No, Suicide Isn’t Always Preventable

It’s a popular message: Suicide is preventable. You can find it on thousands upon thousands of websites.

“The good news is that suicide is preventable.” (U.S. Centers for Disease Control and Prevention)

“Suicide is preventable: Here’s how to stop it.” (CNN).

“Today, experts agree that suicide is preventable.” (Illinois Department of Public Health)

You get the idea.

I appreciate the benevolent intent behind these messages: Instill hope. Defy the malignant myth (and yes, it’s a myth) that once somebody decides on suicide, there’s nothing anyone can do to stop them. Educate people about how to help. Prevent as many suicides as possible.

These are noble intentions, but there are two problems with the unqualified statement that “suicide is preventable”:

1. It’s not always true.
2. It can do harm.

In the interests of accuracy and empathy, we should be careful to qualify the statement “suicide is preventable” with “often” or “many” or “most”:

Suicide is often preventable.

Many suicides are preventable.

Maybe even most suicides.

But, tragically, not all.

Why We Can’t Always Prevent Suicide

There are many, many things we can do to help prevent suicide. I describe those measures further below, but here’s the sad truth: even if you do everything possible, the person you’re trying to help still might end their life.

There’s just too much we can’t do, and by “we” I mean both lay people and mental health professionals:

We can’t read somebody’s mind.

If we don’t know someone’s considering ending their life, how do we stop them? The person has to tell someone – with words or actions (like, say, attempting suicide and surviving) – for anyone to know.

In fact, only 46% of people who died by suicide let others know – directly or indirectly – that they were considering ending their life. Along the same lines, people who later died by suicide were asked directly in the week before their death if they had suicidal thoughts. Half said no.

Parents often don’t know the extent of their teens’ suicidal thoughts and behaviors, even among teens hospitalized for depression. Mental health professionals are often in the dark, too; in a study of teens and young adults, 39% had never disclosed their suicidal thoughts to their therapist.

Beyond a person’s disclosures and behaviors, we have no way to reliably identify if someone is considering ending their life. How can we prevent someone from dying by suicide if we don’t know they’re considering it?

We can’t identify who will become suicidal.

Suicidal thoughts and intent can fluctuate dramatically over the course of days, hours, even minutes. So, someone you care about might seem safe from acting on suicidal thoughts when you part ways after a visit, and five minutes later, without your knowing, they might fall into suicidal despair.

We can’t predict who will act on suicidal thoughts.

Researchers have conducted hundreds of studies on scales and questionnaires designed to elicit suicidal thoughts or intent. So far, none is able to reliably predict who will attempt suicide.

Here’s one example: In a study of people classified as high vs. low risk for suicide, 96.3% of the high risk group did not go on to die by suicide, but 37 people classified as being at low risk for suicide ended their life, meaning they were “false negatives.”

Suicide risk assessment scales and questionnaires do so poorly at identifying who will act on suicidal thoughts that the UK government’s National Institute for Health and Care Excellence (NICE) recommends against using them to make predictions.

We also don’t have the means to foresee impulsive suicide attempts. Though some people plan their suicide attempt for a long time, 1 in 4 people who attempt suicide act within 5 minutes of making the decision to kill themselves.

Warning signs for suicide abound. Some are specific to suicidality, such as expressing a wish to die, obtaining means for suicide, and writing about suicide. Others are more general, such as rage, anger, reckless behaviors, increased alcohol or drug use, withdrawing from others, anxiety, agitation, insomnia, hypersomnia, dramatic changes in mood, and feeling trapped.

Some people who go on to die by suicide exhibit no warning signs. And some people have many warning signs but no suicidal thoughts. And in still other cases, the warning signs are so constant and long-lasting that they’re unrecognizable from the person’s day-to-day presentation.

We can’t always know someone’s intentions.

In a journal article, I reviewed the many challenges to assessing a person’s level of suicidal intent: the person’s fear of judgment, desire to avoid hospitalization, and memory gaps, along with the ephemerality and impulsivity of suicidal urges. Heck, even suicidal people themselves don’t always know their true intentions.

Ambivalence is a hallmark of the suicidal mind, making intentions muddled and contradictory.

We can’t watch someone 24 hours a day indefinitely.

Here, I’m referring specifically to family and friends of people who vigilantly monitor a loved one with suicidal thoughts. We have to sleep sometimes. And eat and use the bathroom and maybe work at a job, too.

Psychiatric hospitals can monitor people 24/7, but even they have limitations. Every year in the U.S., 37 to 52 patient suicides occur in a psychiatric ward or hospital. (And there’s also increasing evidence that psychiatric hospitalization can do more harm than good.)

We can’t control other people.

We generally can’t force someone to see a doctor or take medications or do other things that might help them recover the will to live. We also can’t force people to do things that would protect them from danger, like follow a safety plan or stop drinking.

The legal system has avenues for requiring people to get treatment, but involuntary treatment has the potential to do harm. You can find excellent and unsettling examples of such harm in Susan Stefan’s book, Rational Suicide, Irrational Laws: Examining Current Approaches to Suicide in Policy and Law.

We can’t provide enough mental health services.

Even if we persuade someone to get professional help, they might spend weeks or months on a waiting list. More than half of people in the U.S. live in an area with a shortage of mental health professionals.

Psychiatrists are an endangered species in many areas, extinct in others; half of U.S. counties don’t have a single psychiatrist, according to this article. Even in major cities, horror stories abound about teens waiting weeks in hospital emergency rooms for an inpatient bed to open up, and about months-long waiting lists to see a psychiatrist or psychotherapist.

We can’t guarantee a treatment will be successful.

Evidence-based treatments, both psychotherapeutic and pharmaceutical, reduce suicidal urges and behaviors in some people, but not all. Sadly, some people receive the best care possible and still end their life.

We can’t rid the world of every item that people can use to end their life.

Firearms are plentiful in the U.S., and so are medications and other potentially lethal means. Even when loved ones are able to secure obvious weapons, nobody can really remove all potentially dangerous items from their home. An adolescent client once said to me, “You can’t suicide-proof the world.” She was absolutely right.

We can’t overcome societal problems that make life unbearable for many people.

A student of mine recently asked, “How can you help someone who is suicidal if you can’t help solve the real-world problems causing their pain?” Ouch. Such a tender, painful question.

The fact is, some problems that can activate suicidal thoughts are so big that changes are needed at the societal level. Homelessness, poverty, racism – to name a few examples. These kinds of systemic problems are sometimes referred to as social determinants of suicide. They underscore that suicide is not only a mental health issue. It’s also a social justice issue.

The psychiatrist Amy Barnhorst captures the intractability of societal problems in her essay The Empty Promise of Suicide Prevention. She writes:

“Many of the problems that lead to suicide can’t be fixed with a little extra serotonin. Antidepressants can’t supply employment or affordable housing, repair relationships with family members or bring on sobriety.”

Why Saying Suicide is Preventable Can Do Harm

People who have lost a loved one to suicide report feeling blamed, judged, and hurt by the implicit message that they could – and should – have prevented the suicide. After all, if suicide is preventable, why didn’t they prevent it?

Consider the words of Jaletta Albright Desmond, whose teenage daughter died by suicide, about September being “National Suicide Prevention Month”:

“For those who’ve lost a loved one to suicide, every day of September can feel like a slap in the face. They are reminded that they didn’t prevent the suicide death of their child, spouse, parent or best friend.”

She advocates for changing the name “Suicide Prevention Month” to “Suicide Awareness Month.”

Saying suicide is preventable means, well, it could have been prevented. Someone could have stopped the person from ending their life – if only they’d known the signs, or gotten the person to an emergency room, or helped them want to live again, or done something else that they didn’t do. If only it were that simple.

I recently saw a website that stated, “Suicide is preventable if you learn the warning signs and speak up if you’re worried about yourself or a loved one.” See? If someone you love dies by suicide, that message implies you failed at learning the warning signs or speaking up. And it implies if you’d done those things, the person would still be alive.

Not necessarily, unfortunately. Joanne Harpel, president of Coping After Suicide, says slogans that suicide can be prevented if people reach out or listen are well-meaning, but “can still land with a painful, tone-deaf thud on those of us who did those things — sometimes hundreds of times over months or years — and yet still lost someone we loved to suicide.”

Some people say that proclaiming suicide preventable also blames the person who died. Sophia Laurenzi, whose father died by suicide, wrote in a recent Time essay:

“Right after my father’s death, everywhere I looked I read that suicide is preventable. This instilled an immediate, unconscious conviction in me of a double failure: my father, who had not done enough to save himself, and those of us who loved him most, who had not done enough, either.”

The phrase “Suicide is preventable,” much like “achieving zero suicide,” is aspirational. Many people wish suicide were always preventable. Many people wish we could achieve a state of zero suicides. But wishes aren’t facts.

If someone you love has died by suicide – or dies in the future – it doesn’t mean you failed. It typically means that you, like all humans, were limited in what you could do for the reasons listed above.

The same limitations apply to mental health professionals. No doubt professional negligence does occur sometimes, as the book The Suicide Lawyers makes clear. And mental health professionals receive little training in helping suicidal people. But in some cases, clinicians do everything they’re supposed to do – everything we know to do – and suicide still occurs.

There are things beyond our control when it comes to stopping someone from dying by suicide. These challenges sometimes – let me emphasize sometimes – are impossible to overcome.

What We Can Do to Help Prevent Suicide

I need to be careful here not to foster nihilism or hopelessness about helping suicidal people to stay alive. There’s a myth that if someone makes up their mind to die by suicide, there’s nothing anybody can do about it. Don’t believe it.

An especially compelling research study followed up people who were stopped from jumping off the Golden Gate Bridge. Many years later, 90% had not ended their own life.

We’re not helpless. We can do many things to try to help a suicidal person stay alive:

Ask – and Listen – about Suicidal Thoughts

As noted earlier, many people hide their suicidal thoughts. Asking directly if someone is considering suicide doesn’t guarantee they’ll answer honestly, but it shows that you want to know, can handle the topic, and care. Even if the person chooses not to answer frankly, you might be planting the seed for them to come to you later.

Asking about suicidal thoughts doesn’t give the person the idea. You might worry that asking the question will anger someone. It’s unlikely, but even if it does, that’s reparable. You can explain why you’re worried. How much you care. Even if asking this sensitive question is uncomfortable for you, wouldn’t you rather ask and try to help than not know? (For tips on how to ask, see my article Uncovering Suicidal Thoughts.)

Perhaps more important than what you say is how you listen. I advocate for brave listening, which I define in my recent book as “resisting the temptation to change the subject, give advice, lecture, offer reassurance, or convince the person to think or feel differently. It’s focusing on the person’s needs, not on your own wish to feel less helpless, worried, and stressed as you listen.”

Listening bravely means encouraging the person to tell you more, rather than shutting down the conversation with a lot of yes/no questions, or judgmental responses, or minimization of the person’s problems. (For other examples, see my post 10 Things Not to Say to a Suicidal Person.)

Attend to the Person’s Physical Safety

If somebody’s in immediate danger of acting on suicidal thoughts (versus thinking about suicide without the intent to try anytime soon), stay with the person. In the U.S. and Canada, you can call 988 for guidance, or take the person to an emergency room for an evaluation. In extremely dangerous cases, you might call 911, but this should be avoided whenever possible because police involvement carries its own dangers.

Sometimes, someone’s suicidal thoughts rev up when they’re intoxicated, and staying with the person till they sober up – or taking them somewhere for help – can get them through the danger zone. (In the U.S., 1 in 3 adults have alcohol in their system when they die by suicide.)

Help Connect the Person to Professional Help

Psychotherapy of any type can help prevent suicide, according to numerous research studies. And there are evidence-based treatments at therapists’ disposal to help reduce suicidal thoughts and behaviors. Dialectical behavior therapy (DBT), cognitive behavior therapy (CBT), and the Collaborative Assessment and Management of Suicidality (CAMS) are the biggies, but there are other therapies with emerging evidence of effectiveness, such as acceptance and commitment therapy (ACT) and mentalization-based therapy.

Some medications also might weaken suicidal thoughts and urges for some people. In particular, lithium, a mood stabilizer, and clozapine, an antipsychotic, appear to lower suicide risk, and ketamine is showing promising short-term results.

Alert the Person to 988, Crisis Text Line, and Warmlines

Suicide hotlines get a lot of criticism, but they do help many people to live another day. In the U.S., calling 988 will connect you with the 988 Suicide and Crisis Lifeline. You can also text 988 or use their chat service. The Crisis Text Line can be reached at 741741, or you can use the service via chat or WhatsApp. Warmlines tend to be answered by people with their own lived experience of suicidality or other mental health challenges; you can find a directory here. And I list other resources here for people with suicidal thoughts and their loved ones.

Help Create a Safety Plan

In study after study, people who engage in safety planning are less likely to attempt suicide than those who don’t. To create a safety plan – or a crisis stabilization plan, as CAMS calls it – a person identifies in advance people and places they can go to for distraction or help in a crisis, as well as ways to keep their environment safe.

(For an excellent overview of safety plans in general, see this article, “Suicide Safety Plan Templates and Examples.” For information specific to safety planning with adolescents, see this article, “Helping Teens with Suicidal Thoughts Make a Safety and Coping Plan.”)

Make Suicide Methods Less Accessible

Protecting suicidal people from weapons they can use against themselves, especially firearms, is one of the most effective deterrents to suicide. Lay people and clinicians alike can receive free training on CALM: Counseling on Access to Lethal Means.

Reducing access to lethal means is a part of safety planning, and it’s something we can do at the societal level, too. Suicides at the Golden Gate Bridge, for example, decreased by half even before a new suicide prevention net was fully completed.

Provide Support and Connection

A surprisingly easy way to help some people is to stay in touch. Researchers sent postcards to people after their discharge from a psychiatric hospital, and they had a lower suicide rate than those who didn’t receive postcards. Studies into these “caring contacts” methods have had mixed results but overall are promising.

Social isolation is a huge risk factor for suicide. Spending time with someone you’re concerned about, making plans to get together, texting them to see how they’re doing or just to send funny memes, sending them a care package – all of these can help someone feel more connected.

Advocate for Social Change

Suicide isn’t just an individual issue. We can make changes at the societal level, too, that would help prevent suicide. Big things, like improving the quality of life via social services and economic supports. Ending racism and other bigotry. Making the world a place where more people want to be alive.

A popular meme by Mental Health America lists housing, affordable health care, food security among other suicide prevention measures.

Doing the Best We Can in Suicide Prevention

Even though we’re limited in our ability to prevent suicide, we still need to try. Most people who survive a suicide attempt don’t go on to kill themselves. Many such survivors are grateful to be alive. (As just a few examples among many, see the poignant and uplifting stories of Kevin Berthia, Shannon Parkin, and Linda Straubel.)

Nobody’s suicide is inevitable. There are so many things we can do to help people resist suicidal urges and feel better that I filled two books on the topic.

Suicide is often preventable. Very often, in fact. That statement acknowledges our limitations while also creating space for hope.

Many thanks to suicidologists Nina Gutin, Ph.D., Lena Heilmann, Ph.D., and David Jobes, Ph.D., for generously reviewing this article before publication and providing suggestions that improved it.

I welcome feedback for further improvements. If you’d like to share, please leave a comment below. If you don’t want your comment to be published, please say so and it will remain private. – Stacey Freedenthal

_{© 2024 Stacey Freedenthal, PhD, LCSW, All Rights Reserved. Written for Speaking of Suicide.}