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In 2004, suicide accounted for more than 32,000 deaths in the United States, making it the eleventh leading cause of death (American Association of Suicidology 2007). If it is challenging to imagine what this number means, it translates into one suicide approximately every sixteen minutes, or more than 89 people per day. But this is only the tip of the iceberg. For every death by suicide, there are roughly twenty-five attempts, and among young people the rate of attempted suicide is higher still. For every young person who dies by suicide, anywhere from one to two hundred others will make a nonfatal suicide attempt, sometimes resulting in serious physical injury (Goldsmith et al. 2002). Hospitalisations for serious self-injury exceed 150,000 each year.
Another vast chunk of the iceberg likewise remains hidden. In any twelve-month period, literally millions of people in America think seriously about suicide (Goldsmith et al. 2002). In a study conducted among high-school students in 2005, 16.9 percent reported that they had seriously considered attempting suicide within the past twelve months, and 8 percent actually made one or more attempts during the same period (Eaton et al. 2006).
As such statistics suggest, anyone who works in the field of mental health encounters suicidal people. The question is not whether we will meet suicidal people but how well prepared we will be to help them when we do. Research has confirmed that, above all, it is the accurate diagnosis and aggressive treatment of underlying psychiatric disorders that helps to prevent suicidal behaviour. Having worked with hundreds of suicidal patients over almost four decades of practice, and having kept up with the literature on the relationship of suicide to mental illness, I am certain of one thing: Treatment saves lives.
I am also certain of another thing. Not every suicidal person will seek treatment, and, of those who do seek help, not all will accept it when they find it. Nor will the appropriate treatment necessarily be made available to them. An elderly, retired white male will be diagnosed with a sleep disturbance, but his primary depression will remain undetected. A suicidal alcoholic who was a victim of physical and sexual abuse in early childhood will be arrested on a drunk driving charge, prosecuted, and directed to an alcohol recovery program. But the post-traumatic stress syndrome with co-occurring depressive disorder from which she now suffers will go undiagnosed and untreated. An angry young black man with a history of irritable and aggressive behaviour will be jailed for petty robbery, but his bipolar mood disorder will be ignored. Preconceptions, carelessness, complacency, expediency, poorly conceived approaches to mental health problems, simple ignorance – all can lead to errors that could have been avoided and thus to needless tragedies.
If mental illness carries a stigma, being mentally ill and suicidal carries a double stigma. Too many people suffering from psychiatric illnesses have died by suicide without ever realising they were sick. The love of friends and family and the imagined protection of above-average intelligence, a superior education, and worldly success are no protection against the agony of a tormented mind tantalised by the perceived relief that suicide promises.
Suicide is extremely complex – perhaps the most complex of all human behaviour. Counterinstinctive, impossible to predict in the individual case, suicide has historically been surrounded by fear, accusation, and inadequate scientific understanding.
But things are changing.
Since the first edition of this book appeared, in 1992, and especially since the Surgeon General’s Call to Action to Prevent Suicide was issued in July 1999, suicide prevention has moved forward. Leadership has emerged, and the National Strategy for Suicide Prevention has outlined a public health approach to the problem of suicide. Sources of funding have opened up, and implementation has begun. State-wide plans have been developed and brought to life. Colleges and universities have become involved in efforts to deter suicide, as have law enforcement agencies, leaders of Native American tribes, the military, and emergency services personnel. Two new national crisis lines are operational: 1-800-SUICIDE and 1-800-273-TALK. All across America, suicide prevention programs are up and running.
In addition, people who have lost a relative or close friend to suicide have chosen to take action. Survivors of suicide have joined groups, founded organisations, rallied their communities, sewn quilts, petitioned Congress, and helped pass legislation. Their efforts have contributed to a growing public awareness not only that suicide devastates millions of lives each year but that suicides can be prevented. The public is beginning to realise that:
In short, suicide is no longer the taboo subject it once was but has become instead an issue of practical importance – to ordinary citizens and, in particular, to those of us in the helping professions.
As the public comes to understand the connection between untreated psychiatric disorders and suicide and to recognise that suicide can be prevented, greater expectations for quality care will be directed at professionals who work with persons at risk. Those of us in the helping professions must be prepared to respond in an informed and effective fashion. What we were not taught as students about the detection, assessment, management, and treatment of suicidal persons will become apparent if a suicidal loved one dies in our care, and we will be held accountable. In fact, it is already happening: Alleged negligence in cases of suicide is reportedly the leading cause of malpractice suits filed against mental health professionals (Slovenko 2002, 779). Unless we acquire greater skill in working with suicidal people, our credibility as healers will be diminished – and, more important, lives will continue to be unnecessarily lost to suicide.
Fortunately, we understand much more about suicidal behaviour and its causes than we did even ten years ago. We are not without resources. Research is expanding our knowledge, and therapeutic approaches grounded in solid scientific evidence have been developed and are constantly being refined. Each of us already possesses a powerful medicine: the lifesaving skills of understanding, empathy, and caring, the ability to listen and to guide, and the desire to give hope to the hopeless. Each of us can learn something of value that will help suicidal people. There is reason to hope that our successes will more and more outnumber our defeats.
This book is devoted to what we as practitioners can bring to the healing environment that is established when one human being offers help to another. The ideas and recommendations to follow are based both on the current scientific literature and on experience gained in my career in the fields of clinical suicidology, substance abuse, suicide prevention, and psychotherapy. My perspective is personal as well as professional, and what I have to say should certainly not be construed as the last word on the subject of suicide intervention and treatment. Detailed information regarding these topics is available in many of the sources provided in the list of references.
For information to be helpful, it must be clear and comprehensible. With a view to enabling a broad base of practitioners to make good use of what we know, I’ve done my best to write in language unencumbered by professional jargon. And in response to the many requests of my students over the years, I have tried to focus on concrete, practical interventions, ones that I have found to work.
If this is your first step along the road to understanding suicide, I encourage you to continue your journey.