Ask Me Anything About Suicide

Note: Even though World Suicide Prevention Day is over, I’ll keep answering questions that are sent to me on this post.

For World Suicide Prevention Day, I tweeted that people could ask me anything about suicide. Thanks to everyone who already sent me questions – they’re really good ones! If you want to submit a question, tweet it to me (@DrKathrynGordon) or e-mail it to me (kathrynhgordon@gmail.com).

If you’re in crisis, please contact the National Suicide Prevention Lifeline or the Crisis Text Line. The responses below are my opinions and should not to be taken as professional advice. More suicide prevention information and resources are available here.

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Added September 11, 2019

Anonymous asked: What criteria do mental health professionals use when deciding whether someone should be admitted to a hospital involuntarily for suicide risk?

Laws vary by location, and the criteria depend on the particular mental health professional, client, and situation. The typical criteria for involuntary hospitalization is that the person is at imminent or immediate risk for suicide. The field has a lot of work to do to get better at predicting when someone is at immediate risk for suicide (e.g., see Franklin, Ribeiro, et al., 2016). Some factors that therapists tend to view as indicative of immediate risk for suicide include (e.g., see Chu et al., 2015):

  • a clear, resolved plan and/or preparations made for suicide, intent to act on the plan, and access to lethal means (or plans to acquire lethal means)
  • multiple past suicide attempts (especially if recent)
  • the therapist and patient cannot create an alternative plan for safety (e.g., staying with a friend, temporarily storing lethal means elsewhere, identifying ways of coping with emotional pain that don’t involve suicide)

The mental health professionals who I have interacted with over the years tend to be eager to find alternatives to involuntary hospitalization. They seek to respectfully and collaboratively create a safety plan with their clients. However, I know from listening to other people’s stories that it’s not always the case. For example, Rudy Caseres is a mental health advocate who has spoken and written about these issues, and I recommend checking out his website here.

Published September 10, 2019

@ToWit12 asked: Let’s go worst-case scenario, where I encounter someone already with a gun to their head or about to jump off a bridge. What is the right (or rather, least wrong) thing to say/do?

Most people in that kind of emergency situation are experiencing pain, loneliness, and hopelessness. Individual situations vary quite a bit, but this would be my default:

I’d ask them to put the gun away or step away from the bridge, so we can talk (to increase safety). I’d talk to them in as calm and warm of a tone as possible. I wouldn’t endanger myself in this process, say they’re bluffing, or ignore them. I’d call for help if I could (911). I’d tell them I care about them, and that I’m there to listen and not to judge them. If I had struggled in my life, I’d let them know that (to increase a sense of connection). I’d commit to helping them find resources for addressing their problems (to increase hope).

For more on this topic, I recommend listening to this Story Corps segment about a police officer (Kevin Briggs) who helped a man (Kevin Berthia) who was about to jump off of the Golden Gate Bridge. It’s also worth watching Kevin Berthia’s TEDx Talk, The Impact of Listening and listening to this NPR segment, Mental Health Cops Help Reweave Social Safety Net in San Antonio for their approaches in mental health crises.

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Anonymous asked: I developed PTSD in the course of supporting a suicidal friend. Now other people’s suicidality is triggering to me, and I expect it to be that way for a while. I want to support friends who need it, but I want to support them at arm’s length. I’m in no position to be in the front lines of anyone’s mental health support team. This has been a problem: having gone to bat for one suicidal friend, I seem to be socially marked now as a person who will be supportive, even among people who are intellectually aware that it traumatized me. I’ve been somewhat beset by men, in particular, who demand that I provide womanly sympathetic listening without regard for my own mental health. Dealing with this gently while managing my PTSD symptoms is challenging.

World Suicide Prevention Day is coming up and I dread it. This is the kind of season in which I’m approached directly for mental health support that I’m not in a position to give.

I want to set very firm boundaries about how much mental health support I’m willing to do, preferably without hurting or antagonizing extremely sensitive people or getting into any arguments about whether I’m an ableist who’s contributing to stigma. How do I do that?

First of all, I’m very sorry that you had to go through such a painful experience. I hope that you have been able to find effective treatment for your PTSD.

Secondly, in my work as a therapist, I’ve heard a useful analogy used about helping others. When you’re on an airplane next to a child, they tell you that you need to put on your own oxygen mask in an emergency situation before assisting the child. If you don’t, you could suffocate while trying to put the mask on the child, and then neither of you will survive.

Right now, it sounds like putting on your own oxygen mask first means not being available to others in suicidal crises. I would say something like this, “I see that you’re in a lot of pain, and I really feel for you. I can’t be the one to support you right now. I’m struggling too, and to be well, I really need to focus on working through that first. If you can’t think of anyone else to talk to, you can always contact the National Suicide Prevention Lifeline. I hope you find the support that you need.”

My hope is that most people would respond to that in a positive, understanding way. However, if they perceive your response as ableist, stigmatizing, or anything else like that — it’s important to stick with your boundaries anyway (repeating what you said, if necessary). We can’t control what other people think of us, but we can do our best to live according to our values and strive to be okay with our own decisions. Your mental health matters, and good friends should support your decisions to take care of it.

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Zach Clement asked: How can I support a friend who is considering suicide while keeping myself emotionally healthy, and how do I disengage with them when my relationship with them becomes unhealthy for me?

I recently was trying to give support to someone because I knew they were having a hard time, and they had said that they thought about killing themself. However, as time went on, they started attacking me and my relationships with others. I realized that my only reason for talking to them was that I knew I would feel guilty if I didn’t. Eventually, I told them that I wouldn’t talk to them anymore if they continued to attack the things that I valued, and they didn’t stop, so I told them I would just ignore them. I offered to help them find a therapist when I cut things off with them, but I still sometimes feel like I should have done something differently.

This is a really tough situation, and I don’t think these potentially complicating factors are included enough in public discussions of suicide. It sounds like you told the person how they were affecting you and gave them chances to apologize and change their behavior. Unfortunately, the person didn’t. A natural consequence of someone attacking you and your relationships with others is that you’re going to want to distance yourself from that person. And no amount of the other person’s pain gives them a right to be abusive toward you.

Honestly, I think I would have done the same thing that you did. I’d tell them that I couldn’t keep being around them if they treated me like that, but that I wanted to help them get connected with a therapist. The fact that you offered that was very kind and above and beyond what most people would do. I might give them some additional information like the National Suicide Prevention Lifeline. If I knew someone else close to them – and it fit with the situation – I would mention that the person brought up suicide before and that you’re concerned.

I’d probably feel a bit unsettled about the situation, because I’d worry if the person hurt themselves I’d feel responsible. From my perspective though, you can’t allow someone to treat you like that repeatedly because you feel guilty. It sends the message to the person that it’s okay for you to be treated that way or that it’s okay for you to suffer because they are. So, then I’d try to cultivate some acceptance about the limits of what I can do for the person. It sounds like you made a healthy and correct decision for yourself. I hope the person pursues professional help and that you feel at peace with the way you handled it.

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Tyler Pritchard asked: Who are your top 3 influences in suicidology research and/or practice?

  1. Without a doubt, the most influential person in my scientific and clinical work is Thomas Joiner. He was my research mentor during undergraduate and graduate school. Thomas also directed my graduate program’s training clinic and played a huge role in my development as a therapist. His compassion, intellectual curiosity, and direct approach are all qualities I admire and strive to bring into my work.
  2. Marsha Linehan created a therapy for people who were traditionally excluded from clinical trials (e.g., high suicide risk, multiple mental health issues) with an empathic, skills-based approach. Her courage, irreverence, and dedication to helping people build lives worth living inspires me.
  3. It’s hard to pick the third person, so I’ll say my former grad school labmates as a group (e.g., Kim Van Orden, Tracy Witte, Jill Holm-Denoma, April Smith, Ted Bender, and Mike Anestis). They’re brilliant scientists and clinicians and also exceptionally kind people. Conversations with them over the years have helped me to understand suicidology at a much deeper level than I would without their friendship and collaboration.

Even though I already exceeded the 3 with that last one, I’ll also mention David Klonsky. The way he thinks about science and his 3-step theory of suicide have influenced me a lot too.

There are a bunch of others that come to mind, but you didn’t ask for my top 300, so I’ll stop here. 🙂

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Mike Heady asked: I’m not sure you have an answer for this but here it goes. I’m looking for data on how many people present or are admitted to hospitals for suicide risk when in fact the person is having intrusive self-harm OCD.

Unfortunately, I didn’t have any luck finding data on this either. This is a great question though, and I want to discuss the meaning of it for any interested readers out there.

Obsessive-compulsive disorder (OCD) often includes unwanted, distressing images or thoughts (referred to as intrusive thoughts). Sometimes, these thoughts are about contamination with germs, hurting others, or hurting oneself. You can see what this looks like in this video of an adolescent being treated for self-harm OCD symptoms.

Many people — even those without OCD — have experienced a self-harm image or thought come into their mind, even when they are not suicidal. For example, Hames et al. (2012) asked a college student sample (n = 431) if they ever had an urge to jump when in a high place. They found that it was fairly common, including among participants with no history of suicidal ideation (see the table below).

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For some individuals with OCD, their thoughts about self-harm are alarming, distressing, and feel like no part of what they would actually want to act on. They are not typically at high risk for suicide, because they usually try to decrease their anxiety about intrusive thoughts by taking extra safety measures (e.g., not handling knives). They’ll say that the thoughts are disturbing because they really do not want to die.

For other individuals with OCD, they may be struggling with their symptoms and considering suicide, because they believe it would be an escape from their pain. This type of situation is more worrisome.

Clinically, I’d look at the context of their suicidal thoughts to make my best judgment about their risk and whether hospital admission is appropriate. The presence of any of the following would put them at higher risk for suicide: a lack of distress or even a sense of comfort when thinking about self-harm, a history of self-harm or other suicidal behavior, a suicide plan and lack of fear about carrying it out, access to lethal means (e.g., an unsafely stored firearm), sleep disturbance, agitation, social withdrawal, severe mood disturbance, or significant weight loss.

For more information, check out this blog post: When People with OCD Fear Harming Themselves.

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Anonymous asked: Suicide is a concept I am ambiguous about. When I am distressed over something after a day, or when I feel I don’t belong in society or I will never be able to function normally like other people would, I feel or think that suicide is an escape route. Like, if all else fails and pain is too unbearable to take, I could choose it. That way, I would get rid of all the things that are troubling me. 

Or sometimes, I think that I am not courageous enough to pull the last act for suicide. When I brought this up during one of our sessions with my therapist, she told me that suicide is not about being courageous it is about cowardice.

So, my question is,

1 Is suicide about courage or cowardice? Does it take courage to commit suicide or does it means cowardice? Well, of course if doesn’t have to be one of those, but saying it’s cowardice feels like it’s underestimating the pain underneath. What do you think how should we look at this?

2 What do you think about the existence of the idea of suicide lingering in your head as an escape route as a comforting idea? Is it healthy, if not what can I put in its place?

1. Suicide is not an act of cowardice. Though there are different pathways to suicide, most people get there because they see no other way to escape excruciating emotional pain. They often mistakenly believe that they are doing others a favor by not living any more. Even very brave people are vulnerable to, and die by, suicide when afflicted by this pain. It’s not a sign of weakness (more about this on an NPR segment, Deconstructing Myths about Suicide).

In terms of courage – that’s not the word that I tend to use, because of it’s kind of value-laden. I prefer to describe to the ability to die by suicide as others have: capacity, capability, or fearlessness (about the pain and injury involved in suicide). For someone to kill themselves, they have to override a very strong human survival instinct. That drive to live is protective and life-saving for many people. Tragically, people who die by suicide break through that.

So, I don’t think suicide is an act of cowardice or courage in the vast majority of cases. It is an outcome that occurs when people are intensely hurting and don’t see another way out. Suicides hurt those who are left behind, even if that is not what the person intended to do. In the eyes of the bereaved, I would be surprised if they see either cowardice or courage in the situation — just heartbreak.

2. I have spoken with people personally and professionally who think about suicide to decrease painful emotions. If you’re interested, there’s some research on it in this paper called Daydreaming about Death: Violent Daydreaming as a Form of Emotion Dysregulation in Suicidality.

First, I want to say that there’s nothing to be ashamed of and that you’re not alone in doing that. It’s valid to want to decrease your emotional pain. However, I do suggest that people find other strategies for feeling better. My concern is that fantasizing about death might increase suicide risk. It could potentially reduce the protective fear that surrounds suicide and strengthen the links between positive feelings and death.

In terms of what to put in its place, you could try to imagine feeling better and that your problem is solved. If that doesn’t feel authentic or practical for you, I recommend finding ways to remind yourself of your ability to cope from past situations, that you can take things one day at a time, and that you find other ways of dealing with distress. For example, there are some ways listed in this post here that include distraction and finding emotional uplifts (e.g., watching comedy, intense exercise, seeking social support, etc.). If it’s relaxation that you are looking for, this website has some nice audio recording options that are worth trying instead. I hope you find some of these other approaches helpful and comforting.

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Coral More asked: Do you see another model than assess & refer to 911/hospital given what we know about trauma resulting from police encounters and hospitalizations/emergency rooms? I know it’s a very tricky one but I never see folks talking about it.

I’ve been on both sides of this, feeling the need to call emergency services but also voluntarily presenting to the emergency room and being absolutely traumatized by the dehumanization and cruelty there.

I personally have recommended calling 911/the hospital in certain (though very few) situations where other options were exhausted and there’s urgency. These include situations where: 1) the person already hurt themselves or 2) they’re at immediate risk of self-harm. This pathway can be lifesaving, appropriate, and beneficial (though experiences vary a lot, as you said above — people can also have horrible, terrifying experiences that are detrimental to their well-being).

There are many, many more situations where I have collaboratively worked with someone to find an alternative suicide prevention approach. My default is to collaboratively create a safety and coping plan. This includes reducing access to lethal means, identifying supportive people (I often try to call at least one friend or relative with the consent of the patient, and this tends to go well), and listing methods for reducing emotional pain (e.g., emotion regulation skills, crisis survival strategies for distress tolerance). In addition, I provide them with emergency numbers, and we identify when they would need to go to the hospital or call 911 (e.g., if their suicidal thoughts escalate to suicide planning or preparation).

Part of the discussion also includes ways to intensify treatment without using the hospitalization or emergency services route. For example, increasing the frequency of therapy sessions or attending a partial hospitalization program (where people go in for treatment during the day, but sleep at home).

This article is good for looking at suicide risk as a continuum with a variety of interventions that correspond with severity: Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update.

I like what Marsha Linehan says in this video about hospitalization (keeping a person alive through constant monitoring) versus taking a risk by not always hospitalizing at any threat of suicide, so they can have a chance at building a life worth living.

I also recommend listening to Rudy Caseres, a mental health advocate, speak about his views and experiences with hospitalization in this interview.

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Does Cognitive-Behavioral Therapy Apply to Campus Politics?

Note: Usually, when I write about any remotely politically-charged topic, I make sure my arguments are very clear in my mind and supported by 9000 citations first. This isn’t the case with this topic, which I’m still forming ideas about. I’m posting this because I’d love to hear feedback/counterpoints from cognitive-behavioral therapy (CBT) and social justice perspectives: kathrynhgordon@gmail.com.

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I was recently on Jesse Singal’s podcast, and he asked thoughtful questions about the applications of CBT to campus culture war issues. Apparently, a side effect of asking me good questions on a podcast is that follow-up blog posts occur (well, it’s happened twice so far, anyway).

Here are my current, still-forming thoughts about whether CBT should be applied to college students making claims about politically-related offenses and psychological harm. My points are based on a variety of different arguments I’ve heard and are not directed at particular people/texts, though I believe this is the original article applying CBT in this way.

1. CBT is excellent and improves the lives of a lot (but not all) people struggling withBurns.jpg mental health issues. I’d love for all college students to read David Burns’ self-help CBT book, Feeling Good: The New Mood Therapy (which is referenced in the original article on this topic). I read it in college, found it eye-opening, and then proceeded to recommend it and loan it to countless people since — including undergraduate students who I taught when I was a professor. Seriously, ask anyone who knows me — I have probably recommended that book to them. Not all students find it helpful (which is consistent with research on any treatment modality), but some really do. However, it’s important to recognize that CBT is designed and scientifically-tested as a treatment for people who are having mental illness-related distorted cognitions and thinking errors. It does not focus on societal stressors related to healthcare access, income inequality, rights, or prejudice, and it doesn’t offer solutions to those issues either. My concern is that placing thoughts related to these issues in a CBT framework reinforces some individuals’ default position that people talking about experiencing prejudice or feeling upset about political issues are exaggerating. Within a therapeutic context, these complexities can be addressed with nuance. Outside of that context, I worry that it bolsters notions that people can and should just think their way out of these types of stressors. This NYT article is about an illustrative real life example of how this kind of disbelief or minimizing default can lead to negative consequences.

2. Relatedly, I’m wary of using CBT as a method for ‘correcting’ other people’s thoughts and feelings about offense or harm unless I’m the person’s therapist (and even then I’m cautious) for the following reasons:

Humility & AccuracyIf you think someone is overreacting to a politically-related incident, you can just plainly state that as your appraisal of the situation instead of using CBT language (e.g., calling it catastrophizing or emotional reasoning). When you say someone’s thinking is distorted, the assumption is that you know for sure that they’re overreacting and also that you know why they are (and that is mindreading). I don’t see the incremental value of using CBT terms in situations where you don’t know much of the context, unless it’s to tone down the fact that you’re making a judgment about the accuracy of a person’s thought by framing it as a concern about their mental health.

EffectivenessIn the self-help version of CBT, a person learns tools for investigating their own distortions and thoughts. In therapy, it’s a collaborative process, where the therapist hears the person’s point of view and guides them through the steps of evaluating their thoughts in a compassionate, contextualized process. By design, CBT helps people arrive at reframed thoughts that ring true for them. It can be hard to get to that place in therapy — it seems much harder to get to that place through some of the other methods I’ve observed (articles/posts referring to students’ behavior as evidence of their fragility). To be clear, I’m not saying that thought errors don’t happen in certain college campus situations — I’m just saying I don’t see how motivated the average college student would be to evaluate thinking errors when presented with them as a sign of their fragility.

Ignoring Real Problems Where They ExistAs I wrote about before, I think that disproportionate focus on students’ purported lack of resilience ignores the valid reasons for their actions. If students get painted with too broad of a brush and are characterized as simply being unable to tolerate opinion differences, then it distracts from points of legitimate concern about the spread of ideas that perpetuate social inequities. When therapists disagree with their clients’ approaches to situations, they motivate change by looking for and validating the truth in what the client is saying and collaboratively generating ideas about adaptively achieving their objectives.

Furthermore, there’s a long history of people from marginalized groups being misdiagnosed and poorly treated within mental health fields (e.g., 12). Broadly applying cognitive distortion framework in a public way doesn’t allow for a culturally appropriate framework that therapists are trained to use in treatment. Without that context and training, people might minimize or deny others’ valid experiences–which could be harmful to their health.

In conclusion, there are helpful elements in cognitive-behavioral therapy that apply to particular types of problems — especially when depression- or anxiety-related thinking errors are present. I have reasons to doubt it would generalize beyond what it’s been tested on and designed for, but could be convinced otherwise with empirical data.

When Gratitude Gets in the Way

While research on the effectiveness of gratitude interventions appears mixed, there’s a shared wisdom that being thankful for what you have is good for you. Most of us have had experiences where something stressful happens (e.g., a minor car accident, an argument with a friend), and we gain perspective by stepping back and appreciating the positive aspects of our lives.

But I’ve also observed instances when gratitude gets in the way. I’ve had friends and therapy patients start to talk about something that bothers them and then they cut themselves off and say, “But I know other people have it worse, so I shouldn’t complain.” I get the impulse–I do it too. I think it serves the purpose of displaying self-awareness or maybe mitigates fears that you’ll be judged as having petty concerns or maybe you think telling yourself that will make the feelings go away. To be sure, there are times when people could use a more zoomed-out perspective and appreciation for their lives. However, I’ve observed this approach hindering progress and worsening well-being too.

The pattern is usually that a person experiences distress, they try talking themselves out of it being a big deal, and then they end up avoiding actions that would actually help them feel better and improve the situation (e.g., leaning on a friend for support, doing something healthy like exercising, gaining clarity about painful emotions, problem-solving, going to therapy). If you’ve tried to address a situation by telling yourself that you should be more grateful and the feelings persist, it’s time to try something else. It doesn’t mean that you’re an ungrateful person for recognizing that you’re bothered by something despite all the people who have worse lives (and by the way, many of the people I’ve heard say this have had objectively terrible things happen to them!). It just means that you’re human and affected by the events surrounding you. Acknowledging your experiences and directly addressing them is a healthy way to deal with them and not an act of self-indulgence.*

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*I think it’s really hard to make any general statements when people can be all over the spectrum of gratitude and stress responses and vary from situation to situation, but thought I’d write this out for people who happen to fit into this kind of scenario.

 

 

Science Can Meaningfully Advance Public Discussion About Suicide

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Public discussion about suicide is dominated by particular types of narratives. Media outlets tend to focus on celebrities who, despite outward signs of success, are tragically driven to despair. Other news stories tell heartbreaking tales of young people who end their lives after experiencing readily identifiable stressors. This coverage is important, and compassionate media depiction is crucial for public understanding. However, discourse that’s constrained to certain kinds of stories obscures two key points: 1) suicide is really complicated and 2) it can affect anyone. With a trend of rising suicide rates in the United States, we need to expand our conversations and make more room for nuance.

Five years ago, I heard a story about a suicide attempt that broke the typical media mold. It was this powerful NPR Story Corps segment about a man named Kevin Berthia, who was extremely close to jumping off the Golden Gate Bridge. In under three minutes, listeners learn that Berthia suffered from depression throughout his life and that this escalated to suicidal thinking when he couldn’t pay for his infant daughter’s enormous medical bills. This triggered embarrassment, self-directed anger, and feelings of failure. Filled with urgency to escape his overwhelming pain, he got directions to the bridge and climbed over the railing. He was stopped by an empathetic police officer, Kevin Briggs, who spoke with him for an hour and a half on the ledge before he decided to climb back to safety. Berthia’s life was saved, but his struggles continued for years. In a piece for the Guardian, he wrote, “Reporters are always after the happily-ever-after ending.” This coverage stands out because it includes his backstory and the moment-to-moment details of Berthia’s path toward, and ultimately away, from suicide.

Suicide is the result of a culmination of factors pushing people into excruciating states where death is viewed as relief. Suicidologists acknowledge that diverse pathways lead to suicidal desire and seek to identify commonalities among people in acutely risky states. For example, Berthia had pre-existing vulnerabilities related to growing up with some family conflict and in a neighborhood where he was pressured to hide his depression. Then, compounding the uniquely jarring worry of having a child in compromised health, Berthia also blamed himself for not being able to foot medical bills to the tune of a quarter of a million dollars. This propelled him to the Golden Gate Bridge with the thought, “All I gotta do is lean back and everything is done. I’m free of all this pain.”

Between StoryCorps and the Guardian article, we get a sense of several contributing factors and potential intervention points that are generalizable beyond Berthia’s individual situation. For example, there seems to be a sustained cultural push against the belief that people should hide depression. And while the Affordable Care Act sought to partially address the dire state of affairs for many Americans facing medical costs, additional changes are desperately needed to overhaul a system that leaves people struggling to meet basic physical needs. A comprehensive suicide prevention initiative would address these and other empirically-linked risk factors (e.g., incarceration, homelessness, combat exposure, physical illness, mental illness, and discrimination). This long list of suicide risk factors can leave people feeling overwhelmed and unsure of how to help. Thankfully, Klonsky and May (2015) developed a scientific framework called the Three-Step Theory (3ST) that meaningfully organizes and prioritizes this information:

3ST diagram

from Klonsky, May, & Saffer, 2016

Berthia’s experience appears to fit within the 3ST. The first step proposes that people desire suicide in the presence of pain and hopelessness about the future, “If someone’s day-to-day experience of living is characterized by pain, this individual is essentially being punished for living, which may decrease the desire to live and, in turn, initiate thoughts about suicide” (pp. 116-117). Within the 3ST, suicidal desire could be reduced by targeting both distal factors (e.g., eliminating environmental factors that increase the probability of emotional pain) and proximal factors (e.g., increasing hope and coping skills). People advance to the second step of increased suicidal intensity if their pain overpowers meaningful connections to life. In the moment Berthia was about to jump to his death, Briggs emphasized Berthia’s connection to his daughter and the suicidal intensity decreased, “My daughter, her first birthday was the next month. And you made me see that if nothing else, I need to live for her.” A society seeking to prevent suicide would foster these kinds of connections, at multiple levels, for as many people as possible. The 3ST makes the case, building on the interpersonal theory of suicide, that the survival instinct prevents most people from attempting suicide even if they desire it. The third step usefully identifies three facets of a capacity to override this survival instinct: dispositional (e.g., genetics related to pain sensitivity), acquired (e.g., experiences that result in decreased pain sensitivity and lowered fear of death), and practical (described as knowledge of and access to lethal means – e.g., in Berthia’s case, getting the directions to the bridge and not facing a suicide barrier once there). The practical aspect of capability for suicide has been the focus of initiatives to reduce access to lethal means in times of suicidal crises (e.g., through safe gun storage). Increasing safety at times of suicidal crisis can have long-lasting positive effects, as most suicide attempt survivors do not go on to die by suicide.

Suicide is complicated and that contributes to widespread misunderstanding. Science can guide us away from investing resources in domains that have unknown relationships with suicide and toward those that have demonstrably stronger ones. Research illuminates potent risk factors and makes our understanding of suicide more precise. Suicide prevention advocates have increased public awareness about a variety of different suicidal experiences and continue to fight for public policy aimed toward saving lives. Recently, there have been excellent examples of compassionate, realistic media coverage and fictional depictions of suicidal behavior. Altogether, this suggests that the public has the will to prioritize suicide as a public health problem. Scientific frameworks like the 3ST can steer us in productive, solution-focused directions.

Suicide prevention information resources are available here, and here’s a summary of intervention research.

You can hear more of Kevin Berthia’s story here:

You can hear Kevin Briggs speak about Berthia’s story here.

 

The Cost of Giving the Benefit of the Doubt (or the Downside of an Elastic Heart)

warning: lots of speculation in this post and only a little science

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Something that preoccupies me these days is the puzzle of sharing psychological science in accessible, interesting ways without undermining its complexity. This is isn’t a new problem – many brilliant people have been working on it for a long time. There’s been substantial progress, even when it’s hard to compete with the attention paid to public-facing psychologists who sacrifice accuracy for various incentives (see Ali Mattu for an excellent example of someone not sacrificing accuracy for engagement). Still, there’s a core challenge that keeps running through my mind that’s not fixable through improving technology or reducing jargon or changing incentives. It’s that there’s rarely (ever?) a one-size-fits-all (or even-a-vast-majority-fits-all) situation in psychology due to variability between situations and people (which Sanjay Srivastava wonderfully captured when he deemed psychology the hardest science).

One way that people get therapeutic-like info out to the public is through the kernels-of-wisdom model (e.g., a tweet, a meme, or Instagram photo with a message like, remember that you’re trying as hard as you can and that’s good enough). This model is appealing because it’s low cost and could be just enough to brighten up someone’s day or spread some insight (by the way, check out Anna Ropp‘s awesome, scientifically-informed Psych Tidbits Instagram account). No one’s under the illusion that it would replace therapy or other bigger life factors related to one’s mental health, and it’s unlikely to harm anyone.

Then, there are more concerted efforts at advice-giving through videos, books, and social media with varying levels of credibility and scientific support. To oversimplify things, the advice is usually get yourself together or stop being so hard on yourself. So, herein lies my concern: I think people are bad at guessing which message applies to them. And while I don’t think a little-bit-of-wisdom type message here and there causes problems, I think there could be a negative cumulative effect of repeated messaging out in the world that people should take one of these two approaches to improve their lives. For example, I’ve seen people who could use the message about not being too hard on themselves absorb the one about getting themselves together and consequently pushing themselves even more to the brink. Meanwhile, there are people who could improve their lives by pushing themselves in certain ways but avoid that by telling themselves they’re just engaging in self-care. And I’m sure I’ve done both at times; it’s human nature to find justifications for the thing we already want to do.

I’m slowly funneling to a specific example, which is this: advice that is often given, including by psychologists, is to give people the benefit of the doubt. This appeals to me in a number of ways consistent with my values – it seems like a nicer, more hopeful, and less angry way to be. It’s consistent with the scientific framework of waiting to interpret something based on evidence instead of intuition. And it’s good advice if you’re the type of person who would otherwise lean toward hostile attributions. On the other hand, consistently giving people the benefit of the doubt has costs that I rarely see acknowledged:

-It means questioning yourself a lot more when you sense that someone intends harm, which can erode your ability to trust your own perceptions.

-Without a belief that you can accurately assess and interpret situations, you can get stuck in a state of inaction rather than moving to resolve an issue.

-It can mean ignoring ambiguous, but existent warning signs that would have removed you from a dysfunctional situation earlier.

-If you’re prone to self-doubt, it may lead you to feel foolish for assuming good will in the first place. This is taxing and can affect productivity even once you’re in a better subsequent situation.

-People often trust cynics more than recurrent benefit-of-doubt-givers, as though they’re closer to truth when they assert their opinions. Cynicism is more likely to (erroneously) signal critical or deep thinking than benefit-of-doubt giving, which is typically linked to being naive or a pushover.

-A nontrivial number of people won’t reciprocate. It’s a good thing to assume the best in people in and of itself sometimes, but it’s also useful to strategically employ it with the hope of improving communication. Unfortunately, there are people who will take advantage of your approach while not extending any charitable interpretations to your behavior.

Despite every single cost I mentioned, I’d still argue that benefit-of-the-doubt giving is worthwhile and generally good advice to follow (perhaps because it’s aligned with my values or simply to justify my own past and future behavior). But, I’ve been reflecting on the costs more recently and thought writing them out might lead to hearing other people’s perspectives — so, I’m eager to hear what others think about the specific example or the broader issue of communicating universal psychology messages (but only if you mean well).*

*I’ll assume you do.

Can Offensive Political Speech on Campus Cause Trauma?

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I went on Half Hour of Heterodoxy to talk about student reactions to political extremists giving speeches on college campuses. I was grateful for Chris Martin‘s interesting questions and wanted to expand on a few of the discussion points.

What’s the definition of trauma?

The DSM-5 defines trauma as exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1) directly experiencing the traumatic event(s), 2) witnessing, in person, the event(s) or the event(s) as it occurred to others, 3) learning that the traumatic event(s) occurred to a close family member or close friend, 4) work-related repeated or extreme exposure to aversive details of traumatic event(s).

Do political extremists cause trauma when they speak on campus?

DSM-defined trauma is unlikely to occur at these events unless there’s actual or threatened violence involved (e.g., 1, 2, 3, 4). It’s important to avoid watering down the term trauma through misuse in situations where it doesn’t apply. However, I don’t think fear of acute trauma typically drives the opposition to political extremists on campus. I think the fear is more commonly about political extremists using campus appearances to spread discriminatory beliefs that perpetuate social inequities. The sense of threat comes from historical knowledge about the uses of propaganda, and it’s amplified when violent acts are carried out that reference this propaganda (e.g., 1, 2, 3, 4). Some political extremists explicitly state that they’re trying to recruit college students to their causes (1, 2) and have developed strategies for persuading people through coded language (e.g., 1, 2, 3). Despite trauma being an unlikely consequence of these speeches, there is a robust literature showing that experiences of discrimination are related to worse mental and physical health (e.g., 1, 2, 3)* and that people can have physiological stress responses when exposed to discrimination and racism.** For example, it’s been proposed that these types of stress responses contribute to birth outcome disparities between Black and White women in the United States (e.g., 1, 2). 

What should universities do?

1) Actions should be individually-tailored for the particular university and involve discussion with students and faculty, instead of something pushed top-down from administrators. Include mental health experts in these conversations.

2) Express support for faculty and students. Even if you disagree with their viewpoints, don’t ridicule students or erroneously reduce all of their concerns to an inability to handle differences of opinion. Students are exposed to politically extreme views in spaces outside of campus speeches, and that exposure often shapes their beliefs about the particular speaker and the potential for harmful societal consequences. It’s not helpful to deride students who respond by using their time and resources to organize nonviolent protests to combat social inequality.

3) Don’t equate mental health issues with weakness or confuse therapy with avoidance. Normalize discussions about mental health on campus. University-wide e-mails are sent around about flu shots and other medical issues – it can be helpful to do the same with mental health information and resources. When people seek counseling, the first step involves determining whether the person has a mental health problem. If a student refers to something as trauma when it’s not, therapists provide them with that valuable corrective feedback. There’s also a misconception that therapy is about unconditional reassurance or hand-holding, but it’s actually all about empowering people to face their problems skillfully.

4) Be precise in stating your rationale for hosting speakers on campus. I doubt that many university administrators think there is educational value in speeches by people like Richard Spencer. Usually, they’re motivated by the importance of upholding free speech principles and are legally obliged to host speakers in public spaces. I’ve heard some arguments that there are educational and mental health benefits to having political extremists on campus (e.g., via exposure to “new and challenging” ideas). The free speech argument is compelling, but the educational and psychological growth arguments are not. I’m not aware of any evidence that exposure to inaccurate, dehumanizing ideas about groups of people confers psychological benefits (if you are aware of such research, please share it with me). For example, some students have opposed Ben Shapiro speaking on their campuses. As I have written about, he spreads false information about suicide and trans people (also watch Natalie Wynn refute Shapiro’s claims). It’s hard to comprehend how learning inaccurate ideas, which are used to restrict rights (e.g., 1, 2), add value to students’ lives. When someone argues that accuracy and education don’t matter when it comes to protecting free speech, I find that much more convincing and honest.

A recent video by Natalie Wynn included a nuanced description of her response to Ricky Gervais telling transphobic jokes in his comedy specials. She made it clear that the thing that bothered her wasn’t that he’s allowed to tell those jokes (she’s a huge proponent of free speech) or even that the jokes are unoriginal, unfunny, or offensive. Rather, she’s afraid that he’s spreading untruthful ideas that make the world a harder place for people like her (she’s a trans woman). Her descriptions reflect the kind of complexity and clarity needed for productive conversations about the psychological effects of these types of speech.

*This paper describes the complexities of measuring discrimination in research.

**Individual differences between people and situations determine the extent to which any particular person will be affected by an event.

Information & Resources

Accurate information about trauma and posttraumatic stress disorder is available here.

For student organizer perspectives, listen to Hoai An Pham here (episode 10) and read Maximillian Alvarez’s article here.

Chris Martin‘s Half Hour of Heterodoxy podcast has featured guests with a variety of opinions on free speech and other campus-related issues.

Two particularly thoughtful academics who write about campus free speech issues are Aaron Hanlon and Jeffrey Sachs.

I’ve learned a lot about First Amendment litigation from reading work by Ken White and FIRE.

I co-wrote a blog post on college mental health that you can access here.

Acknowledgments

In preparation for the podcast, I reached out to three people with relevant expertise and experience: Dr. Yessenia Castro, Linda Gordon, and Carly Marten. They generously shared research, articles, resources, and their thoughts with me. I’m thankful for how much they deepen my understanding of these issues and for all that they do to make the world a better place.

A Short Guide to Everything You Need to Know About Eating Disorders

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In honor of National Eating Disorders Awareness Week, I will attempt to create a post that links to everything you need to know about eating disorders.*, **

*Or at least gets you within a couple of clicks of a lot of things that are good to know.

**Scientists and clinicians don’t actually know everything we need to know about eating disorders yet, but I’ll share what we do.

Definitions

The Diagnostic and Statistical Manual of Mental Disorders includes formal definitions of eating disorders, such as anorexia nervosa, bulimia nervosa, binge eating disorder, and others. Even if someone does not meet full diagnostic criteria for an eating disorder, they may still struggle with eating disorder symptoms such as body dissatisfaction, loss-of-control overeating or undereating, preoccupation with food, weight, or shape, or unhealthy weight loss behaviors (e.g., abusing laxatives, self-induced vomiting, compulsive exercise). If you’re curious about your own eating behavior, you can take an online screening here.

Causes

There are a variety of different factors that increase the risk for eating disorder symptoms. You can read about them here or see the biopsychosocial model below for some of the main factors associated with eating disorders.

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Treatments

Current research-supported eating disorder treatments include: family-based or Maudsley treatment, cognitive-behavioral therapy, integrative cognitive-affective therapy, and interpersonal psychotherapy.

There are also some scientifically-informed self-help books available:

Help Your Teenager Beat an Eating Disorder

Overcoming Binge Eating

The Body Image Workbook

Additional Eating Disorder-Related Topics

Activism

Emotion Regulation

How to Help A Loved One

The Marginalized Voices Project

Statistics

Suicide

Warning Signs

Weight Stigma

More Eating Disorder Resources

Association for Behavioral and Cognitive Therapies

Academy for Eating Disorders

Find Treatment

Helpline

Maudsley Parents

Mirror-Mirror

National Eating Disorders Association

Podcast Episodes on Eating Disorders (1, 2, 3)