“You just don’t wake up one day and become a racist” a commuter says to his passenger, a fellow commuter in “The Commute”, a recent television programme. I immediately thought this fits with my take on suicide, namely, an individual’s pathway to death by suicide does not emerge overnight: it’s a dynamic if dysfunctional response to their unbearable ongoing psychological, social, biological predicament.
Research by Joiner (2005) identified an essential factor that’s present in each suicidal death, namely the victim’s ability to kill themselves, or ‘acquired lethality’: the soon-to-be-deceased must have taken the time to learn how to do it. Shneidman (1971) and Maris (1981) had suggested that each victim’s death by suicide might represent the tragic conclusion to a lifelong journey, long or short, that morphed into a fatal trajectory.
On a positive note, this scenario suggests that multiple opportunities may exist, for the person at risk, and for their relatives, carers, friends, neighbours, colleagues and clinicians to intervene and influence the potential victim’s deadly intentions and terminal destination. It’s like if everybody else did something different, then this person would not, or could not or might not take their own life. Does this matter? Nothing matters more since failure to act upon such opportunities can be fatal for the vulnerable individual at risk.
Each death by suicide is as unique as an individual’s fingerprint. Learning to recognise and act upon the ‘signs of suicide’ represent important objectives for awareness-raising efforts by suicide-prevention organisations and individual helpers. Almost fifty years ago Shneidman (1971) listed some high-profile ‘markers’, or indicators for suicide ideation or suicidal behaviour, including conspicuous instability, depression and problems in relationships, especially early ones. These days, most if not all that’s written about suicide prevention includes schedules of signs, or symptoms, for suicide risk. A fairly random Google search for ‘signs of suicide’ identified 25 of these in four categories: behavioural, physical, cognitive and psychosocial: there’s nothing simple about suicide.
Regrettably professionals and volunteers in suicide prevention work will be relatively ineffective without considerable expertise in understanding, recognising and acting upon these signs. I would argue that developing and maintaining such expertise demands focused education and training in suicidology and psychotherapy, initially to certificate / diploma / master’s level and then by continuous professional development. Two day courses with occasional refreshers will not do. It seems self-evident to me that what you don’t understand you’ll find very difficult to change.
Unfortunately there are many combinations of suicide ‘symptoms and signs’. Research has not identified, and may not ever identify conclusively, which individual ‘symptom’ or group of ‘symptoms’ might accurately predict a death by suicide. To date neither blood test nor brain scan can conclusively confirm a person’s propensity towards suicidal behaviour in the short, medium or long term. This is because suicidal behaviour’s neurobiology represents a most serious problem in both psychiatry and general medical practice that remains to a large degree unclear. Perhaps the best that can be done by experienced helpers for an at-risk individual is appropriate, compassionate engagement, offering genuine, empathic, non-judgemental support, including when available and appropriate, expert psychological guidance.
To sum up. Suicide is a highly complex, perhaps the most complex, human behaviour. Each incidence of suicidal behaviour, I would argue, is a unique phenomenon unlike any other. Yet medicine, including psychiatry, currently expends scarce research resources in a desperate if futile search for similarities, commonalities and degrees of sameness in suicide-related cases. Why futile? Because of that idiosyncratic ‘unique factor’.
Better perhaps to emulate a leading local legal organisation that acknowledges individual differences by aspiring to treat every client as an individual.
BBC (2016) The Commute. BBC TV Channel 1 N Ireland. 29 Sept 2016
Furczyk,K., Schutová, B., Michel, T.M., Thome, J. and Büttner, A. (2013) The neurobiology of suicide - a review of post-mortem studies. Journal of Molecular Psychiatry, 2013, 1:2
Hawton, K. and van Heeringen K. (Eds) (2000) The international handbook of suicide and attempted suicide. Chichester, England: John Wiley and Sons, Ltd
Joiner, T.E., (2005) Why people die by suicide. Cambridge, MA: Harvard Univ Press
Maris, R. (1981) Pathways to suicide. Baltimore, MD: John Hopkins University Press
Shneidman, E.S. (1971) Perturbation and lethality as precursors of suicide in a gifted group. Life Threatening Behaviour, Spring, 1971, 1, 1
Valley Behavioural Health System (US) Website accessed on 6 Oct at: http://www.valleybehavioral.com/suicidal-ideation/signs-symptoms-causes]
van Heeringen, K., Hawton, K. and Williams, J.M.G. (2000) Pathways to suicide: an integrative approach. In K. Hawton and K. van Heeringen (Eds) The international handbook of suicide and attempted suicide, pp. 224-234. Chichester, England: John Wiley and Sons, Ltd
Brent, D.A. and Mann, J.J. (2006) Familial pathways to suicidal behaviour – understanding and preventing suicide among adolescents. New England Journal of Medicine. 355,26: 2719-2721
Byng, R., Howerton, A., Owens, C.V. and Campbell, J. (2015) Pathways to suicide attempts among male offenders: the role of agency. Sociology of Health and Illness. 37(6): 936-51
Gray, L-A. (2013) Can school stereotypes be a pathway to suicide? Huffington Post. Nov 27 2013
King, C., Senior, J., Webb, R.T., Millar, T., Piper, M., Pearsal, A., Humber, N., Appleby, L. and Shaw, J. (2015) Suicide by people in a community justice pathway: population-based nested case-control study. British Journal of Psychiatry. 207:175-176