “coward’s way out.” Not so. That was only the mode of death. It takes great fearlessness to actually kill oneself. To be able to actually pull that trigger requires a state of mind few of us, thankfully, have. To develop this capacity for self-inflicted violence one has to build up to it through the hard work of exposing oneself to trauma, gore, pain, violence, and by enduring life-threatening circumstances and experiences. (My colleague and friend, Dr. Thomas Joiner, is the chap to read on these matters; especially his book, The Myths about Suicide. http://www.amazon.com/Myths-about-Suicide-Thomas-Joiner/dp/0674061985 )

Therefore, the real causes that led to Papa’s death were the excruciating pain and suffering he experienced from an unsuccessfully treated mood disorder, the ravages of alcohol – perhaps abused in an unsuccessful effort to treat his unending anguish. Some authors argue that the residual symptoms of traumatic brain injury (fist fights, plane crashes, etc.) may have impaired his writing ability, thus fueling his depressed mood and sense of despair. More than anything else, Ernest Hemingway died of hopelessness. The GSW to the head was only the coup de gras, in this case delivered by the sufferer himself.

If you’ve read Mr. Hemingway’s collected letters carefully you will find that shotgun trigger was cocked in his youth, most likely by his father when he shot himself to death while Ernest was still a boy. As a blood relative and survivor of suicide, Papa’s risk for self-destruction quadrupled immediately. From my reading of his Paris letters, he was ready and prepared to make his own ending before he’d turned 25 and well before he’d come to any true adult power or recognition as a writer. If we knew his mind as a boy and the life script written for him by his father, we might all remember the playwright’s rule that if you introduce a gun in Act I, you must use it by Act III.

Lesson eight. Dying by suicide is not a character flaw. It is not a weakness. It is a method of delivering oneself from a living hell that has become unbearable and unendurable. To the oft repeated questions, “Why did he leave us?”  “How could he be so selfish?” and the accusations of cowardice, I can only say that unless you have been the same place yourself you will never understand the final motive, and that unless you can develop a terrible fearlessness of death, you will never be able to kill yourself. Only when you have personally experienced the searing psychological pain and suffering of utter despair and hopelessness can you imagine what a wonderful, simple, logic suicide-as-solution makes. The very best book on the subject is William Styron’s, Darkness Visible.

In Ernest Hemingway’s case, treatments had failed him; hope was gone. One of my psychiatrist colleagues had been a resident where Hemingway was treated for a short time in the months before his death, and even took him for a spin in his sports car to get him out of the hospital for an hour or so.  “We didn’t have much to offer him,” said my psychiatrist friend, “other than shock treatment.” When Papa was ill those many decades ago, there was no medicine but hope and, as Emily Dickinson wrote of hope, “… the thing with feathers that perches in the soul and sings” was a simple wing shot for a man like Hemingway.

May I make a small request on behalf of a much-loved man of letters? I think Papa would approve.

If someone you know  seems down, cranky, despondent, or irritable, and has stopped fishing or having fun, and who says anything at all about desiring death or wishing life was over, get them immediately to a competent mental health professional for evaluation and possible treatment. Don’t wait. Don’t pause. Don’t think it over. Just do it.

Remember, suicide prevention is not so much the stopping of a self-inflicted death as it is the restoration of hope in the hopeless before the fatal planning begins.

Finally, when we speak of one of America’s greatest writers, can we say that Ernest Hemingway died of an untreated brain disorder and chose to end his own suffering rather than continue to endure the unendurable?


Dr. Paul


Last week, a few days after I testified to the Washington state House of Representatives Committee on Health and Wellness that doctors and nurses ought to face required suicide-prevention training, I received a call from a newspaper reporter. He wanted to know why I was so adamant.

I told him what I tell the professionals I train: “You can’t make a diagnosis you don’t know, and you can’t treat a problem you can’t diagnose.”

Or, as I sometimes put it, “If you don’t want to know if your patient has a temperature, then don’t take his temperature.”

As regards suicide, if you don’t want to know if your patient is suicidal, then for Pete’s sake don’t ask! Because if you ask and the patient is suicidal, you’ve just created a big problem for yourself. And it is usually a good idea to have a solution to a problem you just asked for.

Most doctors don’t.  Including my own. With exceptions, routine avoidance of this diagnostic probe is the rule. The danger is this: Risk you don’t know about cannot be managed, mitigated, or controlled. When the Buddha said, “Recognize all danger and avoid it” apparently there were no doctors in the audience.

Each of us recognizes danger and tries to avoid it every day. We don’t drive unbuckled through freeway traffic. We don’t drink and drive. We walk carefully on ice and make sure our children brush their teeth.

Ask yourself, “Would I fly on a plane whose pilot had very little training and doesn’t know what a pre-flight checklist is?”

Ask yourself, “Would I send my suicidal brother to a doctor who has very little training in suicide prevention and doesn’t know what a suicide checklist is?”

The problem with the S Question is that if the patient is positive for suicidal ideation, a past suicide attempt, or a current plan, now you have to do something. And that something matters.

I explained to the reporter that in the absence of specific training on how to detect and diagnose suicidal behavior it is essential that clinicians be able to A) ask the suicide question in a way that the patient is not encouraged to say no, and B) conduct a structured interview to learn if the patient desires death, is planning to die, and how, where, when, and why.

If you don’t want to know all this, here’s how to get patients to lie to you: “Given all you’ve told me, you’re not suicidal are you?”

Patients are polite; they would rather lie to you than upset you.

The majority of mental health care is provided by non-psychiatric physicians. Since the majority of people who end their own lives suffer from an untreated or undertreated mental illness, and given that they are cared for by these same professionals, it only makes sense that improving their ability to diagnose would improve their ability to treat.

But rather than lecture to you about all of this, how about I tell a personal story about my own doctor.

Now retired, Dr. Fred Viren is an internal medicine physician still conducting research and training in his subspecialty.  

As my personal physician he has followed my suicide prevention work for better than 30 years. When he retired, we moved from a professional relationship a more personal one. He’s an avid fly fisherman and we see each other on the stream from time to time, where it is much easier to talk about fly selection than blood pressure and my eating habits. 

During my doctor visits I taught Fred how he could routinely ask his patients about suicide. He then instituted the practice, not with everyone, but with people that worried him or about who he felt some concern.

Some weeks later I got a call at my office:

“Paul, I just asked one of my older depressed patients whose wife died last year and who has a low-grade prostate cancer, if he was having thoughts of suicide. He is! Now what do I do!?”

Fortunately at the time I was, among other jobs, the Director of Elder Services at Spokane Mental Health.

I asked, “Can you keep the patient there for a little while?”

He said, “Sure I know the patient well.”

I was then able to send a psychiatric nurse and social worker to his office to see and assess the patient, and to coordinate a treatment plan. Turns out this older gentleman – I’ll call him George – had also lost a brother to illness within a year, and was terribly isolated. George was seriously depressed and required a brief hospitalization at our local inpatient psychiatry unit. After a week of getting his sleep reordered and his brain functioning close to normal limits, he made a wonderful recovery, got back on his feet, and eventually became a volunteer driver for our Care Cars program at Elder Services program in Spokane County, a division of Frontier Behavioral Health. George died a few years later of natural causes, but his remaining time on the planet was spent with purpose, meaning, and in the service of others.

Let me end this post with a couple of observations and links.

There are at least 10 reasons why doctors and nurses don’t want to be required to complete some kind of suicide prevention education or training. A colleague and I published an academic paper on this question in the Journal Suicide and Life-Threatening Behavior, wherein we attempted to counter these arguments with ones of our own.

Academic publications are just like blog posts, but with the nerve extracted. You can find the copyrighted article at: http://onlinelibrary.wiley.com/doi/10.1111/sltb.12010/abstract, and you may have to pay to read it.  Or, you can find the pre-publication version (which does not violate copyright law) at: http://www.qprinstitute.com/pdfs/PCP%20SLTB%20Word%20F_SLTB9_24.pdf

It is not that doctors and nurses don’t know there’s a problem. They do. And they care. It’s just that they don’t have enough time or help available from mental health professionals to whom they could refer the suicidal patients they find. Given the pay and hours and cost of training, there will never be enough mental health professionals to take on this job. So in my view doctors and nurses need to step up and learn how to help these patients themselves.

Personally, I’ve been working with schools of nursing education to see if nurses could not take on the role of suicide care in the front lines of medicine.  We are testing embedded training in one college nursing course now and some nurse educator leadership believes nurses could do this job as well as anyone. Nurses are already in place and are expected to deliver most of the medicine this country needs in the years to come. As a profession they already enjoy great respect from the public.  Who doesn’t love a nurse? 

Here’s a link to one informative article on the detection of suicide risk in primary care, “Let’s Just Not Talk About It: Suicide Inquiry in Primary Care” published by Dr. Feldman and his colleagues in the Annals of Family Medicine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/.  It a good study and a good read.

Finally, my friend and colleague Jenn Stuber published this op-ed in the Seattle Times just a few days ago: http://seattletimes.com/html/opinion/2022749817_jenniferstuberopedsuicideprevention27xml.html.

Oh, and that reporter who interviewed me and provided the lead to this blog post just published his story on what’s happening in Washington state.  It’s an excellent summary at: http://www.auburn-reporter.com/news/242804151.html

Thanks for your time.

Suicide is not so much a tragedy of what was, but what might have been.

Dr. Paul

Preventing suicide… it's what people do.

%d bloggers like this: