The recent findings from National Center for Health Statistics indicating that the suicide rate in America has reached a thirty-year high have prompted a wave of alarm. What is driving this disturbing upward trend? Why are our current suicide prevention efforts failing? What is to be done?
In a timely new book, Rational Suicide, Irrational Laws: Examining Current Approaches to Suicide in Policy and Law, veteran civil rights attorney Susan Stefan sheds much-needed light on our current predicament. This volume reads more like compelling investigative journalism than a legal tome. The book is brought to life through the inclusion of the perspectives of 244 suicide attempt survivors she surveyed and interviewed in the course of writing the book. (Full disclosure: I am one of the attempt survivors she interviewed.) Stefan's narrative is clearly driven by survivor insights. She is honest about her struggle to remain objective in the face of her "affection and admiration" for the people she interviewed. Frankly, I welcome this sort of "bias" in a field that, until very recently, has been far more preoccupied with studying those who died rather than listening to those who survived.
Stefan delivers a scathing indictment of the suicide prevention and care status quo, based on her in-depth study of history, case law, and the first-person narratives of providers and survivors she interviewed, "our policies and practices regarding suicide create an irrational incentive structure where people understand they have to attempt suicide to get help, help which is of questionable utility, while community-based approaches that are less expensive and work are underfunded. We have a system that doesn't work for anyone -- neither the people who are supposed to be providing help, nor the people who are supposed to be receiving it." She points out the hypocrisy in the caring rhetoric of suicide prevention versus the reality: a series of legally-sanctioned, uncaring policies and practices that may actually increase, rather than decrease, suicide risk.
The book tackles head-on perhaps the most controversial issue in law and social policy regarding suicide and mental health in general: legal capacity to make decisions regarding one's own life and care. Stefan draws a conclusion from her research that may stun many: "The vast majority of people who are thinking about suicide, attempting suicide, and committing suicide are nowhere close to incompetent under our current legal standards." The problem, however, is that any expression of suicidality is all too often presumed to be a sign of incompetence. This "suicidality equals incompetence" assumption, Stefan argues, "shuts down the conversation at the very point where the conversation is most needed." It leads to coercive, knee-jerk responses that can be experienced as punitive and re-traumatizing by people in suicidal states.
Thankfully, the field is beginning to understand this. A recent essay entitled "A Handful of Doctors are Working to Revolutionize How We Think About Self-Harm" features clinicians who support Stefan's analysis. As prominent suicide prevention expert Dr. David Jobes notes in the essay: "Much of what was done in the name of clinical suicide prevention was actually coercive, shaming and controlling."
Stefan also blasts the current paradigm in law and policy, which assumes that suicidal thinking and behavior is always the result of mental illness. She asks us to challenge that oft-cited statistic that "90% of suicides are caused by an underlying 'mental illness,'" noting that perhaps at most, 50% of suicidal people actually have a co-occurring mental health condition. This 90% statistic is arrived at via so-called "psychological autopsies," which are rather unscientific surveys of friends and families after a suicide loss, often conducted by a person who had no connection whatsoever to the deceased when they were alive.
She notes that when we put this "suicidality equals mental illness" assumption aside in policy and practice, we have the opportunity to shift to a public health, prevention-oriented approach that would prioritize evidence-based treatments. These treatments, being provided on an outpatient basis, may carry some degree of risk but would rightly focus on suicidality, rather than on treating it solely as a symptom of "mental illness." These treatments include Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP), Dialectical Behavioral Therapy (DBT), and Collaborative Assessment and Management of Suicidality (CAMS).
Stefan notes that no study has ever found that inpatient hospitalization, the prevailing approach to suicide "care," actually reduces suicide, while there is evidence to indicate that inpatient hospitalization may increase suicidality over the long term. This is particularly true for a substantial percentage of suicidal people who are survivors of childhood and adult trauma, who may find what is on offer -- loss of liberty, one-to-one observation, and seclusion and restraint -- to be re-traumatizing and harmful.
She proposes a creative solution that would involve shifting away from the paternalistic tendency towards over-hospitalization, instead using Medicare and Medicaid dollars to fund Personal Care Assistants (PCAs) to support vulnerable suicidal people in their homes. Stefan notes, "instead of pouring millions of research dollars into devising yet another set of five questions to figure out who's going to commit suicide, maybe we should divert that money to fund PCAs and crisis respite, paying for someone to provide a personal connection and help out another person who's floundering and desperate." Sounds sensible, but sadly, common sense does not often prevail in our current approaches to people in suicidal crisis.
Stefan also proposes a bold new policy and practice change that would radically change the way community-based mental health professionals respond to suicidal people: limiting their liability if one of their clients dies by suicide. This would, of course, exclude gross negligence or misconduct on the part of outpatient providers, and would also exclude inpatient settings that have an obligation to ensure the safety of those in their care. She describes many positive consequences of such a policy change: reducing perverse disincentives to treating suicidal people in the community; admitting to the reality that no one can predict who will attempt suicide with any more reliability than a coin toss; decreasing over-reliance on inpatient hospitalization and forced treatment; promoting improved provider-client communication and honesty; and supporting greater implementation of the proven community-based interventions mentioned above.
An entire chapter is devoted to discussing the forms of discrimination experienced by suicidal people, in particular college and university students. At many institutions of higher learning, if a student is found to be suicidal, they may be subject to such indignities as involuntary medical leave, sometimes being summarily barred from campus. To add insult to injury, students placed on involuntary medical leave may be unable to get a tuition refund for missed classes, adding additional financial stress. As Stefan notes, "fear of liability drives many of these policies and practices." And these policies and practices can have a disastrous effect on vulnerable students, for whom the structure of campus life and the presence of friends can serve as important protective factors. Some suicidal students may be discouraged from seeking help, as these sorts of policies are well-known on campus. Stefan notes that the most important thing universities can do is to change their policies of exclusion and to listen to what students want and need.
She also devotes a chapter to discussing and describing what does help suicidal people, based on the interviews she conducted with many suicide attempt survivors. These include: connections with children and grandchildren; connections with other family and friends; connection with pets; spirituality and spiritual support; and peer support, including crisis respite. Our current policies and practices, which generally remove people from their community and any existing support systems by hospitalizing them, or take their children away (in the absence of abuse or neglect), fly in the face of common sense and what people are saying actually helps them to stay alive and heal.
There is no way to do justice to all of the groundbreaking analysis and novel policy and practice solutions proposed in this book. It should be required reading for everyone in the fields of mental health and suicidology. My only critique is that because Stefan has written an academic book, the radical yet commonsense ideas proposed here will be largely out of the reach of the mainstream public. (A way to help increase access to the book is to request that your local library carry it.) One can only hope that the ideas in this book will reach policymakers, mental health professionals, employers, university administrators, and advocates who are in a position to help change our laws and practices to truly support suicidal people to find reasons to live again.