A 61-year-old man, E.H., survived suicide attempts, received care for depression in psychiatric hospitals, and battled alcoholism for many years. His father died by suicide. E.H. was convinced that one day he, too, would kill himself, and he did.
Was his suicide inevitable?
Ernest Hemingway, the famous author and the man described above, died by suicide in 1961. Eventually suicide also would claim two siblings and a granddaughter. A controversial article uses Hemingway as an example of what the author calls “inevitable suicide”: “the patient whose suicide will occur regardless of the most expert and skilled therapeutic intervention.”
The article’s author, Benjamin Sadock, MD, blames this (supposed) inevitability on the unfortunate confluence of factors that can create excruciating despair, pain, and pathology: “When all of these areas—mental illness, genetics, and other risk factors— reach a critical mass, the extent of which remains to be determined, the likelihood of a particular patient taking his or her own life is increased to the point of inevitability.”
Two letters to the editor came out a few months after Dr. Sadock’s article. One letter, by psychologist Thomas Ellis, PsyD, states:
“…the word inevitable is appropriate in some contexts, such as, ‘It is inevitable that some suicides will occur among psychiatric patients.’ But it is a different matter to suggest that some individuals’ suicides are or were inevitable. To do so is to risk rationalizing patient care practices that should be examined and corrected.”
The other letter, by Thambu Maniam, MBSS, MPsychMed, likewise objects to the notion that any one person’s suicide was inevitable:
“I remember a psychiatrist, whose patient had recently committed suicide, saying ‘You can’t stop suicide. Whatever you do, they will still die.’ I wonder what consequences such a fatalistic view would have on his practice.”
It is true that suicide is not, with our present state of knowledge, 100% preventable. So in that sense, in general, some suicides are inevitable. But – and this is an important distinction – the suicide of any one person in particular never is or was inevitable.
As long as the suicidal person is alive, there is hope for change. Anything can happen in life at any moment to change the person’s situation, suffering or outlook.
For our part, as mental health professionals, we have many tools to help a suicidal client recover hope, strengthen reasons for living, learn to cope better with emotional pain, and recover from psychological problems such as depression. Cognitive behavioral therapy and other evidence-based treatments, active listening, risk assessment, safety planning, skills training in mindfulness and other coping techniques, and the therapeutic relationship itself are just some of the healing tools that mental health professionals can draw from. Physicians and prescribing nurses have the added tool of medications.
So why would Dr. Sadock declare some people’s suicides inevitable? He has good, if misguided, intentions. He writes that the concept of “inevitable suicide” can lessen the guilt of clinicians who unfairly blame themselves for the suicide of a client.
The implication seems to be that if a specific client was going to die by suicide no matter what, then the people treating that person are not to blame. But this is a false dichotomy. A suicide need not be “inevitable” for a clinician to be blameless.
A great many factors that can lead up to a suicide are well beyond the clinician’s control. This fact does not mean that any one specific person’s suicide is inevitable, only that psychotherapists and other mental health professionals are inherently limited in what they can do to prevent suicide in general.
“Inevitability of Suicide” versus “Limitations in Suicide Prevention”
As I said above, anything can happen at any moment to change a suicidal person’s path. This works both for us and against us. Although positive changes can occur suddenly, so can negative changes. There are so many things beyond the clinician’s control that the suicide of a client does not necessarily mean that the clinician did a bad job.
With our current state of knowledge and tools, it is impossible to predict who will or will not attempt suicide. Some clients understate their suicidal intent, to avoid psychiatric hospitalization or interruption of their suicidal plan. On top of that, mental illnesses respond unpredictably to psychological and pharmacological treatments, with no treatment offering 100% effectiveness.
And those are only a few of the limitations inherent to suicide prevention.
Even when mental health professionals bring all their skills and training into the room, even when they conduct a thorough risk assessment, even when they develop an attentive, empathic, therapeutic relationship with the client, even when they do do everything they can, the client still might die by suicide.
It might sound like I agree with Dr. Sadock about the inevitability of some people’s suicides. I do not. Recall that he defines inevitable suicide as “the patient whose suicide will occur regardless of the most expert and skilled therapeutic intervention.” I agree that some people will die by suicide despite their clinicians’ “most expert and skilled therapeutic intervention.” I disagree that this means those people’s suicides were inevitable.
Instead of deeming suicide inevitable for any specific suicidal client, we need to look at the limitations that mental health professionals face with every suicidal client. These limitations merit research and other efforts to diminish them. I am grateful that we usually can help suicidal clients in spite of those limitations.
© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All Rights Reserved. Written for www.speakingofsuicide.com
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