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

/ kgordonlab / 4 Comments

nedawareness_week_2019-shareables1

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)

How Psychologists Capture the Complexities of Mental Illness

/ kgordonlab / 6 Comments

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

1) Biopsychosocial Model

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

biopsychosoc

2) Diathesis-Stress Model

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

DSM

3) Multifinality and Equifinality

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

EM

4) Distal vs. Proximal Factors

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

distal proximal

5) Nomothetic vs. Idiographic

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

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

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

Clinical Versus Actuarial Judgment

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

What Can the Clinician Do Well?

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

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Suicide is Not Reducible to Simple Explanations

/ kgordonlab / 1 Comment

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

/ kgordonlab / 2 Comments

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:

grassley

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

COI

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

4. Labeling someone with a mental disorder is stigmatizing.

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

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

5. Diagnostic categories do not accurately reflect nature.

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

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

Benefits

1. Agreed upon definitions facilitate clinically-relevant research.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Suicidal Behavior on Axis VI – Crisis

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

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

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

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Suicide Prevention Information & Resources

/ kgordonlab / 6 Comments

If you want to learn and do more to prevent suicide, I want to help you out by linking to some resources. I hope you find them useful.

Double-Rainbow.jpg

If you need help:

National Suicide Prevention Lifeline

Trans Lifeline

The Trevor Project (for LGTBQ+ youth)

Veterans Crisis Line

Crisis Text Line

Find a Therapist

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

Research-Supported Treatments for Adults

Research-Supported Treatments for Children

How to help others:

Warning Signs

How to Help Someone Who is Suicidal

Take a Mental Health First Aid Training Course

Get involved:

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

Participate in an Out of Darkness Community Walk

For information:

When It Is Darkest: Why People Die By Suicide And What We Can Do To Prevent It

Suicide in Schools: A Practioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention

The Suicidal Thoughts Workbook

Live Through This Photo Project

Rudy Caseres, Mental Health Advocate

Robert Vore, Mental Health Advocate

It Gets Better Project

Why People Die by Suicide by Thomas Joiner

Cracked Not Broken by Kevin Hines

Speaking of Suicide by Stacey Freedenthal

Brother Ali’s Song about Losing His Dad to Suicide

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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

/ kgordonlab / 10 Comments

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

rtable

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:

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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):

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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.

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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:

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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 Dowling, Chaz Bono, ContraPoints, Janet Mock, Jazz Jennings, Laverne Cox, Leelah Alcorn, Live Through This Project, Trans documentary, True Trans documentary series with Laura Jane Grace

Suicide Prevention Resources: American Association of Suicidology, American Foundation for Suicide Prevention, Darcy Jeda Corbitt Foundation, National Suicide Prevention Lifeline, Trans Lifeline, The Trevor Project

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

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

How Can Professors Help Students with Mental Health Concerns?

/ kgordonlab / 1 Comment

This post was co-written with clinical psychology graduate student and Jedi Counsel podcast co-host, Brandon Saxton.

Disclaimer: Policies, procedures, and resources vary by university, so it’s important to check with your own university and to defer to those over our recommendations.mental-2470926_960_720

In the early 1900s, faculty and staff at Princeton University noticed that several students were dropping out of school due to mental health problems. They sought to prevent this by creating the first campus mental health program in 1910. Since then, it has become standard practice to offer counseling along with physical health services on college campuses. For a fascinating overview of this history, we recommend reading this Kraft (2011) article. Here’s a sample excerpt:

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Professors often serve as an initial contact for students with mental health concerns. Some students are unaware of the available resources and reach out to professors to point them in the right direction, while others feel more comfortable checking in with a professor before seeking help from someone they don’t know.

We’ll start with some general guidelines for assisting students when they approach you for help:

  1. Listen to and assess the nature of the problem in a nonjudgmental fashion. Asking about mental health is typically beneficial for people experiencing problems and does not generally have a detrimental effect on people who aren’t experiencing them (e.g., 1, 2, 3, 4, 5, 6, 7).
  2. Respond with compassion and acknowledge their concerns. This can provide a sense of hope and validation.
  3. Refer them to appropriate services for their needs (more on this below). When in doubt, choose the services that seem most fitting. If it turns out that the student doesn’t need services or requires a different resource, the specialists at the initial referral source will know how to best proceed.

To expand on step #3, we have listed some of the most common scenarios below:

Worry about mental health symptoms: We usually start with recommending the on-campus counseling services for students. Depending on a variety of factors (e.g., the severity of the problem, their insurance coverage), they may also be interested in off-campus recommendations. We typically give them the link for the Association for Behavioral and Cognitive Therapies website to find therapists who use scientifically-informed practices. If you or the student are unsure about whether the student’s issues warrant intervention, you can assure them that the first step in mental health care is to undergo an evaluation to answer that question and then formulate a plan based on the findings. If they are reluctant to go to the counseling center, we will sometimes offer to walk over there with them or tell them that we understand and that those services will be available when they are ready. If appropriate, we also provide students with information for the National Suicide Prevention Lifeline.

Displaying unusual/worrisome behavior: If a student is exhibiting odd or potentially harmful behavior (e.g., their assignments have violent or suicidal content, they are showing up to class intoxicated, they seem disoriented), then you can typically contact a Behavioral Intervention Team on your campus for guidance. Behavioral Intervention Teams are composed of individuals who represent different components of the campus community (e.g., residence life, student affairs, faculty, law enforcement, counseling center, etc.) and provide consultation, advice, and follow-up with students who need it.

Class accommodations request: Sometimes, students will ask for accommodations without the required formal paperwork. In these cases, it’s important to refer the student to the campus counseling center or the disabilities office, so that they can go through a formal assessment process rather than leaving it up to your own discretion. If students tell us about a life circumstance that affected their ability to complete an assignment, and it’s a one- or two-time incident, we’ll typically allow them to make up the work. However, when the request is more long-term in nature or requiring special accommodations that may be unfair to other students, it’s important to defer to the experts in the disabilities office to make the decisions.

Harassment/discrimination: If a student tells you that they have experienced harassment or discrimination, you should take time to listen attentively, sympathize, and then refer them to the office that handles Title IX issues. We strongly recommend visiting your university website for that office, so that you are familiar with the most up-to-date mandated reporting guidelines and the processes for filing complaints. Here again, if you are unsure whether something rises to the level of harassment or discrimination, it’s important (and sometimes mandated) that you report it to the appropriate office so that they can use their specialized training to make a determination (rather than your own judgment).

In summary, we recommend expressing that you care while also recognizing your boundaries as a professor. You should not act as their therapist, but you can help by connecting them with one. Professors have the power to create an educational environment that reduces mental health stigma and increases students’ willingness to seek help when they need it. We try to communicate this to students by showing that we welcome their questions, providing them with mental health resource information in class, announcing mental health-related community events, and treating such topics with care. As a testament to the positive influence a professor can have through these strategies, look at this letter that Dr. Jeffrey Cohen received from one of his students (thanks to Rob Gordon for sharing it).

Please feel free to contact us if you have any questions, concerns, or corrections. We’ll conclude by linking to two informative articles and our podcast episode on the topic, which goes into more detail. Thank you for reading!

  1. Graduate Students Need More Mental Health Support, New Study Highlights by Elisabeth Pain
  2. The Myth of the Ever-More Fragile College Student by Jesse Singal
  3. Graduate Student Mental Health: Lessons from American Economics Departments by Paul Barreira, Matthew Basilico, and Valentin Bolotonyy

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A Note on the Tragedy at Douglas High School

/ kgordonlab / 1 Comment

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All school shootings are heartbreaking. The one at Marjory Stoneman Douglas High School hits close to home. I grew up in the town neighboring Parkland. I have seen many of my friends from high school express similar sentiments: Douglas was our “rival” high school, but we all got to know each other in middle school and were friends. We hurt for our friends. Most of us still have connections with the area. Our family and friends live there. We can vividly picture the details revealed in the news because we’ve been in those locations. Most of us remember being there without fear that a mass shooting like this could ever occur.

For parents who lost their children in the shooting, this must be an absolute gut-wrenching nightmare. I hear my parent friends saying that they worry about mass shootings when they send their kids off to school. The things that they used to tell themselves to reduce their worry (e.g., we live in a safe town, the school prepares with active shooter drills, the school has security in place, armed resource officers are on campus) start to lose their power when a mass shooting like the one at Douglas happens. The fact that school shootings are statistically rare in an individual risk sense provides little comfort to concerned parents. All children deserve to go to school in safe places, and parents shouldn’t feel like they’re putting their kids in harm’s way simply by sending them to get an education.

For the family, friends, and people directly affected by gun violence of all kinds…no words suffice. I have nothing but compassion, sympathy, and motivation to do my part to address this painful problem. The loss of a child is unfathomable, and I send nothing but love your way. I will conclude with two suggestions for coping, in case they’re helpful to anyone.

Connect

In the face of painful emotions, it can be tempting to withdraw and isolate oneself…to avoid processing or thinking about hurtful realities. While taking time to oneself and breaks from tragic news are components of healthy coping, it’s important to balance that out with taking time to connect with others about your feelings. Interpersonal connections are crucial to good mental and physical health. Communicating with others during stressful times helps to remind us that we’re not alone in our experiences, that we have people who we can depend on, and that there are many kind people out in the world. The American Psychological Association’s press release provides additional resources for coping in the face of this tragedy.

Contribute

This Twitter thread spoke to me. It says that we must act in the face of tragedy 1) to reduce the number of people who are victims in the future and 2) to show our children that we care enough to keep trying. When we take action, it can provide hope in times of despair – for ourselves and for others. Over 10,000 people have already joined a Mobilizing Marjory Stoneman Douglas Facebook group. Over 100 mental health professionals in Florida have said they’re willing to donate time to provide therapy for Douglas students and their families. There is a benefit concert being organized to help victims’ families. There is a fund to help Marjory Stoneman Douglas victims. Students and teachers who survived are courageously speaking out, organizing groups, and planning rallies and marches. People are pulling together to contribute what they can with their diverse resources and talents.

Let’s remember these students and staff and find ways to honor them. Let’s lean on each other for support in the wake of this tragedy.

What Can We Learn about Suicide from S-Town?

/ kgordonlab / 2 Comments

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It’s been over five months since S-Town, the Serial podcast series, was first released. It captivated so many listeners with its compelling story about a bright, unique, complicated man named John McLemore. Even though the major media hype about the show has kind of passed, I chose to write about S-Town in honor of World Suicide Prevention Day. My goals are to highlight some of the main risk factors featured in S-Town, to place them in the context of related empirical research, and to increase awareness about suicide prevention resources. If you want to avoid spoilers for S-Town, please stop here, go listen to it in rapid succession, and then come back in 7+ hours to read the rest.

As a bit of background information, I listened to all of S-Town in two or three days. The first time I listened to it was all about being absorbed in John’s story – experiencing all of the painful aspects, struggling with mixed feelings as complexities were revealed, and fitting puzzle pieces together. I walked away from it for a few days to process my emotions and thoughts about it all. Then, I listened to it a second time through the lens of a suicide prevention researcher and identified risk factors that I think may have contributed to John’s tragic death. My understanding of John is limited by what the folks at S-Town chose to include in their framing of his story in their seven episodes. In addition, I am attempting to extract general suicide risk factors from one person’s story (as best as I can I know it) and that necessarily involves speculation. With those limitations in mind, I have listed some of the risk factors below:

Demographic variables. John’s age (49), race (White), and sex (male) placed him in the highest risk group for suicide in 2015, the year that he died. Alabama has a suicide rate that is somewhat higher (15.1/100,000) than the national average (13.8/100,000). John also told Brian Reed that his sexual orientation was “semi-homosexual” and suggested that he was secretive about it to avoid discrimination. Research with lesbian, gay, and bisexual youth suggests that they have higher suicide attempt rates than their heterosexual peers, and that this is linked to more frequent exposure to stressful experiences (e.g., stigma, being threatened with violence, institutional discrimination). These stressors may have been particularly prevalent where John lived. As a reflection of the local attitudes, S-Town points out that the county that John lived in refused to issue same-sex marriage licenses following the Supreme Court decision to legalize same-sex marriage nationwide. Importantly, there is evidence that less discriminatory state law is associated with fewer suicide attempts.

Mood disturbance. John told Brian, “I guess if I sound like I’m disinterested today, it’s firstly because I’m tired and wore-ass out. And secondly because, you know, I just—I’m not the most cheerful person. You know, I spend most spare time now either studying energy or climate change, and it’s not looking good. So yes, sometimes it’s hard for me to get focused back on something when the whole goddamned Arctic summer sea ice is going to be gone by 2017. And we’re fixing to have heat waves in Siberia this year, and sometimes I feel like a total idiot because I’m worried about a goddamn crackhead out here in fucking Shittown, Alabama. So yeah, that’s just a personality disorder of mine. You know, sometimes when you call me, I’m kind of in an upbeat mood. And sometimes, like today, you caught me in one of these tired, somber, you know, reflective moods, where I’ve been, you know, sitting there mulling over climate change for about the past 10 damned hours.”  That quote is characteristic of many of John’s quotes with similar themes throughout the series. Relatedly, Brian makes an observation about John in the first episode, “No positive comment, no matter how innocuous, survives his virtuosic negativity.” However, John’s long-time friends later tell Brian that John used to be “idealistic” and joyously participated in community events (e.g., the Christmas parade). Per their report, he had not become consistently irritable and dysphoric until closer to his death.

While it appeared that John had long struggled with untreated mood problems (with the exception of brief treatment for depression in college), the series posited that his condition deteriorated markedly over time due to mercury exposure. Brian presents compelling evidence that John may have been experiencing “mad hatter syndrome” and it is presented as a primary factor in his suicide. John knew the dangers of mercury exposure, but chose to continue working with it without safety precautions. It is unclear if this choice was due to a devotion for utilizing what he viewed as the best approach to fix antique clocks, if it was some kind of neglectful, self-destructive behavior related to his mood problems, or both.

While mercury exposure in itself is rare in modern times, mood disturbances and mood disorders (regardless of cause) generally increase the risk for suicidal thoughts and behaviors. Therefore, it’s of the utmost importance to seek evidence-based treatments to effectively combat mental health problems, prevent suicide, and to improve quality of life.

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Loneliness. John also told Brian, “But I think the thing that’s happened is I’ve gotten myself in an almost prison of my own making, where all my friends have died off. Because I only had contact with people much older than me. Even when I was a kid in school, I didn’t want to hang around other kids. Because kids are talking about getting girls, or deer hunting, or football. Whereas I was interested in the astrolabe, sundials, projective geometry, new age music, climate change, and how to solve Rubik’s cube.” This quote and others like it (including John discussing his romantic hardships) suggest that John felt he was alone, which is a major risk factor for suicide. One of many surprising turns in S-Town occurs when Brian learned that John actually had a number of people that cared about him. He also had a solid group of friends that he spoke to on a fairly regular basis. John was arguably closest to Tyler at the end of his life and apparently begged him to not leave him alone on the night that he ended his life. This happened right after they had spent the whole day together affirming how much they meant to one another. This speaks to a key, painful point about suicide – feeling disconnected from others leads people to want to end their life EVEN if they actually are loved by many people.

Hopelessness. John blamed himself for his misery and attributed it to never leaving Woodstock, Alabama (i.e., S-Town). He expressed insight when he told Brian, “I need to get out of my depression. I need to get over this attitude problem I’ve got, that nothing can be done.” In the last decade of John’s life, he faced multiple stressors that could have contributed to his sense of hopelessness: his dad died, he had a falling out with a close friend, he was heartbroken when the man he loved stopped returning his calls, and he was caring for his aging mother. He also seemed to suffer from a broader sense of hopelessness about the injustices of the world related to climate change, the legal system, and a variety of other issues. He expressed a particular pain in feeling like he was the only one so upset about it all. The combination of pain and hopelessness are particularly linked to suicidal desire. Finding ways to build real hope (e.g., through connecting a person to a mental health professional) can be important for decreasing suicide risk.

Plans and preparations for suicide. Most of John’s friends knew that he planned on killing himself at some point. He spoke of his suicide plans matter-of-factly, kept a lengthy suicide note on his computer, left a list of people to contact after his death, and had access to lethal means for suicide. John’s resolved plans and preparation were particularly dangerous in light of his apparent fearlessness about suicide. Many more people consider suicide than ever attempt or die by suicide, in part, because of a survival instinct that protects people from acting on suicidal thoughts. Under these circumstances, one powerful suicide prevention action is to remove their access to lethal means (e.g., store their gun, pills, or other possible means safely).

Nonsuicidal self-injury.  Toward the end of S-Town, we discover that John went from despising tattoos and piercings to asking Tyler to regularly tattoo and pierce him. Eventually, John was covered in tattoos and would ask Tyler to pierce and re-pierce him and even use the tattoo needle on him without any ink. Tyler told Brian that he thought it was John’s version of cutting, with the purpose of distracting from emotional pain with physical pain. In my opinion, based on the information available, it sounded like a form of nonsuicidal self-injury. Tattoos and piercings are not typically considered nonsuicidal self-injury because they are culturally sanctioned, but the way that John experienced them was atypical and extreme. Nonsuicidal self-injury is associated with higher suicide risk, and this connection is thought to be, at least in part, due to the experience of nonsuicidal self-injury increasing an individual’s pain tolerance while reducing fear about self-inflicted harm.

In the interest of keeping this post relatively brief, I focused on what I view as some of the major risk factors for suicide present in S-Town. There is so much more to John’s story. One of the most moving and painful components of S-Town was hearing John’s loved ones struggle with his death. Many of them experienced self-blame, regret, and wondered if they could have done anything else to prevent it – all feelings that are common for people who have lost someone to suicide.

I thank you for taking the time to read this post. Below are some suicide prevention resources that I hope you find useful:

-The American Association of Suicidology website has a list of warning signs.

-The National Suicide Prevention lifeline has contact information for people in crisis.

-The American Foundation for Suicide Prevention has tips for helping someone who is at risk for suicide.

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