One of the hardest things about being a therapist is knowing that someday one of your clients might act on the urge to kill themselves, yet being unable to accurately predict who and when it will strike. Roughly one in 10,000 people will die of suicide each year. Many more will try to kill themselves and survive, and even more will contemplate the act. A lot of the factors that are known to increase the risk of suicide are also the sort of things that prompt people to see a therapist. So with each passing day, despite the best of intentions and every effort to practice vigilance and effective helping skills, the odds of something bad happening increase.
Despite over 50 years of intensive research no features have been identified that significantly improve our odds of accurately spotting who will attempt to die or succeed in the effort ”1”. We know of countless features in a person’s life that slightly increase the accuracy of predictions, but the change is on the level of buying two lottery tickets instead of one. To put it in practical terms, even with the best tools, the odds of correctly identifying someone who is going to kill themselves are impossibly small, whereas the odds of incorrectly identifying someone as mortally in danger from self harm are impossibly large ”2”.
I am telling you this to emphasize a very important point relevant to anyone who is motivated to help others: if all we did was try and predict suicide, therapists (and anyone else for that matter) would be next to useless, but when it comes to prevention, really significant changes become possible. In the case of suicide, it turns out that there are a lot of actions that can be done to prevent bad outcomes and insure that people have a chance to work out their problems ”3”. Recently, the World Health Organization released a groundbreaking public policy paper outlining many of the issues and their solutions ”4”.
Overall, the WHO report breaks suicide prevention strategies into two broad categories. The first involves changes that society on the whole can implement to make suicide more difficult to carry out. The second type of intervention involves health care interventions that can help reduce or eliminate the kind of thoughts and feelings that lead to suicide attempts. Here is a list of just a handful of the prevention strategies that the report describes:
1: Smaller Is better
One of the more common ways that people kill themselves is by taking an overdose of medication. Often, this happens when someone is in distress and turns to their medicine cabinet. Most people keep bottles of common pain remedies like tylenol or aspirin handy, and in most cases these bottles contain lethal amounts of the drug. Trying to guess who might employ this method is not an effective prevention strategy. However, doing something as simple as reducing the quantity of pills available in each bottle can work wonders. In England, legislation was introduced that did just that, and this simple change has been linked to a 50% reduction in poisoning death cases from such over the counter medications and a 60% reduction in transplants due to overdose liver damage.
2: Bridges, buildings & railroads
Jumping is a common method of suicide, whether it be from a high building, bridge, or in front of a train. Jumping sites are often easily accessible and the potential for acting impulsively is high. In many cases, places become known for their potential as jumping spots, yet year after year nothing happens save a gradually increasing death toll. Despite this, there are many simple structural changes such as gates, fences, and barriers that can restrict access to high risk areas. These have been shown to dramatically reduce deaths. For example, in Toronto the Bloor Street Viaduct became a renowned jumping spot. When a competition culminated in the installation of a dramatic – and beautiful – physical barrier the death rate dropped from close to 10 people each year to zero.
3: Make guns harder to access
There is a well established correspondence between the number of households owning guns and their use in suicides. While it is not reasonable to take everyone’s guns away, many simple measures related to the control of lethal weapons can help reduce suicide rates. For example, when the Brady Handgun Violence Prevention Act was put in place in 1994, people in many US states were required to observe a waiting period and undergo a background check before they could complete a handgun purchase. There was a corresponding 10% decline in suicides for people 55 and older. More stringent legislation restricting ownership has been put in place in several countries, with a corresponding reduction in firearm suicides.
4: Introduce guidelines for responsible media reporting
The media is important in society for providing people with information. Most of us rely on one or more news services or newsfeeds in order to keep up with events, whether they are in our immediate neighborhood or the world at large. However, just as the media can be helpful in providing information, the way the information is provided can influence our behavior. In the case of news about suicides, information is often presented using extensive and graphic stories because this catches and holds our attention. Unfortunately, the way media present news about suicides can also influence suicide rates.
A good example of this took place when Vienna opened its first subway line in 1978. Within a short time the news was awash with dramatic accounts of people throwing themselves in the path of trains, and this very coverage seemed to correspond with a rise in occurrences. When guidelines were introduced encouraging more responsible media reporting, suicide attempts in the Vienna subway dropped by 87%. This gets at what the media intellectual Marshall Mcluhan meant when he stated that “the medium is the message”. Applied to tales of suicide, sometimes what is most important is not the content of the news, but how it is presented.
5: Remove barriers to health care
When a behavior is difficult to predict, the odds of someone getting the help they need are diminished. Add to this the stigma associated with having suicidal thoughts, and you end up with a lot of people going it alone at a time when they really could benefit from a helping hand. Given what we know about the effectiveness of treatment in preventing suicide, this suggests that anything we can do to make healthcare more accessible to people should drive down the rates of suicide. In fact, this is the case. The availability of services like 24 hour crisis support lines show a strong correspondence with reductions in suicide attempts and suicide deaths. Training doctors to recognize and treat risk factors is another way of reducing barriers to effective care. In one telling example, the US air force initiated a program among its members geared to increasing help seeking behaviors, improving the availability of support and ensuring the delivery of effective treatment. The result? Not only were suicide rates cut by two-thirds, homicide rates and reports of family violence dropped by 50%.
6: Provide medic alerts for the elderly
Suicide rates tend to diminish with increasing age, but then rates climb again once people get beyond retirement. The elderly face many challenges that increase stress, physical discomfort, and mental health issues. All of these things increase suicide risk, yet trying to undo the effects of age is not going to be a winning method for preventing self harm. However, a recent study looking at attempts to improve access to emergency services by the elderly had some unexpected effects. The study, which provided medic alert devices to people living on their own so that they could easily access medical services in a crisis, resulted not only in improvements in overall health care, but cut the rate of suicides in the elderly participants by over 60%.
7: Use CBT or DBT Treatment for high risk clients
It’s not enough to simply insure that everyone has access to a health professional. When people present to their doctor, therapist, or other counselor with suicidal thoughts, it is important that they receive the proper treatment. Just as there are many factors that contribute to risk but offer little accuracy in predicting outcomes, there are countless therapies that are known to help people in general, but do little to reduce the incidence of suicide. One exception is cognitive behavioral therapy and similar techniques making up dialectical behavior therapy. These treatment methods teach people how to monitor their thinking, identify problem thoughts, learn skills to modify those thoughts, and reduce problem behaviors and feelings. Using CBT or DBT in suicide prevention with high risk groups cuts reattempt rates by 50%.
8: Use lithium to treat bipolar mood disorder
Along with many other things, mental illness is a potent risk factor for suicide. Among the types of mental illness known to put people at risk, bipolar mood disorder stands out as a particularly dangerous condition. This is because when bipolar disorder goes untreated, it can cause immense stress and suffering. Episodes of mania can result in impulsive behaviors that are self destructive if not outright lethal, and the suffering that goes with corresponding bouts of profound depression can be equally deadly. Unlike most other types of mental illness, cognitive behavioral therapies are not of much use to someone constantly cycling between profound mania and deep depression. However, when bipolar disorder is treated with lithium, a simple salt that is the gold standard for effective care, suicide rates drop by as much as 80%.
We can do better
Research suggests that when a person decides to kill themselves it is often a spur of the moment decision influenced by a complex web of factors 5. The sort of things that help prevent suicides from happening require relatively simple interventions, but involve a lot of planning and preparation. Communities need to be as safe as possible, and helping professionals need to be accessible and properly trained. Prevention strategies need public support and funding in order to be properly implemented. Making sure that society as a whole is taking the right steps to keep people safe and offer the most effective interventions needs to be a public health priority. That’s the sort of change we all should encourage. So don’t limit your interest in this topic to suicide prevention week, or those brief moments when a tragic death hits the news or impacts you personally. Be sure to do whatever you can to educate people you know about the issues and support prevention initiatives that can benefit everyone, every day.