How Psychologists Capture the Complexities of Mental Illness

When it comes to understanding and treating mental illness, clinical psychologists must strike a balance between grouping people with shared characteristics together and recognizing people’s individual paths, circumstances, and needs. Below I’ve described some of the models that clinical psychologists use to reflect these complexities.

1) Biopsychosocial Model

Most modern psychologists understand that mental illness is the result of both nature and nurture. Accordingly, biopsychosocial models map out biological, psychological, and social risk factors for mental health outcomes and highlight potential intervention points. This model is so prominent that clinical psychology graduate programs require education in human development, individual differences, and biological, cognitive, affective, and social aspects of behavior, and you can’t become a licensed psychologist without passing a formal test on these topics. The idea is that mental health outcomes result from the interplay of biological, psychological, and sociocultural factors and that different people arrive at outcomes through different combinations of factors. Here’s a sample I constructed from some suicide risk factors:

biopsychosoc

2) Diathesis-Stress Model

People with identical genetics (i.e., monozygotic twins) and people with shared stressful events (e.g., witnessing the same violent act) can have different mental health outcomes. For example, many people with family histories of eating disorders will not develop eating disorders. Likewise, many people who have been bullied about their weight will not develop eating disorders. A diathesis-stress model of eating disorders explains this by saying that a person must have both a vulnerability (e.g., a genetic predisposition) and a significant stressor (e.g., weight-related bullying) to develop an eating disorder.

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3) Multifinality and Equifinality

People who experience a similar event (e.g., trauma) can have disparate outcomes that depend on other factors (e.g., financial resources, societal views of survivors). This is called multifinality. Meanwhile, people with similar outcomes (e.g., posttraumatic stress disorder) can arrive there via distinct pathways (e.g., surviving sexual assault, a car accident, being the victim of gun violence). This is captured with the term equifinality.

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4) Distal vs. Proximal Factors

Most research on mental illness focuses on a few risk factors per study. Organizing findings across studies can feel like fitting puzzle pieces together to create a holistic picture. One way to do this is by grouping risk factors in terms of how far in time (distal) and how close in time (proximal) they are to the onset of mental illness. For example, strategies for reducing distal risk factors for adult depression may include public policy efforts to prevent childhood maltreatmentincrease access to quality health care, and decrease discrimination. Meanwhile, therapy for individuals with depression may focus on more proximal factors (e.g., enhancing coping skills, increasing social support, behavioral activation).

distal proximal

5) Nomothetic vs. Idiographic

I highly recommend this article by Beltz, Wright, Sprague, and Molenaar (2016) for detailed definitions of these terms:nom idioFor example, imagine that a client gets diagnosed with obsessive-compulsive disorder (OCD). In order to figure out the best way to help, a therapist begins with nomothetic information (e.g., the diagnosis) to select a treatment. A randomized clinical trial suggests that a type of cognitive-behavioral therapy called exposure and response prevention (EX/RP) leads to significant improvement among 80% of people with OCD after 17 sessions. Based on available information, EX/RP is a good place to start. However, it’s possible that the client will be among the 20% of people who don’t respond to EX/RP. Therefore, therapists must also pay attention to idiographic information after initiating treatment (e.g., by regularly assessing the client’s OCD symptoms over time). If the client’s not responding to therapy, the idiographic data signal that the therapist must figure out why and make appropriate changes.

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For more information on nomothetic and idiographic approaches, check out:

Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis

Clinical Versus Actuarial Judgment

Single-Case Experimental Designs for the Evaluation of Treatments for Self-Injurious and Suicidal Behaviors

What Can the Clinician Do Well?

I’ve described frameworks that clinical psychologists use to understand people’s mental health needs at multiple levels while respecting their individuality. The dedicated people working hard to alleviate suffering in the face of these challenges give me hope for the future of the field.

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Suicide is Not Reducible to Simple Explanations

It is unlikely that any one theory can explain phenomena as varied and complicated as human self-destructive acts. At the least, suicide involves an individual’s tortured and tunneled logic in a state of intolerable, inner-felt, idiosyncratically-defined anguish. 

-Edwin Shneidman, founder of contemporary suicidology

When criticizing aspects of society, some people amplify their arguments by saying that those aspects cause suicide. Typically, the claim goes something like this, “____ is so bad that it leads people to kill themselves. Therefore, it’s urgent that we stop ____.” You should be skeptical when you hear these kinds of claims, because suicide is not reducible to simple explanations. It hurts to think about people grieving a suicide loss and then hearing that there was a simple fix all along. This is especially painful when there is little or no evidence that ____ substantially increases suicide risk. Additionally, if an empirically-weak claim receives enough public attention, limited suicide prevention resources can be squandered in the wrong places.

How to Evaluate Causal Claims about Suicide

Suicide is complex, and it’s extremely challenging to conduct research that yields results with causal implications. The closest we have to experiments may be randomized controlled trials designed to reduce suicidality. Keeping in mind that the majority of suicide research is correlational, here’s one set of criteria that you can use to evaluate whether ____ causes suicide.

1) temporal precedence: If ____ causes suicide, ____ must occur before the suicide (or a societal change must precede changes in suicide rates). Non-experimental research can speak to this criterion through longitudinal studies or other examinations of suicide rate data over time. However, it’s important to look at long-term trends rather than capitalizing on specific time points with fluctuations that are consistent with the claim.

2) covariation: If ____ causes suicide, then changes in ____ must accompany changes in suicide rates. I often see partial demonstrations where someone will say, “Here are higher suicide rates coinciding with more of ____,” but then leave out the necessary counterpart of establishing correlation: less of ____ should also be associated with lower suicide rates. Both are required to meet this criterion, and you don’t need experimental studies if you examine it through naturally-occurring differences. For example:

-Looking at World Health Organization suicide data, do countries with more of ____ have higher suicide rates than countries with less of ____?

-Do demographic groups who experience more of ____ have higher suicide rates than groups with less of ____ over the same time period?

If the answer is “no,” then the covariation criterion has not been met.

3) nonspuriousness: If ____ causes suicide, then the relationship must persist even after ruling out alternative explanations. This criterion is arguably the most difficult to prove without experimental studies, but there are some correlational data that you’d expect to see if the claim is true. Questions to ask of such claims include:

-What else increased aside from ____ during the time period of increased suicide rates? Is there research linking those other factors to suicide, and could that better explain the observed pattern?

-Do people experiencing more of ____ also experience more of something else empirically-linked to suicide that could better explain the observed pattern?

Here‘s a strong example of someone evaluating an alternative explanation for an observed pattern using correlational data on a completely different topic (specifically, the part on self-censorship).

I wrote this post to share a framework for evaluating causal claims that I learned in grad school, and I hope that you find it useful. Even if it’s completely unintentional, when people use unsubstantiated claims about suicide to magnify societal concerns, it can feel exploitative of a group of people I care deeply about. Fortunately, this is outweighed by incredible, compassionate work reflecting the complexities and multiple pathways to suicide. I’ll link to some of my favorites below:

American Association of Suicidology

The Best Way to Save People from Suicide

The Interpersonal Theory of Suicide

Live Through This

Suicide Prevention Social Media Chat

The Three-Step Theory

We Tell Suicidal People to ‘Get Help.’ But What Happens When They Do?

Thank you for reading! Here’s a post with more information and resources about preventing suicide.

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In Defense of Diagnosis

In “Why I Do Not Attend Case Conferences,” Paul Meehl (1973) described reasoning errors that emerge during case conceptualization conversations among mental health professionals. One of the issues Meehl discussed at length (pp. 272-281) was an antinosological bias, defined as “an animus against diagnosis.” Here’s his response to a common objection to diagnostic labels:

passage

Meehl described his style there as “highly critical and aggressively polemic,” which he justified by saying, “If you want to shake people up, you have to raise a little hell.” The second section has a much more constructive tone. Both sections are valuable, and I agree with his overall thesis that compassionate, effective mental health care requires clearheaded case conceptualization. Meehl is also correct that 1) meaningful diagnostic systems are crucial for advancing the field and 2) some critiques of the Diagnostic and Statistical Manual of Mental Disorders (DSM) reflect misunderstandings of the diagnostic process. I’ll discuss some of the major criticisms and benefits below.

Criticisms

1. The DSM pathologizes nonpathological behavior.

Barbara_Gittings,_Frank_Kameny,_and_John_Fryer_in_disguise_as__Dr._H._Anonymous_

Barbara Gittings, Frank Kameny, & Dr. H. Anonymous, gay rights activists at a 1972 APA convention

This is true in specific cases. One of the most well-known examples is homosexuality being labeled as a mental disorder in older versions of the DSM. As a result of persistent, organized activism bolstered by research, homosexuality was removed from the DSM. You can learn more about it in excellent podcast episodes by This American Life and Radiolab. Currently, the DSM developers attribute elevated mental health problems among lesbian, gay, and bisexual people to discrimination, actively oppose conversion therapy, and push for policies and law that reduce disparities. In order to prevent future harm, this history must be considered in diagnostic decisions. As Martin Luther King, Jr. said, psychology shouldn’t label people as maladjusted for not adjusting to bigotry.

However, we should also consider that appropriate diagnoses have helped people access beneficial services (e.g., children with intellectual disabilities or autism receiving accommodations in school and other public places). Additionally, the DSM specifically instructs clinicians to only assign diagnoses when a cluster of multiple symptoms: 1) causes clinically significant distress and/or impairment, 2) is persistent and severe for a length of time, 3) deviates significantly from developmental expectations, and 4) cannot be attributed to other factors (e.g., medical, cultural). These types of safeguards reduce the likelihood of pathologizing nonpathological behavior.

2. People are over/misdiagnosed.

Misdiagnosis occurs for many reasons ranging from improper assessment procedures, failure to consider pertinent contextual factors, and biases. For example, attention-deficit/hyperactivity disorder is a meaningful diagnostic category with real-world implications. Nonetheless, there’s evidence that it may be overdiagnosed, which can lead to inappropriate treatment plans.

Issues that exacerbate the problem include 1) lack of funds/insurance coverage for comprehensive assessment procedures and 2) diagnosers who rely too much on their intuition instead of established diagnostic tools. The Ethical Principles of Psychologists and Code of Conduct lays out stringent rules for assessment. A system that ensures adherence to these rules would reduce misdiagnosis while permitting proper diagnosis for people who need treatment and/or services.

use of assessments

3. Classification decisions are made by people with conflicts of interest.

There have been some egregious examples of psychiatry researchers receiving large sums of money from pharmaceutical companies and not properly disclosing them. One instance is covered in a PBS Documentary and in this New York Times article:

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In an effort to address this problem, DSM-5 panel members were required to disclose conflicts of interests. Cosgrove and Krimsky (2012) made a compelling case that further action was needed:

COI

To be clear, psychiatric medications have helped numerous people and are warranted in particular circumstances. However, steps must be taken to reduce potential biases driven by the pharmaceutical industry.

4. Labeling someone with a mental disorder is stigmatizing.

Despite signs of improvement, prejudice and stigma continue, especially for certain mental health conditions. The solution is to eradicate the stigma rather than the nosology (but it’s worth listening to Szasz’s arguments opposing that idea). When properly applied and understood, diagnoses can alleviate suffering by pointing to effective treatments, connecting people with support and advocacy groups, and evoking compassion. This was nicely demonstrated in Crazy Ex-Girlfriend:

I’m aware mental illness is stigmatized/But the stigma is worth it if I’ve realized/Who I’m meant to be/Armed with my diagnosis

5. Diagnostic categories do not accurately reflect nature.

There are different versions of this, but I’ll focus on the most common: 1) most mental health problems are dimensional (occurring on a continuum) rather than categorical (e.g., there are gophers and chipmunks, but no “gophmunks“), 2) there’s too much variability within diagnostic categories for them to be meaningful, and 3) DSM symptoms are not necessarily the core symptoms of disorders (e.g., for depression).

In response, 1) people have proposed replacing the categorical model with empirically-informed dimensional models (e.g., even if psychopathy occurs on a continuum, it’s quite meaningful to diagnose those in the highest range), 2) diagnostic presentation variability depends on the diagnosis (e.g., people with bulimia nervosa have more in common, on average, than people with borderline personality disorder) and fewer diagnoses with more specifiers could help (e.g., see Pincus, 2011), 3) network analyses are useful for identifying the central symptoms of mental disorders. A concern about major DSM changes is that they will disrupt the work of clinicians and researchers (see Pilkonis et al., 2012). Despite these issues, we need to create a DSM that’s better at carving nature at its joints rather than resisting change or giving up the enterprise altogether.

Benefits

1. Agreed upon definitions facilitate clinically-relevant research.

I agree with McFall’s Manifesto (1991), which states that “the future of clinical psychology hinges on our ability to integrate science and practice” (to hear this debated, check out this Talk of the Nation episode). For example, treatment research for bipolar disorder has more generalizability to real-world clinical settings when therapists and scientists use the same operational definition of bipolar disorder. Moreover, consistent mental disorder definitions across studies makes cumulative knowledge possible. Classification systems enhance communication and research, which contribute to the big picture goal: alleviating suffering.

2. Diagnoses convey useful information when derived from appropriate assessment procedures.

Accurate diagnoses point to literature on the causes, correlates, and effective treatments for specific mental health problems. If an adolescent girl is accurately diagnosed with anorexia nervosa, we learn that she has an increased risk for bone fractures, arrythmias, depression, and suicide and should be monitored for each of these dangers. Importantly, we also know that family-based treatment is likely to be a good treatment option for her and that her parents can connect with parents experiencing similar struggles. To learn more about the process for evaluating levels of empirical support for therapies, look here for youth treatments and here for adult treatments.

3. Diagnostic feedback (when done well) can lead to positive effects.

People tend to experience positive feelings (e.g., optimism, relief) after receiving diagnostic information derived from appropriate assessment procedures and delivered in a collaborative, constructive manner. Similarly, there’s evidence that taking personality inventories and being told about the results from a therapist leads to increased self-esteem, more perceived self-competence, and lowered distress. Why would people feel better after learning about their mental health problems and potentially maladaptive personality characteristics? My guess is that people already know that they’re experiencing certain kinds of issues. When a therapist demonstrates an understanding of the problems by placing them in a meaningful context, they feel validated and hopeful that they can be helped.

4. Diagnostic labels enhance communication between treatment team members and aid continuity in care.

Diagnostic labels ease the transition for clients from one therapist to another (e.g., by saving them from having to repeat assessment procedures) and by communicating efficiently to other members of their treatment team (e.g., social workers, psychiatrists, physicians, clergy).

5. The DSM-5 has improved since the original version and has built-in mechanisms for change.

Despite the hindrances mentioned above, the DSM has formal, built-in processes for evolving with new scientific discovery. New versions are created with the explicit goal of making the classification system better reflect nature. Hyman (2010) argued that we should not reify existing diagnostic constructs. Instead, we must remember that diagnoses are constructed for clinical and scientific purposes. Therefore, improving the DSM requires openness to change and flexibility.

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In conclusion, despite the concerns highlighted above, I agree with Meehl that antinosological biases impede progress and that mental health classification systems should be improved rather than abandoned altogether. I’m grateful for the dedicated clinicians and scientists working to deepen our understanding of mental health and feel encouraged by efforts to use that information to improve people’s lives.

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In an effort to keep this post relatively brief, I highlighted some main points and examples. Some of the more technical, in-depth things I’ve co-written about classification are linked below:

The Classification of Eating Disorders – The Oxford Handbook of Eating Disorders

Empirical Approaches to the Classification of Eating Disorders – Developing an Evidence-Based Classification of Eating Disorders

Nonsuicidal Self-Injury Disorder: A Preliminary Study – Personality Disorders: Theory, Research, and Treatment

Patients’ Affective Reactions to Receiving Diagnostic Feedback – Journal of Social & Clinical Psychology

Suicidal Behavior on Axis VI – Crisis

Taxometric Analysis: Introduction and Overview – International Journal of Eating Disorders

The Validity and Clinical Utility of Binge Eating Disorder – International Journal of Eating Disorders

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A major inspiration for creating the Jedi Counsel blog and podcast was to demystify issues surrounding diagnosis through analyses of fictional characters.

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Things I Liked In 2018

 

 

There was so much going on in 2018 that I leaned on journalism, podcasts, and art more than usual to challenge, clarify, and enrich my understanding (and for comic relief too). I listed the most memorable of those things below, and I’d love to hear about your favorite things to read, listen to, and watch this year in the comments or on Twitter.

To read

Amber Wyatt Told Her Story Of Rape. This Is How The World Responded. by Elizabeth Bruenig

The Best Way To Save People From Suicide by Jason Cherkis

My Own Devices by Dessa

Finding David Sedaris by Katie Herzog

Everything You Know About Obesity Is Wrong by Michael Hobbes

Here’s How Cornell Scientist Brian Wansink Turned Shoddy Data Into Viral Studies About How We Eat by Stephanie Lee

Protest Isn’t Civil by Vann Newkirk II

100 Million Americans Have Chronic Pain. Very Few Use One Of The Best Tools To Treat It. by Brian Resnick

There Is Only One Trump Scandal by Adam Serwer

When Children Say They’re Trans by Jesse Singal

When The Muzzle Comes Off by Rebecca Traister

To listen to

1A: The Persistence of Segregated Schools

The Black Goat: The Year 2018 In Review

Circle Of Willis: Children At The Border

Everything Hertz: Shit Academics Say With Nathan Hall

Laura Jane Grace & The Devouring Mothers: Bought To Rot

Unerased: Dr. Davison And The Gay Cure

A Star Is Born Soundtrack

Tatter: Mission Creep (On Carrying Implicit Bias Too Far)

Two Psychologists, Four Beers: The Replication Crisis Gets Personal

To watch

Bad Times At The El Royale (and the soundtrack is fantastic too!)

Black Panther

Blockers

ContraPoints

Crazy Rich Asians

Culturally Determined: Life With Depression

NPR Music Tiny Desk Concert: Wu-Tang Clan

Queer Eye

Wynonna Earp

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10-Year Post-Ph.D. Post

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left: my graduate mentor hooding me; middle & right: hooding my first two Ph.D. students

I graduated with a Ph.D. in Clinical Psychology 10 years ago! I thought I’d reflect on that by responding to a tweet by Nathan C. Hall (check out the full thread of responses to his tweet here, an article on it here, and discussion of it on a podcast here.

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1. Don’t despair when you’ve invested a lot of time in a study and the results are not statistically significant. There’s a future process coming that will allow you to publish these studies as long as they’re rigorous (Registered Reports).

2. Even though mentoring graduate students provokes a lot of uncertain/anxious feelings, it will end up being one of the most meaningful aspects of your job.

3. You overestimate how much your treatment of people influences how they treat you. People’s goals, personalities, motivations, and other incentives guide their behavior too (more so than yours in some cases).

4. When deciding what to teach within time constraints, prioritize depth over breadth and make time to teach students about process (e.g., how to find and critically evaluate the research on depression treatment) over content (e.g., reviewing every type of depression treatment currently used).

5. Don’t neglect the importance of sociocultural factors in biopsychosocial models of psychopathology. I didn’t even realize I was almost exclusively focused on biological/psychological factors in my abnormal psychology class until a student commented on it in my evaluations during my first year of teaching. I’m really grateful they did that. It made my subsequent teaching more comprehensive.

NDSU

6. Demonstrate the importance of course subject matter by taking time to discuss it within its historical context and current real-world significance (e.g., on intelligence – 1, 2, 3, 4, 5).

7. Even though you think you’ll regret it later, you’ll actually be grateful that you turned down some work opportunities when you were already overloaded with work.

8. If you’re experiencing burnout, try looking at your situation through an operant conditioning lens. Identifying reinforcements, punishments, etc. in your situation can produce problem-solving ideas. This was advice I got from someone else that stuck with me.

9. There are certain types of work in academia that are more frequently and formally recognized and rewarded than others. That doesn’t mean that the other work isn’t of value. Reminding yourself of that with regard to your own and others’ work is important.

10. I don’t know how to phrase this last one except to say that I am extremely grateful for all of the trusted friends and colleagues I have been able to consult when I am unsure of something ranging from scientific to interpersonal aspects of academia. In advice form: don’t hesitate to ask for help from people you trust. And pay it forward when you’re the one who is asked.

 

Suicide Prevention Information & Resources

This week involved a lot of heartbreaking suicide-related news. We tragically lost Kate Spade and Anthony Bourdain to suicide. We also learned that U.S. suicide rates increased substantially over the past several years. If you want to learn and do more to prevent suicide, I want to help you out by linking to some good sources. I hope you find them useful.

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If you need help:

National Suicide Prevention Lifeline

Trans Lifeline

The Trevor Project (for LGTBQ+ youth)

Veterans Crisis Line

Find a Therapist

Find a Support Group for People Who Have Lost Someone to Suicide

Listen to a Hopeful Music Playlist Made by College Students

Research-Supported Treatments for Adults

Research-Supported Treatments for Children

Feeling Good: The New Mood Therapy by David Burns

How to help others:

Warning Signs

How to Help Someone Who is Suicidal

Take a Mental Health First Aid Training Course

Get involved:

Call Your Representatives and Tell Them to Prioritize Policies linked to Suicide Prevention (e.g., access to quality healthcare, funding for research)

Participate in an Out of Darkness Community Walk

For information:

Suicide Statistics

Suicide Prevention Social Media Chat

Live Through This Photo Project

Wil Wheaton Essay about Mental Health

Rudy Caseres, Mental Health Advocate

Robert Vore, Mental Health Advocate

It Gets Better Project

Why People Die by Suicide by Thomas Joiner

Myths about Suicide by Thomas Joiner

Guns and Suicide by Michael Anestis

Cracked Not Broken by Kevin Hines

Speaking of Suicide by Stacey Freedenthal

Brother Ali’s Song about Losing His Dad to Suicide

I’ve seen Minneapolis-based rapper Brother Ali in concert several times, and he strikes me as someone who’s as kind as he is talented. When I told him at a Chicago show that I had previously chatted with him in Orlando, he tried to remember me. He told me that he doesn’t recall faces due to albinism-related vision issues, but he recognizes people through reminders of previous conversations. He rapped about his experiences in “Us”: And I go with the feeling from the start/Blind in the eye, so I see you with my heart/And to me all y’all look exactly the same/Fear, faith, compassion and pain.

All of this is to say that I’m a Brother Ali fan and my expectations were high for his 2017 album, All The Beauty In This Whole Life. I think it’s a musical masterpiece, and “Out of Here” is a standout song. The lyrics are a detailed expression of his feelings and thoughts after losing his dad to suicide. In this post, I included all of his lyrics (in bold) and my comments (in italics) with some links to relevant research.

I recommend watching his performance of the song before reading the rest of the post:

Okay so it might appear
To an outsider that you found your way up out of here
They’re saying you died of suicide
People who are suffering may view suicide as an escape from a painful life. I like how Ali phrases the third line, because it removes the stigma associated with other phrasing (e.g., commits suicide).
That’s the last thing I want to hear
They tell me that it’s hardly fair to blame myself
What a hell of a cross to bare
You didn’t say it in your letter
But the fact that I failed you is loud and clear
Suicide can be a particularly painful kind of death to grieve because 1) it means someone you love was deeply hurting and 2) there may be more of a sense that you could have prevented it, if only you had acted differently in some way. It’s a common response for people to tell you that someone’s suicide is not your fault, and yet, it can be hard to refrain from blaming yourself for not stopping the person.
Found out the amount of fear
You would drown when you found yourself naked staring down a mirror
And partners are supposed to lay the cards bare
I left you playing solitaire, and I promise you that I’m sincere
When someone dies by suicide, it might feel like there was a misunderstanding or even a kind of dishonesty between you if you didn’t know the person was contemplating suicide. I think Ali is saying that his dad might have been trying to tell him how he felt (‘lay the cards bare’), but that Ali felt like he failed him by leaving him ‘playing solitaire.’ Powerful imagery.
If you’re looking for some judgment, you won’t find it here
Let’s be honest here
I can’t say I’ve never known that kind of despair
When the clouds appear, how’s life fair
Some people erroneously perceive people who die by suicide as selfish or weak. However, Ali feels compassion and humbly links it to his own experiences. He may also be fearful about his own future (e.g., will his suicidal desire increase to the levels that his dad’s ultimately did?).
I just want to draw you near
As he sorts through the different feelings, there’s a basic desire just to be close to his dad again.
Not to make it about me, but how could you check out
Before you really allowed me a chance to sit down and hear?
I think I would’ve listened
Or were you saying it all along and I just missed it?
You sang your swan song, we all dismissed it
Ali acknowledges that the suicide isn’t about him, but feels a frustration about his father leaving without trying to ask Ali for help first. He then changes course and tries to look for signs that his dad *tried* to reach out, but that Ali missed or ignored it.
Because you filled the room with laughter
I watched when you thought no one was looking at you
In hindsight, I wonder where your smile went
When the party ended and you swallowed it
I saw you swallow it
Sometimes, people who have lost someone to suicide say they saw it coming, but others feel completely shocked. It can also switch back-and-forth in the mind of a person as they try to make sense of it.
Okay so it might appear
That you took yourself up out of here
How many cries soak through your disguise
Before you drown in your silent tears?
Okay so it might appear
That you took yourself up out of here
How many times can you fight for your life
Before you throw that white flag up and volunteer? (x2)
Here, Ali seems to be trying to figure out the threshold that was crossed before his dad killed himself. I don’t know if this is Ali trying to understand if his own life obstacles and past suicidal ideation might ever exceed that threshold or if he is trying to understand his dad’s experience better (or both).
I’ve had car accidents
Where everything is slow motion no matter how fast it’s happening
Every second that pass stretches so that you can watch it unraveling
But can’t always react to it
Your whole life might flash before your eyes
The minute when you transition to the other side
But what can actually happen in that time?
In-between the leaping and the moment you collide
In-between the trigger and the blast
In-between you let go of the wheel and you crash
In-between the moment when you swallow the last pill in the bottle
Turn out the lights, roll the dice on tomorrow
Is there a moment to reflect, can there be regret?
Is there a wait, not yet, let me reset?
Or is it just too painful to accept?
That maybe death just seemed best
I think Ali is trying to imagine what his dad was going through at the time he died by suicide since he cannot ask him about it. He’s wondering if he crossed his dad’s mind or any reluctance emerged that could have prevented his death. Or was it more like an uncontrollable-type of experience where he felt like he was watching himself but could not change the outcome?
Suicide prevention researchers, such as Thomas Joiner (1,2), have argued that an innate drive for survival and fear of death saves the lives of many people who desire suicide. I have heard Joiner describe this as a ‘flinch’ that people might experience right before or during a suicide attempt. He has presented compelling anecdotal evidence of this through stories of people who survived suicide attempts. Kevin Hines, a suicide attempt survivor from the Golden Gate Bridge, said he felt instant regret after he jumped. Along with others, suicide prevention researcher Mike Anestis, has proposed that this window maybe an opportunity to prevent some suicides through means restriction during high risk periods
I heard this as Ali arguing for not taking one’s life, even in the face of repeated, seemingly unjust hardships…’you can go down swinging.’
Okay so it might appear
That you took yourself up out of here
I’m trying not to resent you
But you left me defenseless in the life we share
Every man before me in my fam died by his own hands
How am I supposed to understand my own role in the plan
When nobody who grows old stands a chance?
Ali lost both his dad and his grandfather to suicide. He’s wrestling with sympathy for his dad and his own feelings about being left behind.
What about this mysterious dance
Made you cut the cord to the curtain in advance?
But these are questions I can only ask
The person looking back in the looking glass
Ali recognizes that he is full of questions that now must go unanswered.
I’ll close by saying that I am truly sorry if you’ve lost someone to suicide – this post is dedicated to you. I’m especially thinking of a friend who is going through this now. Research by Julie Cerel and colleagues suggests that each suicide affects a large number of people (even larger than previously thought). It’s imperative that we increase the effectiveness of suicide prevention efforts. If you need support, please consider some of the resources below.
Resources
You can find a therapist through the Association of Behavioral and Cognitive Therapy, and you can find a support group for survivors of suicide loss through the American Foundation for Suicide Prevention website.
The National Suicide Prevention Lifeline has an online chat option, and their phone number is 1-800-273-TALK.