September is National Suicide Prevention Awareness Month: What Everyone Should Know

September is National Suicide Prevention Awareness Month in the United States, and September 4-10, 2022 marked National Suicide Prevention Week, an annual campaign to educate the public and promote increased awareness about suicide. On a personal note, one year ago this month an old friend and someone important to me took his own life, so I’d like to use this post to discuss suicide awareness. Suicide is a heavily stigmatized topic many people avoid and consider taboo. But it’s not a contagious disease. It touches so many of us and is getting harder to ignore.

In fact, according to the American Foundation for Suicide Prevention (AFSP), in the United States in 2020, there were almost 46,000 reported suicide deaths; a shocking 53% of them were firearm suicides. During the same time period, the Centers for Disease Control and Prevention (CDC) reports an estimated 12.2 million American adults contemplated suicide, 3.2 million made a plan, and 1.2 million Americans attempted suicide. (The true figure could be much higher, since some suicide attempts go unreported.)

Stop for a moment and consider the human toll beyond the statistics. How many friends, family members, classmates or coworkers are connected to each of those individuals? The AFSP estimates a staggering 53% to 85% of Americans have been affected in some way by suicide – whether it’s trauma from witnessing a stranger’s suicide, coping with losing a loved one, or suffering with suicidal thoughts themselves. You may know someone like this, or this may be you. So if you’re wondering whether you can do anything to help, the answer is yes. And I’m asking you to try. Suicide prevention is officially everyone’s business.

Here are some things everyone can do to support suicide awareness and prevention this month, and every month.


LEARN AND SHARE THE FACTS ABOUT SUICIDE

– There are an average of 123 suicides each day in the United States. (Source: National Today) The AFSP puts the average slightly higher, at 130.

– Suicide is now the 12th leading cause of death in the United States, and the third-leading cause of death for those between the ages of 10 and 19. (Source: AFSP) Now read that shocking fact again.

– The World Health Organization estimates that seven million people kill themselves each year worldwide, and for each person who dies by suicide, 20 more people are considering it. This roughly tracks with CDC estimates that calculate for each suicide death there are 20 times the amount of emergency room visits for non-fatal suicide attempts.


A fact we don’t talk about when it comes to guns in this country: Suicide accounts for more shooting-related deaths than homicides and accidents involving guns combined.

– In 2020, men died by suicide 3.9 times more often than women, yet women were 1.8 times more likely to attempt suicide. (Source: AFSP)

– Nearly 70% of total suicide deaths in 2020 were white males. The rate of suicide is highest overall in middle-aged white men. (Source: AFSP)

– Between 2000 and 2016, the suicide rate in the United States rose 30% overall, and rose a whopping 50% among girls and women. (Source: National Today)

– Those most at risk for suicide include people with substance abuse disorders, a history of prior suicide attempts, family history of suicide, history of physical or sexual abuse, chronic pain, access to weapons, and other factors. (Source: National Institute of Health [NIH])

– Suicide warning signs include isolation, feeling like a burden, giving away or selling possessions, expressing hopelessness, extreme mood swings, anger and irritability, expressing unbearable pain, and increased/abnormal substance use. (Source: CDC)

– People end their lives for a variety of complex reasons, including due to psychiatric illness, financial and legal strain, despondency over a failed relationship, inability to overcome addiction behavior, diagnosis of a fatal illness, and more. Often there are a number of factors and when those aggregate in a suicidal crisis and coincide with a person’s desire to die, their capacity to overcome their own survival instincts, and access to lethal means, the outcome can be tragic.

– As many as 93% of Americans reportedly believe suicide can be prevented. (Source: AFSP) This seems to suggest most people would be willing to help, if they knew what to do.


SUICIDE BEREAVEMENT IS UNIQUE

– It isn’t accurate or helpful to say one kind of grief is “worse” or “better” than another. But suicide bereavement is different than other kinds of grief for many reasons, including the perception the person who died could have chosen to live instead.

– Many people who have lost a loved one to suicide report feeling intense feelings of guilt, rejection, deception, abandonment, shame, anger, regret, and an anguished helplessness that their loved one did not seek their help or say goodbye. When someone dies by homicide, their loved ones can point fingers at the perpetrator; in a suicide loved ones may struggle with alternately seeing the deceased as both the victim and the perpetrator. Grievers may feel uniquely left in a state of conflict with their deceased loved ones, and left to resolve that conflict on their own.

– There may also be religious restrictions around mourning and burial rituals; family tensions around whether to conceal the cause and manner of death from others; shock if the death is sudden, unexpected, public, undetermined, observed by loved ones, or violent; and unanswered questions such as “Why did this person take his/her life?” and “Is there any way I could have prevented this?”

– Because society is uncomfortable with suicide, family and friends of the bereaved may receive less support and find themselves more isolated than they would if their loved one had died of cancer or in an accident. In fact, the people closest to the deceased – and who need the most support – may experience blame and finger-pointing from the community for the person’s suicide. They may worry others are wondering what kind of parent, spouse, or child they were if their person killed themselves. These are the people who are already asking themselves what they did wrong, what they missed, why they weren’t good enough to stay with, what if they had just said or done ‘x,’ and other questions that will likely never be answered.

– Suicide notes are reportedly only present in about half of suicides, and anecdotally it seems they are not very useful in answering the ultimate question of “Why?” It’s unlikely that even if the person who died could be asked they would be able to fully answer that question, or that they could have fully comprehended the reality of their own death.

– People outside the deceased person’s immediate family – such as friends, classmates, co-workers, unmarried partners or ex-partners, and others who experienced a close or intimate relationship with the person but are not privy to non-public information about what happened – are likely to experience some level of disenfranchised grief. Others may not recognize that the deceased person’s death would even affect them at all, let alone grasp the enormous impact.

– Those bereaved by suicide loss are more likely to experience symptoms of post-traumatic stress disorder (PTSD) than other bereaved individuals. According to the NIH, suicide grievers are often preoccupied with themes of violence, victimization, and volition (the choice of death over life, as in the case of suicide), which become added onto and interspersed with other aspects of grief.

– The NIH also reports those bereaved by suicide are 1.6 times more likely to have suicidal thoughts themselves (controlling for pre-existing depression) and disbelief, despair, anxiety, preoccupation with the deceased and the circumstances of their death, withdrawal, hyperarousal, and dysphoria are often more intense and prolonged than for those grieving non-suicide deaths.

– According to the NIH, those affected by suicide bereavement are up to 20% more likely to develop complicated grief, in which the griever is not able to integrate the initial period of acute grief into their life and understand what the loss has meant to them. This means that the first several months of grief usually characterized by shock, numbness, disbelief, intrusive thoughts, feelings of anguish and despair, and longing for the deceased person can transition instead into long-term preoccupation with the death, avoidance of reminders of the loss, blocking of positive memories of the person, prolonged states of reverie that interfere with daily activities, intense yearning, and even suicidal ideations to join the deceased.

– A study conducted in the UK in 2010 found that friends and family grieving a sudden suicide loss had a 65% increased chance of attempting suicide themselves. The same study noted suicide grievers were 80% more likely to drop out of school or quit their jobs. Two particularly interesting things about the study to me were that (a) the findings extended to both blood relatives and friends of the deceased and (b) the findings pertained to only suicide deaths and did not extend to other traumatic non-suicide deaths. In other words, suicide as a cause of death had a profound psychological effect on those left behind that superseded the effects of the actual manner of death.

– Children who lose a parent to suicide are more likely to die the same way. (Source: Johns Hopkins)

What we can conclude from much of this is that while suicide is not “contagious” per se, close exposure to it is devastating to those left behind. In turn, suicide’s societal stigma can deter people who need help from seeking it, and discourage those who would offer help from doing so, lest they say the wrong thing. But not talking about it isn’t making it go away – or stay hidden.


CONSIDER HOW YOU TALK ABOUT SUICIDE

– Have you ever noticed the only time most people talk about suicide is to make a flippant joke? One way we deal with things we don’t understand is to try and make them light-hearted. This happens in the case of suicide to such an extent that it renders language almost meaningless.

~ “I’m going to kill myself!” someone will complain upon receiving aggravating news of a minor nature. Are they really? Of course not. The implication is that some situation is making life unbearable and life not worth living, but that isn’t at all what we mean. Why do we say things like this, while also claiming we cannot imagine how anyone could get to the point of wanting to end their life? Would anyone who actually is experiencing a suicidal crisis feel comfortable talking about it when people neither understand nor say what they mean?

~ “I need a donut like I need a hole in the head,” one colleague will joke to another in an office kitchen after the holidays. I’m guilty of saying this. I almost said it the other day and then stopped in horror. Why would I say something so violent and unnecessary over… food?

~ “Are you going to pull the trigger?” someone asked me the other day, awaiting my decision on a work matter. I flinched.

– I myself cannot even count the number of times I used to roll my eyes and mime shooting myself in the temple with a finger gun to express my feelings about workplace tedium. “Just kill me,” someone else would respond, rolling their eyes back.

This all became a lot less funny when someone I cared about actually became so despondent about his life that he couldn’t think of any other solution than firearm suicide. Do you know for sure no one around you lost someone to a self-inflicted gunshot wound? Trust me, you don’t. And I don’t either. There is absolutely nothing funny about it. I still have nightmares about my friend making that decision and the misery and loneliness he must have felt. So let’s give a little more thought to these insensitive remarks and gestures, and consider finding a more precise and accurate way to express whatever it is we’re trying to say.


Luminarias in honor of my late friend T during National Suicide Prevention Week, Vienna, VA, September 2022

~ Like with many other things, the way we talk about something has origins in how the culture views the subject; reciprocally the way we view a subject both informs and perpetuates the discourse. During the Middle Ages, Christianity excommunicated suicide attempt survivors and did not allow a person who had taken their own life a Christian burial. In 17th century France people took it a step further: the bodies of those who killed themselves were drug through the streets face-down before being thrown into the trash and their property confiscated by the king. Imagine the anguish of the families who not only lost their loved one and the companionship, income, presence, and spirit they encumbered, but also were traumatized by this inhumane and unnecessary behavior.

– In case you were not aware, the phrase “committed suicide” is considered by those in the suicide loss community to be archaic and offensive. It is preferable to say someone took their own life, killed themselves, or died by suicide. Suicide was still illegal in much of the western world until the mid-20th century (source: Wikipedia), which is ironic considering there is no way to punish the dead, and this is where the outdated language of “committing” suicide comes from. It’s a holdover that serves to shame and penalize a person for a final desperate act intended to relieve their own suffering and the burden they felt they were imposing on others.

– The word “successful” to describe a completed suicide suggests that something positive has happened. Instead, a life has ended tragically. By the same token, a suicide attempt that did not end in someone’s death is not a “failed” suicide.

– “Your loved one is in a better place.” I am sure this is an attempt to comfort the bereaved, but can be a terrible thing to hear. Not everyone is spiritual or has religious faith. And even those who do would likely agree their preference would have been to have their loved one alive and with them, not in some abstract “better place.” The flip side is almost as bad; you might be surprised how many people will actually come right out and say something along the lines of, “It’s such a shame that people who commit suicide go to hell.” It’s not a helpful message to hear and you don’t have to engage with it.

– The topic of suicide prevention can be sensitive. I sometimes see social media posts from well-meaning individuals and organizations talking about “easy ways” to prevent suicide. The truth is, it is unlikely all suicides can be prevented. It is unpopular to say, but some people who kill themselves conceal their intentions and those closest to them say they didn’t see any signs. And for those friends and family members who “failed” to “prevent” a suicide, this kind of glib language can feel awful.

– And probably the most persistent and my least favorite statement to debunk: Suicide described as a selfish act. Does anyone actually believe that telling someone their loved one was selfish is helpful or comforting, particularly in situations where someone took their own life in a location where family or friends discovered them? I think this is probably another attempt to comfort the bereaved and emphasize with their suffering by shifting guilt and blame away from them and towards the person who died. But all it does is add another layer of pain onto the people left behind who may be struggling with both anger and defensiveness of the deceased. I have read and listened to many interviews with people who survived suicide attempts, and they almost uniformly explained that prior to trying to end their lives, they felt hopeless, worthless, and a burden to their loved ones. In their minds, they were doing something selfless by removing themselves from the equation, thinking the people they loved would be better off without them. The suicidal brain lies to them, tells them to burrow deeper into a hole instead of reaching for a hand up and out. While the person who dies by suicide ultimately has responsibility for their own actions, particularly in the case of adults, it also seems clear that in many cases of suicide death, brain activity and rational decision-making are hampered so significantly by a confluence of complex factors including mental illness that not all available choices appear accessible until the suicidal crisis has passed. And of course, in some cases by then it is too late.

Our collective failure to explore and improve the way we discuss suicide increases the suffering of those who have lost a loved one to suicide, and deepens the stigma and shame around this misunderstood issue.


BUILD YOUR OWN CONVERSATION SKILLS

You might think, why would I need to talk to anyone about suicide?! I’m not a mental health professional. I’m not a counselor. But the fact is, people are becoming more comfortable talking about their mental health. It’s possible you may end up in a conversation someday with a friend or relative who tells you they have considered, or are considering, ending their life. This has happened to me in professional settings when I used to work in a residential psychiatric facility. I expected it.

I didn’t totally expect it to happen during a personal conversation with my friend 20 years ago. Although the conversation was probably harrowing for both of us, I did feel I had the ability to navigate through it without making it worse. I want other people to feel like they know what to do in that situation too. If your loved one trusts you with this information, it’s your responsibility to be there for them. Please take it as seriously as you would take preparing for a fire drill or learning CPR.



– Did you know… talking about suicide is not going to “give someone the idea” to take their own life? Suicide doesn’t happen through the power of suggestion. In fact, raising the concern directly allows a suicidal person to express themself and potentially feel less alone. Listen, listen, listen to them. And be there, and keep being there.

– The graphic below has specific, evidence-based action steps to help you navigate how to do that. Everyone can take these steps – you don’t need to be a trained counselor or medical professional. There is more on the Five Steps for communicating with suicidal people at the link.

– You can also take five minutes to complete five action items developed by the National Council for Suicide Prevention (NCSP) for their Take 5 to Save Lives Campaign.



KNOW WHERE TO FIND MORE HELP

– Spread the word… the new, federally-funded National Suicide Prevention Hotline launched July 16, 2022 and is operational. Anyone in the United States can now call or text 988 for mental health assistance. Veterans can press “1” after connecting to reach the Veteran Crisis Line. A recent Rand Corporation study said fewer than one-third of state or regional officials indicated they had urgent mental care units, and only half said they had 24/7 mobile crisis response units with trained counselors available.

However, I think the prioritization of a specific line focused on mental health emergencies that isn’t staffed by law enforcement is an enormous step in the right direction. Law enforcement helps a lot, but is also busy. Too often we’ve seen conflating mental health crises with a police response can have deadly consequences for some of society’s most marginalized and misunderstood. Looking at suicidality through a public health lens rather than through a crime and punishment lens makes it more likely that those who need medical or psychiatric help to address their well-being actually will seek and receive proper treatment.

– You can also text the Crisis Text Line by texting TALK to 741741. And the Trevor Project is the first suicide crisis line in the country specifically aimed at LGBTQ youth, to call, text, or find online counseling, peer support, and other resources. It’s also all confidential and free. Call 1-866-488-7386 or text START to 678-678.

– Know where crisis centers are in your local area, in case you ever need to take anyone there.


REFLECT ON LIVES LOST TO SUICIDE

– September 10 is World Suicide Prevention Day. (See the White House statement on the day, here.) Created in 2003 by the International Association for Suicide Prevention (IASP) and promoted by the World Health Organization (WHO), people around the world will mark the day at 8pm in their own time zones with candlelight vigils. You can remember this day by mentally associating it with September 11th as a mnemonic device – it’s the day before.



VOLUNTEER YOUR TIME

– For almost 20 years, the American Foundation for Suicide Prevention (AFSP) has been holding its Out of the Darkness community and campus walks to promote suicide awareness, supporting grievers and those struggling with suicidal ideation alike. It’s easy to volunteer to work at a walk, setting up cones or handing out beads – or you can form a walking team and fundraise! With over 400 walks around the United States, it’s likely there’s one in your area. Check out this link to find a walk near you.

– Participate in events worldwide for International Survivors of Suicide Loss Day, held each year the Saturday before American Thanksgiving. This year’s events are planned for November 19, 2022. Find an event in your country or state at the link.


BECOME AN ADVOCATE

– Listening to podcasts about suicide loss is a great way to start to understand some of the issues faced during suicide loss bereavement. Here are a few I recommend (although you can cast a wider net and search for general grief podcasts to come up with all sorts of good stuff):

~ The Leftover Pieces, by Melissa Botorrff-Arey

~ Understand Suicide, by Paula Fontanelle

~ The Healing Narratives of Suicide Loss, by Dr. Sue Egan

~ Life After Suicide, by. Dr. Jennifer Ashton

– Learn about AFSP’s Project 2025, a nationwide initiative to reduce the annual suicide rate in the United States 20% by 2025.

– Learn about opportunities to advocate for public policies and legislation that can move on the needle on directing much-needed resources towards suicide prevention.


Thank you for reading. And remember, it’s OK not to be OK. It’s also OK to ask for help.

Vienna, VA ~ National Suicide Prevention Week, September 2022

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