The Suicidal Thoughts Workbook is Now Available!

**You can listen to an audio version of this post here.**

I’m excited to share that my book, The Suicidal Thoughts Workbook: Cognitive-Behavioral Therapy Skills to Reduce Emotional Pain, Increase Hope, and Prevent Suicide, was officially published on July 1, 2021! I’m honored that my former graduate school mentor, Dr. Thomas Joiner, wrote the foreword.

One of my driving passions is sharing science-guided, helpful mental health information directly with the people who most need it. I took what I learned from years of research, therapy, and other life experiences and channeled all of that into the creation of The Suicidal Thoughts Workbook. My deepest hope is that readers will feel supported and empowered with strategies for coping with suicidal thoughts. I also hope that the workbook will help people to better understand how to support loved ones who struggle with suicidal thoughts. For therapists and crisis workers, I hope that the workbook will strengthen your confidence and expand your tools for helping people with suicidal thoughts. The book chapters were structured around a leading theory of suicide that was developed by Dr. David Klonsky (the Three-Step Theory). To give you an idea about the scope of the book, here is the table of contents:

I was also thrilled to collaborate with a brilliant artist, Alyse Ruriani, MAATC, to create two illustrations for the book (stickers and other items with these illustrations are available here).

I’m grateful for the positive reviews from people who read advanced copies:

“Kathryn Gordon’s workbook helped me self-reflect when I didn’t feel like I could handle my thoughts. When all feels lost, resources like this are exactly what we need: hopeful, analytical, educational, and practical. I will absolutely be recommending the book to others who might be feeling the same pain of suicidal ideation or hopelessness as well as those who are looking to better understand and help their loved ones.” 
—Marie Shanley aka Mxiety, mental health advocate and live talk show host, author of Well That Explains It

“Kathryn Gordon has translated our best theoretical and scientific understandings about why people are suicidal into an elegant, accessible, and easy-to-use workbook. Short chapters are full of practical and reproducible worksheets that walk the reader through hope and healing. She pairs her deep knowledge of the suicidal person with her expertise in cognitive behavioral therapy to create an invaluable resource for clients, their family and friends, and mental health professionals.”
—Jonathan B. Singer, PhD, LCSW, president of The American Association of Suicidology, and coauthor of Suicide in Schools

“Immediately helpful, this outstanding workbook offers wisdom and big-impact strategies to give you hope—that you can cope with setbacks, work through painful thoughts and feelings, find greater meaning in life, address obstacles to success, and live with purpose. Written with a supportive, encouraging tone, Kathryn Gordon guides you through the challenge of addressing suicidal thoughts, feelings, and behaviors with insight, self-compassion, and action. For anyone overwhelmed by pain and hopelessness, this essential resource will help you take the necessary steps to get your life back.”
—Joel Minden, PhD, licensed clinical psychologist and author of Show Your Anxiety Who’s Boss

The Suicidal Thoughts Workbook has my highest recommendation. The content is informed by Kathryn Gordon’s extensive clinical expertise and deep knowledge of the research literature. The writing is beautiful, clear, and accessible. Gordon has a gift for communicating with her readers and making suicide risk understandable and surmountable.”
—E. David Klonsky, PhD, professor of psychology at the University of British Columbia, developer of the Three-Step Theory of Suicide

“For anyone who’s ever struggled with thoughts of suicide or who has a loved one who does, this workbook is a must-have. Kathryn Gordon is kind and practical in her approaches to managing suicidal thoughts, and in helping us find what we might have lost during the many years of struggle – hope.”
—Janina Scarlet, PhD, award-winning author of Superhero Therapy

“This book is outstanding—compassionate, packed with practical exercises, and based on research, theory, and clinical practice. It can help readers to suffer less, to stay safe, and to want to live. The Suicidal Thoughts Workbook stands alone just fine as a self-help book, and it also will be a good complement to psychotherapy.”
—Stacey Freedenthal, PhD, LCSW, psychotherapist, University of Denver associate professor of social work, and author of Helping the Suicidal Person: Tips and Techniques for Professionals

“I am tremendously grateful for the opportunity to endorse this helpful tool. Having survived suicide attempts, I can honestly say that I wish I had something like this that could have helped me better understand everything that I was dealing with on the inside. Kathryn Gordon, thank you for thinking about those of us who struggle everyday with this invisible illness—we are forever grateful.”
—Kevin Berthia
, Suicide survivor/advocate/speaker, founder of The Kevin Berthia Foundation 

“Suicidal thoughts and feelings can sometimes end in death. And even if people don’t act on them, suicidal thoughts are incredibly painful in the moment. The good news is that for many people, using the skills in this book can help a person cope with suicidal thoughts and intensely painful emotions. Studies show that most people who use skills like the ones in this book can significantly reduce their suffering and help them build a life worth living. It is possible to recover, and this book is a good place to start.”
—April C. Foreman, PhDL.P., executive board member of the American Association of Suicidology 

The Suicidal Thoughts Workbook is a true gem in a world where suicide vulnerability exists in the shadows of shame and fear. Kathryn Gordon brilliantly weaves her professional expertise as a therapist and researcher to deliver a comprehensive workbook that breaks down each layer of suicide complexity, from why suicidal thoughts occur to specific strategies for developing personalized solutions. Most impressively, the workbook is genuinely empowering, offering hope to those who might otherwise feel hopeless.”

—Rheeda Walker, PhD, University of Houston professor of psychology and author of The Unapologetic Guide to Black Mental Health

You can order The Suicidal Thoughts Workbook wherever books are sold (e.g., Amazon, BookShop, and Book Depository for free international shipping), and the first chapter is previewed on Amazon. If you’re thinking about ordering my book or already have, thank you so much for the support! If you find my book useful, please consider leaving a review on Amazon or Goodreads and telling your friends about it. For books like this, word-of-mouth recommendations and social media posts about the book make a big impact!

With gratitude and wishes for good mental health,

Katie

Clinician Resources for Working with Suicidal Clients

Last week, USA Today published an article with this quote:

Suicide is the nation’s 10th leading cause of death, yet experts say training for                  mental health practitioners who treat suicidal patients — psychologists, social                      workers, marriage and family therapists, among others — is dangerously                                inadequate.

That article prompted this post. If you’re a therapist interested in learning more about working with clients who experience suicidal thoughts and behaviors, I hope that you’ll find this useful.

Books

Articles

Websites

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Ask Me Anything about Eating Disorders

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For National Eating Disorders Awareness Week, I tweeted that people could ask me anything about eating disorders. Thank you to everyone who submitted questions – they were very interesting and thoughtful! I aimed to be as concise as possible, while providing links for more in-depth information. If I didn’t fully answer a question, made an error, or was unclear, please e-mail me at kathrynhgordon@gmail.com to let me know. Thanks for reading!

1) @KCapo45 asked:

Is bullying by everyone on social media making it harder for people to be honest in therapy about their true feelings about their body because they are being shouted down by groupthink for not loving their body and being afraid of gaining weight*?

*For extra context, listen to this interview I did with Ken about his recovery from anorexia nervosa. We talked about whether there were any possible negative effects of body positivity movements.

Because Ken specifically asked about people being honest about their feelings toward their bodies in therapy, and I couldn’t find any data on the topic, I’ll share my clinical observations as a therapist:

  • It’s striking to me that many of the patients I see — across a broad range of sizes, mental health issues, and ages — struggle with body image issues.
  • Many don’t hold back and will openly say that they feel bad about their bodies, even when changes are linked to having babies, medical conditions, or menopause.
  • A subset have tried to follow body positivity social media accounts and question beauty norms, so that they can love their bodies more. Still, many have body dissatisfaction and then feel like failures for not 100% loving their bodies. This is the group that will say things like, “And I know I shouldn’t care…” or “And I know I shouldn’t feel this way…” or “I know this sounds superficial, but…” and who end up in an even deeper state of shame and self-criticism.

For these patients, I recommend aiming for body neutrality over body positivity. That means that they accept their body as it is (not reject it or love it, but accept it) and accept their feelings about their body (good, bad, and all else). If they want to make changes in their body and/or their feelings about their body, we can collaboratively discuss those longer-term goals. However, in the short-term, what I’d like is for them to be okay enough with their bodies that they engage in their lives, rather than avoiding valued activities (e.g., socializing, exercising, sex, going out) due to feeling self-conscious or waiting until a time when their body is different. Here are some suggestions for ways to feel more okay about your body.

I think I’m already missing my goal of being concise, but in short, I’ll link to some other approaches I use to work toward this point of acceptance: cognitive-behavioral therapy for body image, I Am Me by Virginia Satir, self-compassion exercises, and opposite action.

Below are some interesting articles on this topic that provide history, context, and more nuance than the headlines suggest.

‘Body Positivity’ Has Had Its Day. Let’s Find Peace with Ourselves.

Body Positivity is a Scam (the author discussed the article on this podcast)

The Problem with Body Positivity

An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy

Self-Care Has to be Rooted in Self-Preservation, Not Just Mimosas and Spa Days by Lizzo

What Jillian Michaels Got Wrong about Lizzo and Body Positivity

2) @on_perspectives asked:

ED is extremely complex and certain treatments can backfire. Does the timing of treatment, in regard to what is going on in a patient’s life, play a role in recovery? When would immediate treatment of ED not be recommended because it would mean a lesser chance of success?

In the vast majority of cases, earlier treatment is associated with better treatment outcomes. The general rule is that a person with an eating disorder should get treatment as quickly as possible. If a person gets worse while in treatment, it’s extremely important to identify the factors that are responsible and adjust the treatment approach accordingly. With regard to what is going on in the patient’s life at the time of treatment, we appear to generally have more effective treatments for anorexia nervosa in youth than adulthood. I think this is due to younger patients being treated within the context of family-based care, though there are treatments aimed toward bringing in a support system for adults as well. Other factors that are likely to play a role in recovery: comorbid psychological problems (e.g., depression, PTSD, substance abuse), social support, access to empirically-supported interventions, readiness to change, other general life stressors (e.g., divorce, moving, bereavement, financial stability), functioning in other areas (e.g., academics, romantic relationships, at work), etc. On average, people who have good social connections and fewer additional stressors in their life tend to do better. This is why it’s important for therapists to look at the whole person and the environment they exist in when planning treatment.

I was trying to think about a time when you wouldn’t want someone to get immediate treatment for an eating disorder. It would be dependent on an individual’s particular circumstances, but some possibilities that came to mind would be if the person has some other more dangerous issue that needs to be immediately addressed and can’t be treated at the same time as the eating disorder (e.g., imminent threat of harm to others, imminent suicidal risk, drug dependence with a high level of associated, immediate dangerousness).

3) @mwebb22752561 asked: 

Re: goal setting in therapy, should target weights be set by the client, collaboratively or prescriptively on the basis of a healthy weight determined by BMI or similar measurement tool?

Whenever possible, all therapy goals should be set collaboratively with clients. This guideline is the same for people with eating disorders, except that sometimes eating disorders (especially anorexia nervosa) can interfere with the person’s ability to set a healthy target weight. The eating disorder can influence the person such that setting a healthy body weight does not feel like a goal they can agree to. When I have treated people with eating disorders, I find the most effective approach is to work with a team that includes a physician that can speak to medical factors relevant for setting the target weight (e.g., lab results, weight/growth history, menstrual status, etc.). I have seen therapists set a prescriptive target weight (in collaboration with a physician) only when the individual with the eating disorder cannot (due to interference from their eating disorder) and is in a state of medical risk.

4) @lluaces said (and @BianchiKristin said she was curious about this too):

Disorders that don’t have to do with body image like ARFID a lot of people get curious about

Anorexia nervosa and bulimia nervosa are eating disorders with DSM-5 diagnostic criteria that specifically mention an excessive concern with body shape and weight that leads to distress and unhealthy behaviors. Binge eating disorder has also been found to be linked to body image issues. In contrast, avoidant/restrictive food intake disorder (ARFID) is characterized by a disturbance in eating, but specifically excludes people whose behavior is driven by a fear of weight gain or disturbance in body image. ARFID often presents as an avoidance, pickiness (e.g., with textures, types) or low/lack of interest in food associated with at least 1 of the following: 1) significant weight loss or failure to achieve expected weight gain in children, 2) nutritional deficiency, 3) dependence on nutritional supplements, 4) interference with social functioning. For a fuller description, please visit this link. ARFID is typically treated with cognitive-behavioral therapy, and I have included links on the model and its treatment below. The purpose of the therapy is to identify and modify the factors that maintain ARFID (e.g., sensory sensitivity, fear of aversive consequences, lack of interest in eating or food).

Avoidant/Restrictive Food Intake Disorder: A Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment

Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults by Jennifer Thomas and Kamryn Eddy

Should Non-Fat-Phobic Anorexia Nervosa Be Included in DSM-V?

5) @ThisIsSpecious asked:

Is it possible to have an eating disorder and not realise it?

Yes, these are the most common scenarios I have observed:

  • people with anorexia nervosa who are severely underweight or who have medical problems, but believe that they are overweight or in good health (this is a particularly painful part of the eating disorder that can make it hard to seek help)
  • people who have binge eating disorder, but think that their problem is “weak willpower” or “no self-control” because they don’t know about the disorder or know about it, but blame themselves anyway
  • people who are dieting, exercising, or fasting to an extent that it is causing significant problems for their health, distress, and/or functioning but who don’t attribute it to an eating disorder (e.g., they think they have an unrelated medical issue causing it)

In these types of scenarios, it often takes a friend, family member, or physician stepping in to suggest that they seek help.

Here are some useful tips for talking to a loved one about an eating disorder, and here is a post about how psychologists determine if someone has an eating disorder.

If you were to go and advise anyone who might have an ED how would you advise them to seek help? Particularly if there is a stigma around that person’s preconceived conditions? (i.e. being overweight etc)

I am most familiar with the U.S. health care system, but I recommend starting with telling your general practitioner/physician about your concerns and asking for a referral/recommendations for local eating disorders treatment. Alternatively, the Academy for Eating Disorders is an excellent organization that has an expert directory search to help you identify an eating disorder practitioner near you (the directory is international). Unfortunately,  people, including health professionals, may have weight stigma or bias that interferes with their ability to recognize an eating disorder in an person who is overweight. If a physician or other health professional is dismissive of eating disorder concerns, please seek care from someone who specializes in eating disorders. Professionals with expertise in eating disorders should be aware that people of all different body sizes are affected by eating disorders.

6) @ahlandreth asked:

Would love to know more about body dysmorphia and the way trauma (injury, illness etc) can play into that

Body dysmorphia is currently classified with obsessive-compulsive and related disorders rather than with eating disorders, but there are definitely overlapping features. Body dysmorphic disorder is diagnosed when someone is overfocused on an aspect of their physical appearance (thinking about it at least 1 hour per day), such that it is causing them distress and impacting their functioning (e.g., in their relationships, in their ability to work). While eating disorders are often related to disturbances in perceptions of body shape and weight, body dysmorphia tends to focus on particular body parts or features (e.g., perceived inadequate muscularity, skin, nose). People with body dysmorphia range from relatively high levels of insight about their misperceptions of their body to relatively low levels and engage in repetitive behaviors related to their concerns (e.g., reassurance seeking, mirror checking, skin picking, extensive grooming routines). For more detailed information, this is an excellent resource.

I did not find much research on the role of trauma, illness, and injury in body dysmorphia, and I have not treated many people who have it. However, people with body dysmorphic disorder do report higher rates of abuse and neglect compared to people without the disorder (e.g., 1, 2, 3). Research suggests that body dysmorphic disorder is caused by both genetic and environmental factors. If someone has a genetic risk for body dysmorphia and then experiences a significant stressor (e.g., illness, injury, abuse), it may increase their risk for developing body dysmorphic disorder through a number of pathways. Their self-esteem, emotional coping, anxiety, negative mood, attitudes toward their body, social support, and other life factors may worsen under conditions of the stressor(s), leaving them more prone to developing the disorder. Importantly, there are treatments available for body dysmorphic disorder, including cognitive-behavioral therapy.

7) @Ivuoma asked:

Can you talk about racial disparities in these disorders and/or disorders that manifest mainly in certain groups?

Udo and Grilo (2018) examined prevalence rates of eating disorders in a nationally representative sample of U.S. adults (n = 36,306) and found:

*Lifetime anorexia nervosa rates were significantly higher among White participants as compared to non-Hispanic Black and Hispanic participants.

*Lifetime and 12-month rates of bulimia nervosa did not significantly differ by race/ethnicity.

*Lifetime binge eating disorder rates were significantly higher among non-Hispanic White participants than among non-Hispanic Black participants, with no significant differences between non-Hispanic White and Hispanic participants.

Due to small ns, the authors combined Asian, Native Hawaiian, Pacific Islander, and Native American participants into one group. Here is the table of lifetime rates:

lifetime prevalence

Here is the table of past 12-month prevalence rates:

12-month prevalence

For more information, I recommend:

America is Utterly Failing People of Color with Eating Disorders

National Eating Disorders Association – People of Color and Eating Disorders 

I’ve done some research examining acculturative stress, perceived discrimination, and body shape ideals and how they’re potentially related to differing prevalence rates:

Cultural Body Shape Ideals and Eating Disorder Symptoms among White, Latina, and Black College Women

An Examination of the Relationships between Acculturative Stress, Perceived Discrimination, and Eating Disorder Symptoms among Ethnic Minority College Students

We need a lot more research in this area! I’m glad to see that it is has picked up quite a bit in recent years.

8) @jonathanstea said:

Brief overview of evidence-based treatments might be helpful. In my clinical experience, our teams find these disorders particularly difficult to treat, especially when concurrent with addictive disorders—and especially when addictive sxs in remission/eating sxs increase.

I completely agree that eating disorders are challenging to treat and that we need to keep improving on existing treatments. I also agree that one of the difficult aspects of the treatment is that many people with eating disorders suffer from multiple mental health issues. I have observed what you are describing too – that some patients were using substances to cope with emotional pain and other stressors. When that strategy is no longer being used (i.e., when they are in remission), you can see an increase in eating disorder symptoms. I find it beneficial to treat the complexities of eating disorders within a team context to best conceptualize and individualize each person’s care with multidisciplinary expertise (e.g., physicians, psychiatrists, dietitians).

The major evidence-based treatments that we currently have include:

  • Family-based treatment (AKA Maudsley) for children and adolescents with anorexia nervosa or bulimia nervosa. This treatment involves empowering caregivers (typically a parent) to warmly and firmly help their child to eat in a healthy, non-disordered way (e.g., meet their nutritional needs, prevent purging and excessive exercise). This is a great article written by a parent and child who received this treatment. More information on the scientific backing for it is available here and here.
  • Cognitive-Behavioral Therapy is used in a transdiagnostic protocol for different eating disorder presentations. It targets maintenance factors for the disorder (e.g., negative mood intolerance, all-or-nothing thinking, body dissatisfaction, perfectionism, fasting/restriction). More information on the empirical evidence is available here and here.
  • Interpersonal Psychotherapy for eating disorders helps the patient recover by identifying and targeting a particular interpersonal domain that is maintaining the disorder: 1) lack of intimacy and interpersonal deficits, 2) interpersonal role disputes, 3) role transitions, 4) complicated grief, or 5) life goals. There is a good review of available evidence here.
  • Integrative Cognitive-Affective Therapy is a relatively newer therapy that appears to be as effective as cognitive-behavioral therapy for bulimia nervosa. It has also been tested in binge eating disorder, but those results are not yet published. It focuses on helping the patient to regulate their eating patterns and then identify an area for skill-building (e.g., assertiveness, healthy ways of relating to one’s self, coping with emotions).
  • Dialectical Behavior Therapy has been used to treat both bulimia nervosa and binge eating disorder. It focuses on increasing skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. More research is needed on the effectiveness of the approach, but here is a useful article on its application.

9) @DrSamanthaMyhre asked:

A general discussion on the overlap of BDD and EDs and how to differentiate (I typically revert to clinical interview + BDD Y-BOCS and EDE-Q to help, but definitely interested in learning other strategies).

Using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Eating Disorder Examination-Questionnaire (EDE-Q) is an excellent way to approach this differential diagnosis. The only other approach I’ve used is the Structured Clinical Interview for DSM-5 (SCID). I think that the distinction is tricky, but body dysmorphic disorder (BDD) often focuses on a particular feature (e.g., skin, nose, ears), while eating disorders tend to focus on body shape and weight. That being said, you can definitely see overlap in checking behaviors, self-esteem issues, and appearance anxiety — especially with muscle dysmorphia (MD). The International OCD Foundation website makes this distinction, “While individuals with MD often follow very precise, time-consuming, and painstakingly picky diets, their eating habits are driven by an all-consuming concern with improving the mass and leanness of their muscles, as opposed to issues relating to their weight or body fat percentage, as seen in individuals with eating disorders.”

I liked the way that the website discussed differential diagnosis:

distinction

I also like their short version as a rule of thumb:

distinction

I could not find a large study with very clear statistics on rates of comorbidity between BDD and eating disorders, but one study found that approximately 1/3 of people with a BDD diagnosis had a lifetime eating disorder diagnosis and another study  found that ~1/2 of people seeking treatment for an eating disorder screened positive for BDD. Therefore, it is certainly appropriate to diagnose both if you see symptoms that are not fully captured by one diagnosis. Our diagnostic system is far from perfect, and I think it makes sense to choose the diagnosis(es) that seems like the best description and guide for treatment for the patient. If you are gathering data from the measures that you mentioned, your clinical judgment and decision-making will be very well-informed.

For more information:

Clinical Assessment of BDD

Male Eating Disorders (discusses muscle dysmorphia)

Thank you so much to everyone who sent questions! I hope that I provided the information you were looking for – but please reach out if you’d like to know more.

For more information, check out my Short Guide to Everything You Need to Know About Eating Disorders.

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We Must Treat Suicide Like a Public Health Crisis

Suicide is a major public health problem in the United States. In 2018, we lost nearly 50,000 people to suicide. That means that 1 person, in a deeply pained state, ended their life every 11 minutes. Left behind are heartbroken family members, friends, and communities who desperately wish they could have helped. Suicide rates are the highest they have been in 50 years, which stands in stark contrast to the declining rates of other types of death (e.g., stroke, heart disease).

Popular press articles have speculated about explanations for climbing rates, including smartphone use, scarce research funding, a weakened social safety net, and income inequality. Many suicidologists agree that we do not yet really know why this is happening. One public response has been to launch campaigns against stigma that encourage help-seeking. These efforts involve people, including celebrities like Lady Gaga, Logic, and Demi Lovato, openly sharing their struggles with suicidality. Another response has been to increase research devoted to understanding suicidal behavior and its prevention. Despite significant funding constraints, the past several years have resulted in a greater scientific understanding of suicidal behavior, how to treat it in a therapeutic context, and how to reduce risk in moments of crisis. If stigma has decreased and scientific knowledge has increased, why are suicide prevention efforts not stopping more deaths?

Many current initiatives advocate for intervening after a person has become suicidal, including improving access to quality mental health care and suicide hotlines. These downstream components are absolutely necessary, but insufficient on their own, for reversing current trends. Suicide prevention must include directing additional, comprehensive resources toward the root causes that put people on a trajectory toward suicide in the first place. As Archbishop Desmond Tutu said, “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.”

A society that is serious about stopping suicide must expand beyond a model where an individual is identified as mentally ill and then referred for services that they may or may not be able to access. Even if all financial-, stigma-, and discrimination-related obstacles were removed to accessing quality mental health care (as they should be), and all existing therapists conducted scientifically-guided practice (as they should do), the field could not adequately meet all of the mental health needs. There simply are not enough therapists, hospital beds, and crisis line staff in many pockets of the country to provide services to all who suffer at the time they need it. And with suicide prevention, time is of the essence.

A public health approach means acknowledging that personal and population health are inextricably linked and that individual-level suicidality occurs within the context of societal structures. It means pushing for health equity, maximizing population-level well-being, and preventing many more people from reaching the point where suicide is viewed as the only escape from their pain. To illustrate the importance of this approach, consider the lead poisoning crisis in Flint, Michigan. Childhood lead exposure is linked to several adverse adulthood outcomes, including worsened mental health. It is absolutely necessary that Flint residents receive safe drinking water immediately, along with services to help with the damage that’s been done. However, effective prevention initiatives must also identify what allowed the lead poisoning to occur and continue in the first place (e.g., racism, irresponsible politicians) and create safeguards (e.g., policy, structural changes) to stop them from happening again.

What do these types of suicide prevention initiatives look like? They would financially empower communities to nourish mental health from the beginning stages of life (e.g., paid parental leave, affordable housing, quality education and health care, fostering community connections). These policies would also allocate resources to people and organizations with the multidisciplinary expertise and experience needed to design, implement, and evaluate community-level policy changes that directly target factors that contribute to suicidality: isolation, illness, unemployment, incarceration, adverse childhood events, and homelessness.

With Flint, the need for a holistic, preventative approach is obvious. A system that stops lead from getting into water is the most powerful way to reduce a repeat of human suffering – more so than providing services after the damage has been done (though this is completely necessary as well). The same holistic approach must be applied to suicide prevention: help those currently struggling and devote resources to upstream prevention. If we want to reverse the trend of increasing rates, save lives, and mitigate suffering, we must treat suicide like a public health crisis.

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Acknowledgment

Many, many thanks to my sister, Linda Gordon, for sharing her expertise in public health and anthropology with me. Our discussions about these topics inspired this post.

Suicide Prevention Information & Resources

More Information about a Public Health Approach to Suicide Prevention

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.

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.

3000x3000_JediCounsel

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.

Fact-Checking 5 Suicide-Related Statements from a Viral Ben Shapiro Video

In a YouTube video titled, “Ben Shapiro DESTROYS Transgenderism and Pro-Abortion Arguments,” Shapiro made several claims about suicide. His video currently has 3,126,889 views, which is probably 3,126,885 more views than this blog post will get. Because I feel strongly about making accurate mental health information available to the public, I decided to put a good faith effort into fact-checking the video despite my limited reach. I focused on the suicide-related claims in the video, because I am cautious about commenting on topics outside of my areas of expertise. His statements appear below in bold and my evaluations of their veracity, using empirical data, are beneath them.

1. “The idea behind the transgender movement, as a civil rights movement, is the idea that all of their problems would go away if I would pretend that they were the sex to which they claim membership. That’s nonsense. The transgender suicide rate is 40%. It is 40%.”

False. The American Foundation for Suicide Prevention-Williams Institute study that he appeared to be referencing found that 41% of a sample of transgender and gender-nonconforming (TGNC) adults reported having a lifetime suicide attempt, not a suicide death. The distinction between suicide attempts and suicide deaths is important for reasons directly noted in page 4 of the report:

deaths

It’s possible Shapiro misspoke here and genuinely could not recall the information accurately, but I have not seen a correction released from The Daily Wire despite the highly-viewed video being out for over a year. If you see that a correction has been made, please let me know, and I will update this post.

2. “According to the Anderson School of UCLA, it makes no difference – there’s a study that came out last year – it makes no difference, virtually no difference statistically speaking, as to whether people recognize you as a transgender person or not, which suggests there’s a very high comorbidity between transgenderism  — whatever that mental state may be — and suicidality that has nothing to do with how society treats you.”

False. As mentioned above, I believe that Shapiro meant the Williams Institute of UCLA study instead of the “Anderson School of UCLA,” and that was simply a mistake. But Shapiro gets two things wrong here. First, I am not certain, but based on the context from the full video, I think he misconstrued or misused how “recognition” was defined in the study. The study measured whether people tend to recognize (in the sense that they can tell) that a person is TGNC rather than recognition in the sense I think Shapiro meant (accepting a transgender person’s gender identity as valid — e.g., personally and/or legally). Secondly, there was a statistically significant difference found in the study’s recognition analysis, as seen in pages 8 and 9 of the report:

recognizetext

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Regarding the next part of his claim, how society treats you does appear to be correlated with suicidal ideation and suicide attempts among TGNC individuals, including in the study he referenced (from the Executive Summary, more details on pp. 11-13):

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In a separate study, TGNC youth reported whether or not people called them by their preferred name in 4 domains (home, school, work, friends). They found that chosen name use in more contexts (which the researchers used as a proxy of gender affirmation — i.e., recognizing the validity of their gender identity) was correlated with lower depression symptom levels, less suicidal ideation, and less suicidal behavior. This study was published after his video was made, but I am adding it here for informational purposes.

3. “The idea that the normal suicide rate across the United States is 4% — the suicide rate in the transgender community is 40% — the idea that 36% more transgender people are committing suicide because people are mean to them is ridiculous. It’s not true, and it’s not backed by any science that anyone can cite. It is pure conjecture. In fact, it’s not even true that bullying causes suicide…according to a lot of studies.”

False/Oversimplified. His larger point of comparing TGNC suicide attempt rates to general population rates is informative for characterizing disparities, but the 4% statistic reflects the lifetime suicide attempt rate featured in the report rather than the suicide death rate. Regardless, I don’t think that people typically claim that the entire explanation for the TGNC/general population suicide attempt rate disparity is due to meanness/bullying. Rather, the argument is that certain stressful factors (including some typically considered mean/bullying) may contribute to a higher risk for suicide attempts among transgender people. For example, from page 13 of the report:

stressors.png

Suicidologists do not talk about suicide as being caused by one factor, because there are a multitude of interacting factors at work. That is why I consider the bullying claim to be oversimplified. Moreover, there is scientific evidence that being bullied is associated with higher levels of suicidal ideation and suicide attempts (e.g., 1, 2,3) and that bias-based harassment (e.g., due to sexual orientation or race) is associated with particularly negative effects.

4. “For example, in the Black community where the idea is supposedly that America’s a racist society….Blacks are bullied a lot. Okay, in the Black community, there’s significantly lower suicide rates than in the White community.”

Half True. It is true that, in the United States, Black people generally have lower suicide rates than White people (over most age ranges, with the exception of the higher suicide rates found among Black children than White children) as you can see from this table of CDC data posted on the American Association of Suicidology website (where rate is defined as number of suicides by group/by the population of the group X 100,000):

Untitled

But this does not, as Shapiro suggested, prove that bullying is unrelated to suicide rates. As mentioned above, suicide is an outcome influenced by the interplay of risk and resilience factors. If, hypothetically, one group was bullied in equal amounts as another group, and there were disparate suicide rates, that does not necessarily mean that the group with the higher rate has a particular mental state with comorbidities (as Shapiro characterized being transgender) that accounts for all of the difference. It could be due to a number of possible factors (e.g., being a member of a group that, on average, has less social support to buffer against risk factors like bullying).

Further, racism is evident in various domains (e.g., discrimination in housing, education, healthcare, voting, and the criminal justice system), but bullying may not be one of them. At least one study using a nationally representative sample found that Black youth (19%) reported being bullied at comparable rates to White youth (21%).

5. “In fact, in third world countries, the suicide rate is significantly lower than in first world countries. Suicide actually seems to be a privilege of the upper classes if you actually look at it from a financial perspective. So, the idea that suicidality is directly a result of people like me saying, ‘No, men are not women and women are not men.’ It’s not true.”

Mostly false. I’m not sure that I fully understand the thread through this argument. My best guess, based on the full video context, is that Shapiro proposed that suicide occurs more among people with societal privilege and therefore high suicide attempt rates among transgender people would not be improved if they had more societal privilege? Or that denying the validity of transgender people’s gender identity and bullying do not increase risk for suicide, but having a lot of money does?

There are two claims to fact-check here. First, I’ll focus on the statement about suicide rates in “third world” (developing) vs. “first world” (developed) countries. To evaluate this, I examined the World Health Organization‘s 2016 suicide data by country (units are # of suicide deaths/100,000 people) paired with the World Bank’s 2017 country classification data (high income, upper middle income, lower middle income, low income). There was a lot of variability within the categories (especially in the high income group). For example, the high income group (n = 50) ranged from 0.5/100,000 (Antigua and Barbuda) to 31.90/100,000 (Lithuania). Meanwhile, the low income group (n = 31) ranged from 3.7/100,000 (Malawi) to 11.7/100,000 (Haiti). I conducted an ANOVA on the 174 countries I had data for and found statistically significant differences in the direction that Shapiro asserted. Stats people may have noticed that the assumption of homogeneity of variance was violated and that the groups are unequal sizes. Parallel analyses using a robust (Welch’s) ANOVA and nonparametric (Kruskal-Wallis) testing suggested comparable results.

Chart 1.png

Because Shapiro mostly meant suicide attempts when talking about suicide deaths, I’ll also include results from a study which found, “twelve-month prevalence estimates of suicide ideation, plans, and attempts were 2.0%, 0.6% and 0.3% respectively for developed countries and 2.1%, 0.7% and 0.4% for developing countries.” There were no meaningful differences for suicide attempt rates related to developed/developing status in that study, and contrary to Shapiro’s second claim, they found that lower income was associated with higher levels of suicidal ideation, plans, and attempts in both developing and developed countries. Similarly, a meta-analysis revealed that low (not high) income level was associated with increased risk for death by suicide:

risk in females

suicidemales

In summary, at a broad level (developing vs. developed countries), Shapiro accurately described the pattern of suicide rates. However, when examining the variables with more precision (e.g., at the individual financial status and suicide risk level), the data are inconsistent with his claim that suicide is a “privilege of the upper class.” It is possible that specific societal structures and cultural elements better account for the observed disparities in national suicide rates.

In conclusion, Ben Shapiro argued that he and others should not be pressured into personally or legally recognizing transgender people’s gender identity as valid rather than their assigned sex at birth. One way that he tried to justify those feelings was to make several statements purportedly proving that societal treatment of transgender people has no impact on their suicide risk. Shapiro has every right to have and express his feelings on this issue. However, his feelings don’t change the fact that societal treatment is, according to a lot of studies, related to suicide risk among transgender people.

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Note 1: The widely-watched Shapiro video is from February 19, 2017, and as of May 14, 2018, I see no notation that corrects any of the misinformation in the video or on his website. If you are aware of such corrections, please contact me, and I’ll update the post. 

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Note 2: For more information and resources about suicidal behavior among TGNC people, please see my post about gender dysphoria and suicidality in Laura Jane Grace’s memoir and the links below:

For Accurate Information on this Topic: American Psychological Association

Learn More about the Lived Experiences of TGNC People in Their Own Words: Aydian DowlingChaz Bono, ContraPoints, Janet MockJazz Jennings, Laverne CoxLeelah AlcornLive Through This ProjectTrans documentaryTrue Trans documentary series with Laura Jane Grace

Suicide Prevention Resources: American Association of SuicidologyAmerican Foundation for Suicide PreventionDarcy Jeda Corbitt FoundationNational Suicide Prevention Lifeline, Trans Lifeline, The Trevor Project

Information for Mental Health Professionals about Affirming Psychological Practice With TGNC People: APA GuidelinesA Model for Children & Adolescents

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Thank you to Linda & Keith for helping me figure out how to best fact-check #5.