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. In 1961, he fatally shot himself in the head.
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.”
Dissenting Views: Suicide is Not Inevitable for a Specific Person
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.”
My View: Suicide Prevention is Limited, but a Specific Person’s Suicide is Not Inevitable
It’s true that, with our present state of knowledge, suicide is not 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.
Mental health professionals 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.
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 we 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. We are limited in other ways, too, which I describe in my post: “You Can’t Do Everything”: Limitations in Helping a Suicidal Person. My motto is, “Do everything you can but know that you cannot do everything.”
Summing Up: Hope, Hopelessness, & Suicide
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. To say that any one person’s suicide is inevitable is a nihilistic view that degrades hope, belies possibility for change, and can lead to complacency on the part of the professional.
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.
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© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All Rights Reserved. Written for www.speakingofsuicide.com.Photo purchased from Fotolia.com.
The position that some suicides are unpreventable but nevertheless not inevitable, is simply illogical; it makes no sense. If anyone’s suicide is preventable, then everyone’s suicide is preventable. A more sensible point of view is that some people’s suicide is indeed inevitable, but it is extremely difficult, if not impossible, to predict who these people are; therefore, psychiatrists and other mental health professionals should treat each suicidal person with the assumption that they can do something to help them.
Furthermore, even if a person’s suicide is considered inevitable, this doesn’t mean there is no value in trying to help them. Suppose that a suicidal person received treatment and, as a result, lived peacefully and in relative happiness for a few years after that. Even if he were to become suicidal again later and eventually take his own life, he has objectively benefited tremendously from the treatment that he received, as did his friends and family who have gained a few more years with their beloved.
Some suicides are inevitable.
Most of you live in a bubble.
Centered around yourself.
The things you’ve seen, what you’ve done, what you know,
amount to nothing.
You cannot be in anyone else’s shoes
nor their mind.
Therefore, if someone is committed – they will die.
Even if it means doing nothing;
until their body loses function and rots.
Anyone who says anything else is fooling themselves.
This comment was edited to abide by the Comments Policy. – SF
I’ve always had a feeling that I would eventually commit suicide. Suicide has always been my back up plan but im somehow still here.
I’m adopted & have never cared to find out who my biological parents are or their medical history. It seems to run in families & I’m doing my best to stop that from happening to my family.
I do know that things can turn around in a heartbeat even though that hasn’t happened with me. I don’t even see how I can be fixed but I’m barely hanging on & struggling to make it through each day.
It’s hard to describe but most of the time I feel like my head is being crushed & I just want to scream.
It’s an end to isolated unspeakable suffering and the wanting of many that need my death for their survival. Simple! The only way to end suffering and pleasing ones who fear my living. Medical health family community was never available to me, I don’t need any more proof that my choice is the only dignified way to end suffering.
Stay.
My kids are in high school and I want them to finish university undistracted. But once they’ve graduated and launched I’m done. I’ve lived with this for so long I’ve basically thrown my life away and most days are unbearable. I have been suicidal since adolescence and it has only gotten worse, and I do see it as inevitable. For some people there’s no question we will do it.
I’ve been thinking of dying a lot lately. And it’s not out of fear but rather because I see no rational and logical reason to live. I don’t like people that much. Even my family who’s pretty close to me, I dislike them very much at times to a point where I question if I’ve ever loved someone before. My best-friend gets on my nerves. I see no real pleasure in material possessions. I’ve grown sick of the fad. When I was in middle school, I forced myself to “like” people because I remember wanting to feel something.. I may be romanticizing my own life. Outside of these things I have my small dream of becoming a polyglot and studying languages. However now I’m a junior in High school and I hate the world, the system, the law. I just don’t understand why I have to submit to the government and society in order to live a very restricted life. I’m aware that we can’t do anything without effort so even if I were to live in the woods.. it’d be hard. But the point is I hate having to do things I don’t want to do and I have no choice but to do them. Math homework.. Spanish tests.. Does this sound very productive to you?! And don’t think my reasons are school based. I am upset of the structure modern civilization has created. It includes school, but it continues after. I look at history especially, which I like, but it makes me terribly sad and upset.
I’m not religious. I often think what if there’s a ghost or demon watching me, but I do not believe in a hell or heaven particularly.. Maybe I’m just dumb. I think I’m inferior to others that want to take their life because they have better reason than me. At least I have my dream. It’s just that I have to bear this crap in order to get to it.. I study languages now too, but other obligations of life get in my way and make me want to die. I will take my mustard seed of faith and continue, but I’m bound to fall again. Good Luck to y’all.
Be a polyglot.
Very good
I think you took a much more Real approch to this Or should i say I relate to this
As i am so tired of fighting to get what i need to stay alive and pain free
No one Really cares anymore about people and i find it hard to be understood or understand this world and the people any more
Umm its like i woke up in this very dark dark place 3 yrs ago I know depression has been creeping up for the last 10 years
But i am soo close to saying fuck you to them
My animals and my giving in to them does stop me
I dont want to hurt others but lately it seems that they are deliberately hurting me
As not doing their jobs and not taking me as a person
I have a strong sense this world has changed for the worse and so have the people so insensitive
So socially messed up
Tons of lonely people besides my self
Thats not a good sign and i mean young people not just old
They stay on the computer like if its Real many cant communicate normal any more
I am so fed up with Fakeness
I lived a good life seen bad and surpassed it but now its ugly and not worth living
Why ?
My time i feel is done
They and the world are not going to change for the better soon
My dogs are cats living the quality life as they did before i got this bad etc
I am really just tired of fighting for my rights
The pain is horrible
Well thank you
I never thought i could explain myself You did it for me
Also to add Tell people ways to help one is never turn your back on them which many do thinking its catching
That just puts in more proof that no one cares any more
And what keeps me going is to get even Not letting them get away from doing their jobs
But i know when i lose that i will fight not much longer
Thank you
Peace
Your animals love you. Stay.
I hope I have the courage to take my own life someday
Dont hope that. You honestly shouldn’t. I don’t care if you’re a kid who has abusive parents or an adult who has depression. Think of reasons why you’re still alive. Is it because you don’t want to cause grief? Or maybe you believe people who die from suicide go to hell?
I hope you don’t. Stay.
Your article seems to imply that hope is a good thing. I don’t think it is. On the contrary ‘hope’ is what we call the lies we tell ourselves in order to comfort ourselves from the truth. The truth is that to many, many people life is grim, and horrible and death is preferable. As the saying goes “life’s a bitch and then you die.’ The kindest thing we can do is stop the pretense, look life in the eye, and decide for ourselves if life is worth the cost.
john, you hit the nail on the head. I struggle with the crap that everyone tells me when I fail at everything I do…. “don’t give up….keep trying.” I’m 34 yrs old, how many times do I try and something actually works out? I don’t want to be 50 years old and have failed at everything i do. The best answer is to just leave the world. I don’t have the balls to do it, but i can be passive about it. Life sucks. There are some of us that just simply aren’t “the chosen ones.” Some people have it all and others can’t have anything no matter how hard they try.
Agree 100%
So so true
When the real truth comes out
Yep you’re so right
And i am finding that i am right the world sucks no matter how i want to convince i am ok or how much I like my life ( lie)
I feel suicide is inevitable for some people with particular thought patterns. I know one day I might take my own life for reasons that may seem trivial to others or to me sometimes but I can’t just help myself. I have lived all my life desperate for some sort of attention and a plan for the foreseeable future. But I’m just so scared and feel life is not worth living if I have lived my childhood in some sort of fallacy. Might seem stupid and all but this sole reason has been the root of many years of depression and hurt as a teenager who dreams of a life he surely cannot have. It sucks so at the end, it is inevitable.