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.