Category Archives: Suicide

Suicide Prevention. Let’s Talk. But Let Us Talk Truth.

By Dr David Laing Dawson MD

A Five Part  Series

1. Background (Reality)

Over the last 20 to 30 years we have all witnessed an increasing emphasis on “suicide prevention”. This has included TV spots, public health announcements, and the development of crisis lines. Most major emergency departments now have some form of mental health team available to them. Many police departments now have mental health teams, psychiatric nurses, or social workers working with them. All doctors, mental health workers, school counselors, school nurses have been encouraged to ask the question. The phrase “suicide ideation” has become part of our popular jargon.

Fair enough. Though some suicides result from competent and rational choices to end one’s suffering from incurable disease, many others are tragic, tragic both to the victim and his or her survivors. And it always seems even more tragic when the victim is young and the suicide unexpected or unfathomable.

One of the obvious results of this heightened awareness of suicide, “suicide ideation”, and the behaviours that are called “suicide attempts”, has been a dramatic increase in the numbers of people seen in emergency departments for the identified problem of “suicide ideation.”

Below are four graphs showing just how dramatic this increase has been. An increase of 11 to 14 percent per year for six years is quite astonishing. These are American figures but I am sure the trend would be the same in Canada.

From: HCUP Overview. Healthcare Cost and Utilization Project (HCUP). April 2017. Agency for Healthcare Research and Qualityfigure1sb220

Now, at first glance this would imply that the new “awareness” and alertness with regard to suicide, and especially suicide ideation, is working. It means, doesn’t it, that far more people are being identified as “at risk” and coming to, or being brought for, an emergency assessment. Which in turn would mean that the actual suicide rate should be declining.

But it isn’t.

The suicide rate in Canada for the years 1950 to 1960 averaged about 7.5 deaths per 100,000 people.

The suicide rate in Canada for the years 2000 to 2009 averaged about 12 deaths per 100,000 people.

In the United States the suicide rate increased 24% between 1999 and 2014 to 13 deaths per 100,000.

I cannot scientifically claim there is a cause-effect relationship here, only an association, but I can certainly claim that the awareness of and the alertness to “suicidal ideation” has NOT decreased the rate of actual suicide in any age group.

But I do think that by focusing on, advertising, talking relentlessly about, “suicidal ideation” we have dramatically increased the use of “suicidal thinking” and suicidal threats as interpersonal negotiating tools, while making no difference to, and certainly not preventing, actual suicides.

What we have been doing is not working. It may even be exacerbating the problem. Yet every month or two I hear more of the same being promoted. We have not reduced, we may even have increased, the incidence of the very personal and often tragic act of suicide. And we may have simply caused or grown another public health problem unnecessarily straining our resources.

(continued in parts II through V)

 

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Understanding Youth “Suicide”

By Dr David Laing Dawson

Our assumptions and the language we use, that we so quickly use, often hinder a fresh and more useful way of viewing a problem. The word “suicide” and the phrase “attempted suicide” are examples of such assumptions and language.

This word and this phrase carry assumptions of intent, a formed intention, an intention to engage in an action that will achieve a goal. With the word “suicide” we imply that the goal is death, the ending of a life.

In the newspaper, and equally in medical charts, the phrase “attempted suicide” is poorly applied to many behaviours that were not “attempted suicide”. For many “attempted suicides” by teens, and some adults, the goal is not death, but …. Well, many things: payback, “they’ll be sorry”, negotiating power and control, making a point, taking a break, sleeping for a while, avoiding, revenge, punishment, getting someone to care, stopping the emotional pain…. Even when the goal is “death”, for a teenager, this can be a very ill-formed concept of death (complete with the idea of being around later to watch other peoples’ reactions), or a very drastic solution to a relatively small and temporary problem.

When the goal is not “death” and yet we call it “attempted suicide”, our interventions will be ill formed and misguided. In fact, I will make the case that when we mistake a teenager’s “getting someone to care”, or “punishing a boyfriend” for a “suicide attempt”, we mental health professionals find ourselves ratifying self harm as a legitimate tool of social discourse and problem solving.

But what is “death” to a ten year old, to a 14 year old? What is “death” to a Catholic or a Moslem?

Some years ago the uncle of a young boy killed himself by hanging. The boy was taken to the funeral of his uncle; he was privy to the conversation and distress of his own parents. And then the boy hung himself.

The community was understandably distraught. His teachers, family, friends, and the social workers working for the school board.

I was asked why an 11 year old would commit suicide? Was it a suicide? Could they have prevented it? I gave it some thought and reassured them that it was “an accident”, a tragic accident, not suicide.

For is it possible for an 11 year old to formulate a goal of being dead? Meaning “dead, dying, and death” as adults mean these words? No. For the boy in question we can never know how much was curiosity, imitation, how much distress, how much distracted parents, what he imagined he was actually doing. I am sure, that at 11 years of age, he did not have in his mind a clear and mature sense of the finality of death.

I am writing about this because of recent news reports of deaths of children age 10 to 14 in two northern Saskatchewan Communities. The reports are labeling these deaths “suicides”. They are also saying many other youth have “attempted suicide.” The responses have apparently been to send in mental health counselors, and to fly one or two out for psychiatric assessment. And these responses go along with the assumption that these children did in fact “commit suicide” and are in fact “attempting suicide.”

Now no doubt they are engaging in behaviours that have the potential to kill them, and that did so in four cases, including the most recent 10 year old. But that is what they are actually doing, these children; they are engaging in behaviours that can result in death. They are too young to know what that actually means for themselves, and for their families.

We do need to send a team in to investigate, but without the assumption that these behaviours constitute either “suicide attempts” or “suicide”, in an adult sense. We should investigate without the assumptions carried by those words.

Exactly what behaviours are these children engaging in, where, how, and why? And then, how can it be stopped. Or what needs to be done to change these patterns of behaviour?

 

A Subjective Unscientific Analysis of Anti-Psychiatry Advocates

By Marvin Ross

Many of my Huffington Post Blogs attract some very nasty comments from the various anti-psychiatry adherents. The same applies to the blogs by my colleague Susan Inman and we get some on this blog. The Boston Globe award winning Spotlight Team featured in the film Spotlight, just did a series of articles on the sad state of mental health care in Massachusetts. Wanting to foster dialogue, they set up a Facebook Page for comments. And did they ever get comments!

I’ve been looking at more than my fair share of these comments over the years but decided to try to categorize them. So here goes.

1. I was badly treated, mistreated, misdiagnosed therefore all of psychiatry is evil. In some cases, this alleged mistreatment occurred over 50 years ago. I do believe that this happened in most cases and it should not have happened but it did. Personally, I’ve run into (or family members have) some very incompetent and inept treatment by doctors and/or hospitals. This has occurred in inpatient stays, visits to doctors or in emergency rooms. And some of these misadventures have been serious but I do not spend my time denouncing all hospitals, all doctors or all Emergency Rooms. What I have done is to complain to the appropriate authorities. And most of the time I’m successful.

As my English mom used to say, “don’t throw the baby out with the bathwater”

  2. The other very common cry is that I got help and recovered therefore everyone can recover and if they can’t, it is because the docs are bad or are trying to keep people sick to make money and peddle drugs. I’m sure there is an error term in logic where you extrapolate your particular situation to everyone. That is what these critics are doing. It is like saying I survived prostate cancer which has a 5 year survival of 98.8% so that someone with pancreatic cancer can too. Pancreatic cancer only  has a 4% 5 year survival rate. It is not the same nor is say mild anxiety comparable to treatment resistant schizophrenia. Stop mixing apples and oranges.

3. Involuntary treatment for those who are so sick that they pose a danger to themselves, others, or will deteriorate further without involuntary committal means that the state will lock up, drug and keep everyone indefinitely. None of these fears are true so learn what is entailed and get over it. And when I post a video or an article by someone like Erin Hawkes who went through about a dozen involuntary treatments till a pharmaceutical agent was found that removed her delusions, stop insulting her as some have done by calling her a victim and that she is suffering from Stockholm Syndrome.

How will you learn if you refuse to listen to other opinions?

What I suspect that these involuntary opponents do not understand is that people are not locked up without just cause or forever. There are safeguards in place to ensure regular reviews and appeals. In Ontario a few years ago, a group of so called psychiatric survivors challenged the constitutionality of community treatment orders and supplied the courts with affidavits from people who found them to be bad. This is what I wrote about that in the Huffington Post:

Justice Belobaba only had to look at the affidavit that the plaintiffs filed as part of their attack on CTOs to get an idea of how well they can work. Amy Ness had, prior to being put on a CTO, been involuntarily committed for showing violent behaviour in 2004. In 2007, while hospitalized, Ms. Ness kicked her mother in the back and hit her repeatedly. Then, in 2009, Ms. Ness grabbed a large kitchen knife and marched upstairs toward her mother after discovering a magazine about schizophrenia. In another incident, Ms. Ness kicked and punched the emergency department psychiatrist. By the time she was given a CTO in 2009, she had five hospitalizations.

Since then, while on a CTO, the judge pointed out, she takes her medication and sees her case worker on a regular basis. She has not been hospitalized, she maintains her housing and she works as a volunteer, has a job and takes courses. She does think, however, that the CTO is an attack on her personal dignity.

Herschel Hardin, a civil libertarian once wrote that:

“The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness – free them from the Bastille of their psychoses – and restore their dignity, their free will and the meaningful exercise of their liberties.”

A psychiatrist I know who is a libertarian (someone who believes that people should be allowed to do and say what they want without any interference from the government) told me that when your brain is immersed in psychoses, you are not capable of doing or saying what you want. Therefore, he was fully supportive of involuntary treatment so that people could get to the position where they had the capacity to do what they want.

4. And then we come to what Dr Joe Schwarcz on his radio show, Dr Joe, calls scientific illiteracy. He used that in his July 10 interview with my colleague, Dr Terry Polevoy, in a discussion on EM Power + and the conviction of the Stephans for failing to provide the necessities of life for their child who died of bacterial meningitis. They refused all conventional medical care, gave him vitamins, herbal products and echinacea till the poor little toddler stopped breathing.

There was a case of scientific illiteracy in that the parents are totally opposed to vaccinations and work for a  company that encourages people with mental illnesses to go off meds in favour of their proprietary vitamins. They had no idea why they were convicted, lashed out at the jury who convicted them and then, at their sentencing hearing, the wife shocked even her own lawyer when she told the court that the Crown had used a phony autopsy report as evidence.

Other examples are that anti-depressants cause violence and suicide. Violence possibly in those under 24 according to a large Swedish study but not in adults. However, the authors state that these findings need validation. There is no definitive proof of this and no evidence of increased violence in adults.

As for anti-depressants causing suicide, a warning that this might be a concern was posted on the labels. Doctors were advised to be cautious when prescribing these for depressed young people.Consequently, this resulted in an increase in suicide attempts.

“Evidence now shows that antidepressant prescription rates dropped precipitously beginning with the public health advisory in March 2004, which preceded the black box warning in October 2004. Since the initial public health advisory, antidepressant prescriptions for children and adolescents decreased, with a consequent increase (14%) in incidence of suicide in these populations.”

On my to-read list is Ordinarily Well The Case for Antidepressants by psychiatrist Peter D Kramer. Kramer is the author of Listening to Prozac and, in this new book, he continues with proof that antidepressants do work and are not simply placebos. Not only do they work, but they are life savers.

In the New York Times review by Scott Stossel, the reviewer points out that when Kramer first began visiting psychiatric wards in the 1970’s, they were filled with people suffering what was then known as “end-state depression”. These were depressed patients in what appeared to be psychotic catatonic states.

Patients like that have not been seen for decades which he attributes to the aggressive use of antidepressants.

And, lest we forget, there is also the common view that the chronicity of psychiatric disorders are caused by the drugs that doctors force on their patients. People love to quote the work of Martin Harrow in Chicago but I suspect that many have not actually read his studies. Some people, he found,  did better after going off anti-psychotics over time than those who continued with their use but that is not surprising. It has always been known that some people improve while others have chronic problems and still others are not able to be helped with anything.

What they do not realize is that in Harrow’s study, 79 per cent and 64 per cent of the patients were on medication at 10- and 15-year follow ups. And that Harrow points out that not all schizophrenia patients are alike and that one treatment fits all is “not consonant with the current data or with clinical experience.” His data suggests that there are unique differences in those who can go off medications compared to those who cannot. And he points out that it is not possible to predict who may be able to go off medication and those who need the long term treatment. Intensified research is needed.

So stop with the reference to Harrow that no one needs meds. And stop also with promoting Open Dialogue when, first, it has never been empirically validated and second, many of their patients are on medication.

5. Regrettably, many of these people lack any civility whatsoever. People are entitled to offer their comments but they should not do so anonymously. And they should show some respect for those who have different views. I’m told that some have been banned from the Spotlight Facebook page and I’ve just banned one anonymous person who posts here for his/her personal attacks. I mentioned above that Erin has been called a willing victim and one who suffers with the Stockholm syndrome for her video and her article. Refute the points she makes but leave the insults aside.

And, one post that I removed from the After Her Brain Broke page on Susan Inman in response to he video What Families Need From the Mental Health System claimed that Susan keeps her daughter locked up and ill and that she likely suffers from Munchausen by proxy.

 

On Adolescent Suicide

By Dr David Laing Dawson

Adolescent suicide is a tragic event. It can have a devastating and life long impact on others: parents, siblings, teachers, relatives, counselors, friends.

Five Woodstock, Ontario  teens have taken their own lives since January this year. A very high number for a small community.

If this were a cluster of deaths from respiratory causes we would surely investigate with a team comprised of a respirologist, an epidemiologist, and the public health officer.

Thus our first step here should logically be an investigation by an epidemiologist, a  psychiatrist, and the public health department. Let us first see if these deaths are a result of undetected, untreated mental illness, if the teens know one another in real life or through social media, if they are all browsing the same toxic websites, or if each has been the target of bullying or something worse, or a combination of these. Let us try to understand before rushing into awareness programs, school assemblies, more crisis lines.

There are several good reasons to not rush to “talking about it” as the answer. These are teenagers, not adults. We know from anti-smoking programs, when we gathered our high school students into the auditorium to talk to them about the horrors of smoking and showed them videos of cancer-ridden lungs and COPD sufferers gasping for breath, the number of teens taking illicit puffs at the local smoking pit increased. Increased. Not decreased, increased.

We are also living with the paradox of contemporary times when kids are inundated with suicide awareness programs, when every school counselor and nurse asks every troubled kid the question, when each community has an advertised crisis line, when the question “do you ever think of harming yourself?” is asked on countless questionnaires and surveys, when our teens are communicating with each other around the clock, when information on any and every subject is as available as the nearest smartphone, and when we are in the midst of public discourse about assisted suicide. It is in these times, not in the 50’s, 60’s, or 70’s ( when the word suicide would only be said in the same whisper as syphilis), that clusters of teens are committing suicide.

Or so it seems.

But what I am trying to say is that we should investigate these phenomena before we rush to “solutions”, especially with teenagers. They are not adults. They often do things just because they have recently learned those things are possible to do. They are often more intrigued when adults bend over backwards to warn them of danger.

The adolescent brain has lost some of the intuitive avoidance and fear of the child’s brain. It is developing some reasoning and analytic processes to replace these. But it does not have the breadth and depth of experience of the adult brain, nor the ability to consider the distant future and the effect on others. The adolescent brain tends to live entirely within its present context.

“Would you swim with sharks?” When a child is asked this question he or she will answer with an emphatic NO. An adult will also offer a very quick negative, though with some adults and a few adolescents the questioner may need to add that ‘sharks’ is meant in a literal sense. But the teenager. Ah, the teenager. He or she asked that same question will ponder it. You can see and sometimes hear the analytic reasoning kicking in: “Well, humans are not the sharks’ natural prey, so….and though I am not a good swimmer….and depending on…”

So far, with teens, my own informal survey has resulted in answers of “yes or maybe or I’d consider it” 100 percent of the time.

I am not saying we should downplay suicide and it’s tragic consequences. I am saying that we should treat an increase, a cluster of suicides like any other serious outbreak of illness. We should study it without pre-judging. And when teens are involved we should take into account their contrary minds.

The Woodstock cluster may be a problem of inadequate resources; there may be a contagion factor at work;  there may be a local stigma about seeking help; there may be some cyber bullying occurring; the means to kill oneself may be too readily available; there may be untreated mental illness involved; they may all have been fans of the same toxic Web site; they may know one another, or not; they may be using or misusing the same drugs; they may be all attending the same counselor; or this cluster might be simply a statistical anomaly…

We should help family and friends cope with these tragedies, but we should investigate before we plan a preventive intervention.

 

Planning Mental Health Services Rationally

By Dr David Laing Dawson

Over the years I have been several times involved in planning mental health services, sometimes in a general and wide sense, sometimes specific programs. In each case I usually ask, “How much money do we have to spend? What is the budget?” And usually there is no answer to this question. The game is not played that way. First the proposal to compete with other proposals and then, within a highly politicized process, the allocation of funds.

This means of course, that the words are being sold, promoted. Not the actual evidence based possibility of major effectiveness with consideration of budget. But rather the most pleasing, hopeful, expansive words of promise (with fewest political complications) are being sold and often funded. This may be a good way to fund an arts program, but for health, we really should turn to science.

If we say, instead, “We have 10 million dollars to spend to prevent suicide in a particular state or province; how should we spend it for best results?” then our thinking might be clarified for us. What do we actually know about suicide and suicide prevention? What do studies from various parts of the world show? Where are the high risk populations? Which ones can we actually target?

Then we might look at the large range of social and economic factors that comprise risk factors that indirectly, or at a distance, contribute to a high suicide rate, and pass on these. They are usually broad conditions that can be gradually improved, and should be gradually improved through political action and do require political will and good economic times. (housing, minimum wage, employment, social programs, education)

Then we could look at specific high-risk populations and figure how we could spend that 10 million effectively to measurably reduce the suicide rate.

Then we might notice that a very high risk group for completed suicide comprises people too-late identified as suffering from severe mental illness, recently discharged psychiatric patients, and especially those suffering from a severe and chronic mental illness who drop out of treatment and/or stop their medications.

And then we can ask if there is a way of spending that 10 million dollars to improve and repair the services offered this group of people. They are identifiable. They are at high risk. And it is possible with limited money to enhance the programs that serve them. Especially during visits to emergency, drop-in clinics, and family doctors, and then in the years following diagnosis and/or discharge from hospital.

Of course we need to improve the resilience and mental health of our children, if we can. But not as a means to reduce the suicide rate, but rather for overall success of our children as adults. And this means, not a suicide prevention program, but rather more money and support for the educational system and improvements in this system utilizing all we know about learning, nutrition, physical health, exercise, social growth, stress management, disability accommodation, ensuring each child has some success and a chance to belong.

When it comes to suicide then, we don’t need a “national strategy”. We need to continue to improve all our services and our lives, with improvements in our educational systems, income support and equality, a healthy economy and good jobs, improved general health care systems and easy access to same, addictions programs, income and social support for the elderly, affordable housing…… And we need to turn our attention to those people we know to be at especially high risk for suicide (sufferers of severe mental illness, recently discharged patients) and improve our services and access to services for these people.

 

 

 

 

Suicide Prevention: In The Real World

By Dr David Laing Dawson

Marvin and I have written blogs about the failure of current and proposed “suicide prevention programs”, the crisis line, the gatekeeper programs, the public awareness programs. He points out these programs make us feel like we are doing something, at least, but are a waste of money.

I would go further. I think they actually increase the number of people who use “suicide threats” as negotiating tools, and then through the intervention of family, counselors, and teachers find themselves in the Emergency Department of Hospitals being assessed by nurses, emergency doctors, social workers, and often the psychiatrist-on-call over a three hour to three-day period. This uses up our resources and poses the risk of inuring these front-line professionals to true suicide risk.

The number of people who actually kill themselves each year is remarkably stable. We know it goes down in wartime, increases in peacetime, and poor economic times. We know the demographics of suicide. We know the high-risk groups.

We know that a few of these suicides constitute rational, understandable, reasonable, sane and logical decisions to end one’s suffering in the face of incurable disease and disability. Hence the current move toward allowing some physician assisted suicides.

We also know that the suicide of someone in other circumstances (temporary distress, intoxication, treatable illness) can be devastating to family and friends. It may in fact be an event from which a sibling, a parent, a child never fully recovers.

We know that many social factors put people at higher risk:

  • inadequate housing,
  • inadequate support systems,
  • social isolation,
  • bereavement,
  • joblessness,
  • addictions.

These factors have no simple solutions but can be gradually improved through well-funded social programs, retraining programs, affordable housing.

We also know that many suicides occur in the population suffering from severe mental illness especially when:

  1.  Discharged from hospital prematurely,
  2.  Unable to be hospitalized in a timely fashion,
  3.  Drop out of treatment or go off medication,
  4.  Their illnesses are not identified nor adequately treated.

We also know a particularly tragic circumstance is the suicide of a teenager, often responding on impulse to something they see as catastrophic, life impairing, hopeless, even while we adults know the situation is transient and will get better.

So what should we do if we want to spend our money on programs that will ultimately make a difference to that completed suicide statistic?

I don’t think I can answer my own question in a blog, but I can start a grounded discussion.

  1. Easy access to family friendly mental health resources including hospital beds.
  2. Hospitals return to somewhat longer hospitalizations with discharge waiting until true stabilization and a good discharge plan. Stop the fast turnover and length of stay pressure.
  3. Better comprehensive outpatient programs for the seriously mentally ill (including PTSD), ensuring the best possible treatment and compliance with that treatment.
  4. Training, organization of services, physical environments that allow optimal detection and response to depression, anxiety and psychosis by family physicians and emergency doctors.
  5. Continue improving our alcohol and addiction programs.
  6. If there are to be government sponsored public education programs they need to counter the very loud voices denying the existence of mental illness, and denigrating medical treatment. They need to focus on parents monitoring their adolescents’ online activity. They need to focus on parents ensuring their adolescent does not have access to lethal weapons and substances.

As for the horribly high rate of suicides on our reserves and among our first nation peoples: I do not think they suffer from a higher rate of actual mental illness than the rest of our country. But all those social factors that increase risk are ubiquitous on many reserves:

  • Alcohol and drug abuse
  • Poor housing
  • Poverty
  • Severe unemployment and underemployment
  • Poor rate of attendance and completion of school.
  • Easy access to lethal weapons and lethal drugs.
  • Social disintegration and corruption.
  • The hopelessness and anger fueled by dependency.

We should study the reserves that are successful, and then work with the leadership of the first nations people to recreate these factors within less successful reserves. Throwing money at the problem does not help. Sending in more “mental health professionals” does not help. Responding to political whims and self-serving demands does not help. We need to help the leadership of these reserves find clear-eyed solutions or improvements to each of the social problems listed above.

 

Suicide Prevention – Thoughts For Practitioners

By Dr David Laing Dawson

I have written a blog before about suicide prevention, about many of the things we do that don’t really make a difference, and about where we could and should put our resources if we want to make a difference. But this is a blog about suicide prevention on the ground.

We can talk about suicide prevention in general terms but the one and only time a health care clinician can actually prevent a suicide is when an at-risk individual is sitting in front of him or her. Your patient, new or known to you, at your office, in your clinic, at the hospital.

Some emergency and rapid response services have mandatory checklists. Most clinicians are taught to always ask the question. Many family doctors are fond of using a self-test for depression with questions like “Do you think of suicide?” with check boxes ranging from “all the time” to “never.” And many clinicians contract with patients – that is they extract a verbal agreement from their patients to not harm themselves, at least not before calling.

My suspicion is that these activities provide a false sense of security for the clinician and do not necessarily make any difference to the outcome.

  • While asking and focusing on the checklist questions and filling in the boxes, and taking notes, a clinician may well miss what I will discuss later.
  • The direct question about suicide intent and suicide ideation yields far more false-positives than useful and truthful answers, to say nothing of a few false negatives.
  • How we answer those self-test questions depends more on how we want to present ourselves to the doctor than a realistic appraisal of mental state, especially when it comes to the question of frequency and future behavior.
  • And contracting with patients poses two problems: one is that it does not work. The other is a logical fallacy: If the clinician truly thinks that the only thing preventing his or her patient from killing himself is a private promise that he won’t, a promise that he won’t let the clinician down, then that patient should be in hospital. And clinicians who contract in this way should think hard about the boundaries, the limitations, the nature and impermanence of the professional therapeutic relationship.

But day to day,  mental health clinicians are faced with the difficult decision to act or not, with the anxiety of predicting human behaviour, in this case with a lethal outcome if they get it wrong.

Let me share with you what both good and bad experiences have taught me:

Rule 1: Be present when seeing a patient, be there, in the room, focused and attentive.

This may require, in many situations, a clearing of the head before entering the room, making sure other loose ends have been taken care of and are not nagging you. It requires an ability to be present in that room no matter how slow, painful, distasteful, or even boring the encounter is, or how many distractions  insinuate themselves . And it requires you to stay away from your computer screen, not take notes, and be quiet.

Rule 2: Talk less. Empathy, the ability to experience what the other is experiencing requires silent observation, watching the eyes and mouth, the movement and posture, listening to the tone, the cadence, the intensity, the timbre, the intention of the spoken word as much as the content.

Rule 3: Without directly asking, listen for the presence or absence of future references in your patient’s words, something he or she plans for next week, next year, tomorrow.

Rule 4: And lastly, watch for, listen for, let yourself experience, the presence of two emotions, the congruence of these two emotions if they are present:

Despair/hopelessness plus  dread/anxiety.

If both of these are present this patient is high risk for suicide. And to know these are both there, residing in your patient today, you have to be there yourself, attentive, present, open, receptive.

On the Efficacy of Suicide Prevention

David Laing DawsonBy Dr David Laing Dawson

In the past decade, make that two decades, we have witnessed a plethora of mission statements, lectures, programs, public health campaigns, TV ads, crisis services, anonymous telephone answering services, crisis lines, websites, information initiatives, task forces, white papers, all aimed at suicide, reducing the suicide rate in our communities, preventing suicide.

Yet the rate of suicides in Canada, completed suicides, remains statistically unchanged.

All of the above activities make us feel we are doing something about the problem. We are trying. But that is all they do.

The problem with a public campaign to prevent suicides is that it is akin to a public campaign to prevent heart failure. Both are end stages of other processes, but in the case of heart failure we know enough to target smoking, cardiovascular disease, obesity, hypertension, diabetes, rather than “heart failure”. We do not say, “Call this number if your heart is failing.”

We know the demographics of completed suicide. We know the risk factors. We know the specific and usually treatable illnesses that all too frequently lead to suicide. So if we truly want to reduce the actual numbers of people who kill themselves (not threats, small overdoses, passing considerations), then we need to stop wasting resources on “suicide prevention programs” and put them into the detection and treatment of those specific conditions so often responsible for suicide:

  • Some suicides are bona fide existential decisions, a choice to end one’s life of suffering: terminal illness, intractable pain, total incapacity.
  • Some suicides are the result of chronic complex social factors: unemployment, divorce, poverty, loss, alcoholism, addictions, isolation, and chronic illness. We can chip away at these factors with better support and rehabilitation services, improved minimum wage, retraining – but there is nothing we can do quickly and easily.
  • Some youth suicides are the result of impulsivity, intoxication, and an available instrument of death. Impulsivity comes with youth. Parents can keep an eye on intoxication. But we can make sure no instruments of death are available. Guns. Pills. Cars. Get rid of the gun(s) in the house. Lock up the serious drugs. Driving the family car is a privilege, not a right.
  • Some teen suicides today are the result of public shaming, bullying. Watch for this. Chaperone the parties. Monitor Facebook, Snapchat. No cell phones or internet in the child’s bedroom. It bears repeating: NO cell phones or internet in the child’s bedroom.
  • And then we have the specific mental illnesses that all too frequently, especially when undetected or under-treated, lead to suicide. These are Depression, Schizophrenia, Bipolar Disease, Severe Anxiety, PTSD, and OCD. And if we really want to make a dent in that suicide statistic then our programs, our money, our resources, should be directed to detection, comprehensive treatment, and monitoring of these illnesses.