Marshmallows and Braking Systems

This chapter argues that suicide can be more usefully understood as a consequence of decision-making processes that are vulnerable to environmental and social influence rather than a consequence of internal states or traits such as mental illness. Mental illness and emotional distress more generally are better understood as one particular context within which the decision to make a suicide attempt or not often presents itself, but this does not mean that mental illness is the only context within which this choice is considered. This also does not mean that mental illness causes suicide. The basic concept involved in the marshmallow experiment—decision-making under different conditions—has received increased attention in the past decade among suicide researchers. Studies reveal that the decision-making process of someone who almost died as a result of a suicide attempt was no different from the decision-making process of someone who had never attempted suicide, was not currently suicidal, and did not have a mental illness. This finding lines up with the idea that there can be multiple pathways to suicide.

Balance Beams and Suicide-Risk Screening

This chapter examines how the mental illness model of suicide has led us to place more faith than may be warranted in concepts such as suicide “warning signs” and suicide-risk screening tools. These concepts are notoriously unreliable indicators of emerging suicidal behaviors because they do not sufficiently reflect the inherently dynamic and ever-changing nature of suicide risk. Any given warning sign for suicide will be wrong much, much more often than it will be right. Even when multiple warning signs are experienced or expressed by an individual, this problem persists. One factor limiting the accuracy of suicide-risk screening is that thoughts about death and suicide fluctuate over time. Thus, we should move away from assuming that we must know who will and who will not attempt suicide to prevent these behaviors from occurring.

The 90% Statistic

This chapter evaluates the centrality of mental illness in discussions of suicide and argues that the predominance of this perspective reflects confirmation bias, which is the tendency to search for and interpret information in a way that supports our beliefs and assumptions. Most people who are actively involved in suicide prevention learned that 90% of those who die by suicide were struggling with a mental illness at the time of their death. As a tool for diagnosing mental illness among individuals who cannot speak for themselves, however, the psychological autopsy method is vulnerable to confirmation bias. Instead of assuming that most or all individuals who die by suicide have a mental illness, a more balanced and accurate perspective would be that some individuals who die by suicide have a mental illness and some individuals who die by suicide do not. The chapter concludes that mental illness is only weakly correlated with suicidal behaviors and a much larger percentage of suicides than we may have traditionally recognized occur in the absence of mental illness.

Creating Lives Worth Living

This chapter explains that suicide prevention is more than just stopping people from dying; it is also about reducing the social conditions that negatively affect quality of life while strengthening the conditions that promote and foster meaningful lives that are worth living. Targeting multiple environmental hazards that increase the risk of suicidal behaviors is necessary to maximize the likelihood of impacting the many different types of individuals who are vulnerable to suicidal behavior. For many Americans, raising the minimum wage could either remove or reduce the hazards of economic insecurity and financial strain, and thereby may reduce their risk for suicide, even if only slightly. Making health insurance more accessible could reduce suicide rates by a few more percentage points. Environmental physical-health hazards warrant attention as well. These strategies address social and environmental hazards that cannot be remedied with mental health treatment.

On the Merits of Productive Stupidity

This chapter discusses how the collective discomfort with the many things that we do not know about suicide constrains innovative thinking about suicide. It begins with a critique of contemporary suicide prevention efforts, looking at military suicide. The inherently complex nature of suicide renders it beyond the reach of causal explanations such as mental illness. Nonetheless, many in the suicide prevention community fell victim to confirmation bias, interpreting these symptoms and problems in a manner consistent with what they already believed: suicide is caused by or results from mental illness. Based on this conclusion, the message was also communicated that mental health treatment can prevent suicide. Ultimately, suicide is a complex and wicked problem with no “right” way to define or conceptualize the problem, and no “right” solutions.

Seat Belts and Second Chances

This chapter argues for a potentially high-impact but underutilized strategy: restricting or limiting access to highly lethal methods for suicide, especially firearms. It begins by describing the role of seatbelts in traffic fatality prevention. Prevention through design assumes that injuries, illnesses, and fatalities can be most effectively reduced or controlled by designing and building systems that eliminate or remove potential hazards from the very beginning, before they can cause any harm. If we shifted our mindset surrounding suicide prevention in a way that better aligned with the prevention through design approach underlying traffic fatality prevention, we might reconsider the considerable time, effort, and resources being devoted to the development and implementation of suicide risk identification and detection methods, and consider instead the potential impact of redirecting these efforts toward environmentally focused strategies that are more likely to reduce suicide rates. The chapter then considers the life-saving effects of laws and policies designed to reduce access to firearms, discussing firearm suicide in the United States.

Introduction

This introductory chapter provides an overview of suicide in the military, detailing the author’s experience in Iraq. The prevailing method for suicide prevention was limited by survival bias, a logical error wherein we focus on the people or things that survive some selection process while overlooking those who did not. This book challenges some of the core assumptions about suicide and typical practices that may not be so helpful or useful after all. It also presents alternative perspectives that implicate different approaches that may work better than prevailing methods. These alternative perspectives have been heavily influenced by the many suicidal individuals who have shared their experiences, trials, and triumphs.

Performance Escapes and Catastrophes

This chapter presents an overview of newer thinking about how suicide risk fluctuates over time using concepts informed by mathematics, which provides a useful model for understanding why and how suicide emerges in different ways for different people at different times. It focuses in particular on the implications of this perspective for understanding suicides that emerge suddenly or “out of the blue” without much advance notice or warning signs. In the world of dynamical systems, sudden and discontinuous change processes are often referred to as “catastrophic” change because they represent a fundamental shift in how a system operates. Catastrophic change can be so dramatic that it defies reason and cannot be easily anticipated. The chapter then considers the cusp catastrophe model, which stands in contrast to the unidimensional suicide-risk continuum model that has dominated thinking about suicide risk for decades.

Handwashing and Changing the Status Quo

This chapter focuses on the mental healthcare system, which has been surprisingly slow to adopt the treatments and interventions that are most likely to reduce the probability that someone will attempt suicide. In many respects, the current state of mental health treatment to prevent suicidal behaviors mirrors the context of the 19th century. Two hundred years ago, the causes of puerperal fever among women giving birth were unknown to the medical community, but evidence from multiple different sources suggested that handwashing could reduce fever-related deaths much better than status quo practices. Today, the causes of suicide are similarly unknown, but evidence from multiple sources suggests that certain types of treatments and interventions can reduce suicidal behaviors better than status quo practices, which often conceptualize suicide as a symptom or outcome of mental illness. The chapter then looks at two treatments in particular: dialectical behavior therapy (DBT) and cognitive behavioral therapy for suicide prevention (CBT-SP). It assesses why suicide-focused treatments work better than status quo treatments.