True suicide prevention

There is something ironic in that the start of the “ber” months, fondly considered by Filipinos as the informal start of the Christmas season, also happens to be suicide prevention month. Holidays have been a double-edged sword in mental health—some people look forward to it, while some dread how it reminds them of their less-than-ideal situations in life. Which one of these two categories you belong to depends on whether you focus on the joy and connection you will experience, or on the social awkwardness and tension you would much rather avoid.

What will it take to truly prevent suicide? Traditional talks on this topic center around watching out for warning signs and what to do when you see them. While these are important for effective management and reduction of acute suicidal risk, this also presupposes that suicidality is already there. So what truly prevents it from taking root in the first place?

We generally interchange mental health with mental health problems. We associate mental health with illness, disorders, and suffering. We don’t usually associate it with good mental health, where we focus on growth, potential, and ways of finding joy and meaning in life. This bias toward problems thus lead us to invest most of our energy and resources toward alleviating symptoms or reducing suffering. There is a logistical and mechanistic way to prevent suicide from happening: simply prevent attempts from becoming successful. Warning signs belong to the same principle, in that it helps us anticipate when an attempt is likely to occur and how to thwart it before it happens. This is why we have plans and strategies that center on intensive monitoring of the person, including suicide watch, hospitalization, and removing potential implements that can be used in an attempt. Don’t get me wrong, I use all of these tools toward helping my clients keep safe and stay alive. Once we have set up physical and environmental barriers to attempts, however, the true meaningful work begins: working through the urge to end one’s life, and start building a life worth living. Merely staying alive is not a good enough goal.

Dialectical behavior therapy, the gold standard treatment for suicide prevention and management, holds a philosophical assumption that to effectively prevent suicide, we need to help clients imagine and build a life worth living. Focusing on symptom amelioration is not enough. We shouldn’t just reduce suffering; we need to make life genuinely better.

The fundamental warning sign of suicide is hopelessness. Hopelessness means that they can no longer envision a life that is different or better than their current experience. There is a sense of permanence in their current suffering, and they don’t see a way out. While some individuals are biologically predisposed to hopelessness, it should be easy enough to realize that our surroundings contribute to hopelessness as well. Adulting, for example, is often seen now by the younger generation as something difficult and full of responsibilities. While it certainly contains that, we have failed to excite them about the joys of being your own person and being able to choose your life freely.

Another example is the seeming endlessness of the pandemic that has led to a widespread sense of hopelessness. We are challenged to envision a way through the pandemic in a way that refocuses on joy and meaning, instead of a new normal that is tunnel-visioned toward simply reducing risk of infection. Recently, we’ve been holding a series of faculty meetings on how to proceed with face-to-face activities. The guidelines were all about restrictions (e.g., no eating except alone in our offices, no socializing in lobbies and general areas) and didn’t offer alternative ways to enjoy our interactions and nurture connections with others. All these restrictions and mandated requirements definitely did not motivate me to return to campus. When life has become meaningless and hopeless, then the only motivation left is to avoid as much suffering as possible. Suicidality represents the ultimate desire to escape suffering. This is the counterintuitive lesson: the more we use avoidance motivations to help a client through their suicidality, the more sticky suicidality becomes.

Building a life worth living is a much better and effective way to motivate people toward life instead of wanting to escape it. One of the questions we often ask our clients is, “Imagine if all your problems and suffering were to go away, what would you want to do?” This nudges our clients to think of life beyond symptoms and to begin to imagine what life they would actually be happy to have. Common answers to this question pertain to spending time with loved ones or pursuing dreams and ambitions. With these stated values as our North Star, we can help them sift through which challenges are worth tolerating in order to build that life.

——————

[email protected]