Thank you so much for writing this! It echoes so many beliefs, stances, and conflicts I have as a therapist and person who has lived with thoughts of suicide. I’m heartened to see more of a shift to understanding and responding to suicidal thoughts this way in the last handful of years, and I hope it continues. I can’t tell you how many people have told me they have been so harmed by therapists’ responses to even vague mentions of suicide without any intent, that they now fear or loathe the idea of getting support from mental health professionals. I hope we will see the day that this field reckons with and takes accountability for the harm it’s caused to the people seeking help at their most vulnerable points.
Beautifully well-written. It's always bothered me the way popular society has developed a set of action plans around the disclosure of suicidality that all have the result of foisting the pain off on somebody else to deal with. Tell people to call a crisis line. Tell them to speak to a professional. Call 911 on them. When in practice, in my personal experience, the things that have helped my suicidal friends the most are simple, consistent companionship, and the promise of confidentiality. The thing you put yourself at risk to give. There's been one exception: I have known one periodically suicidal person who religiously calls crisis lines and believes strongly in professional intervention even against a person's will. But that only serves to underline the importance of respecting people's inherent humanity and free will, their right to make decisions about their own care. Thank you so much for laying out this essay. I think it will help a lot of people.
Thank you for writing this! I read the book Every Cradle is a Grave a few years ago, which is a work of philosophy that takes a more morality-grounded approach to suicide harm reduction. But that book radically changed my perspective on the matter and reading it at a time when I myself was actively suicidal was, somewhat surprisingly to me, immensely comforting. Ever since, I have always been invested in this harm reductionist model and sought to find more texts on the subject. This article along with the zine cited will be good resources! I’d also recommend the article from Ayesha Khan / wokescientist called Destigmatize Suicide. <3
I have recently been reading Undoing Suicidism by Alexandre Baril (https://www.jstor.org/stable/jj.5104041) which explores many of these ideas and proposes a policy/society wide approach to suicide that is consistent with supporting autonomy. It is a long, sometimes dense, read but a valuable one I feel. Thank you for considering so many of the same ideas, and producing such a clear and emotionally connected piece.
This essay is incredible, thank you so so much for writing it. The more I think about it, the more sense this makes. And as I think through my interactions that I’ve had with suicidal people in the past, I can see that a lot of my reactions were counterproductive, and I want to make sure to do better in the future.
Man I wish harm-reduction was more disseminated about suicidality (and by extension self-injury.) I deal with pretty severe NSSI but only recently have I really realized how hard it is for me to talk about the suicidality I experience.
I unfortunately can't avoid interfacing with emergency services when I get necessary medical treatment, so it becomes something I'm pretty vigilant about. I carefully screen clinicians I work with for their attitudes towards mandatory reporting and will have frank and explicit conversations about their threshold for reporting. I acknowledge I have a lot of privilege in being able to vet and choose clinicians like that.
Something that is less commonly disseminated is that psychiatrists, even if they 'determine' that someone meets the 'legal' standard for 'involuntary admission' (incarceration), do not have to admit that person. Unfortunately you get a lot of CYA attitudes w/ doctors, but with proper documentation the risk is overblown. Of course its ideal that people experiencing suicidality don't get to the point of being assessed, but if it gets there, assessing psychiatrists/other drs can (and should...) resist the pressures to incarcerate and instead respect autonomy.
I'm thankful (low bar) that my psychiatrist and those at the hospital I go to understand that involuntary 'admission' will be "counter-productive" and actively harmful, even when presenting with potentially life threatening conditions, but that's always in the absence of suicidal ideation. Its hard to talk about any potential suicidality, even to friends, since i fear they will be more afraid because of my history with NSSI. Its really isolating.
I really hope that more and more non-carceral responses to suicidality will become understood as the ideal, and to center nuance and autonomy over all.
This is- brilliant!!!! I loved every single bit of it and I also appreciate the way you’ve articulated all of it. As someone who has a hx of being suicidal before, and attempted it as well in the past, but (mostly) healed, I couldn’t help but feel so seen and supported. I’m a doctor by profession now and a lot of people in my circle unfortunately don’t echo my emotions wrt the people committing suicide and their need for bodily autonomy and freedom. It is indeed a very disheartening sight to see people making it about themselves instead of offering support to the people who’re suicidal/just being there. It’s articles like these that help destigmatise mental health struggles for what they are and give a very raw, and real perspective on life as a whole. Thank you for sharing!! X
Thank you for your writing! Your challenge to the narrative that “suicide is selfish” is helping me figure out some stuff.
If you want to talk about the link between psychiatrists, the police, and care work I HIGHLY recommend Ismatu Gwendolyn’s “Therapists Are Also the Police”, on the newsletter Threadings on this app.
Thank you for writing and sharing this. It’s very validating, both as someone who has contemplated suicide and as someone who tried, in this sort of manner, to provide support to a partner who did end up committing suicide. The dominant views around suicide and suicidal persons, and the related expectations regarding how to deal with suicidal persons, have contributed to my grief journey being particularly difficult. The guilt and self-doubt have been horrendous and there’s been almost no one I can discuss it with for fear of being blamed or seen as a monster for all the things I did or did not do. Reading this has been really reassuring.
Thank you for writing such a compassionate piece on suicide. I largely agree with it but want to comment that you’re misrepresenting the studies/data that suggest institutionalization increases the risk for suicide.
The “suicide rates after discharge” study finds that people admitted for reasons other than suicidal ideation are 100 times more likely to attempt suicide than the general population. Those admitted for suicidal ideation are 200 times more likely. These rates are unsurprising, given that people being institutionalized are presumably experiencing much greater suffering than the general population. The authors of the study do not claim, as you report, that “being held in a psychiatric institution has been shown to raise a person’s risk of suicide by 100 fold." Rather, those who are institutionalized have an increased risk of suicide. This study also does not distinguish between voluntary and forced institutionalization. The limited conclusion of this study is that post-discharge is a high-risk time for suicide in patients.
The "Perceived Coercion" study finds that perceived coercion in hospitalization is associated with increased suicide attempts after discharge. Of those who attempted suicide after discharge, 66% perceived coercion. It's worth noting that those who are bipolar or psychotic are much more likely to report perceived coercion in hospitalization. Bipolar patients are more likely to be institutionalized when behaving erratically in a manic episode and are more likely to kill themselves during the despair and hopelessness of a depressive episode. Recent self-harm, involvement in treatment after discharge, depression diagnosis, and borderline diagnosis also predict post-discharge suicide attempts. What is clear is that forced hospitalization can be an extremely traumatic measure that should not be taken lightly. I don’t doubt that many people are worse off after such experiences than they were before.
Neither of these studies claims that the data suggest that hospitalization was the causal factor in post-discharge suicide attempts. I believe that it very well could be in some cases, but it's irresponsible to point to these studies as data to back this up. Conversely, forced hospitalization could have been the life-saving measure in many of these cases. The best we can do is say that forced hospitalization is harmful to some and beneficial/necessary to others, but it's hard to draw more specific conclusions. Obviously, we can't control for such studies to get good data. There is no "abundant" research, as you write, that forcing suicidal people into institutions only results in them becoming more suicidal and traumatized.
The Washington Post article does not support your summary that police are "far more likely" to kill a person in distress than help them, as you write. What is clear is that a large portion of people killed by police are having mental crises. This is a problem. I do not advocate for calling the police to deal with such situations, but I do not think misrepresenting this information is helpful.
There is no doubt that the history of psychiatric institutions is full of literal horror stories and instances of "treatment" that can only be accurately described as torture. It is safe to assume that this history has left millions of victims in its wake. Yet the quality of care in psychiatric institutions worldwide varies widely. Just like you say every suicidal person is different, it would be wrong to say that they are all the same or that there is no place for psychiatric institutions in our world. We need to take a nuanced approach to psychiatric care and be rigorous in our approach to analyzing the data that informs how we treat mental suffering.
I'm very sympathetic to arguments for body autonomy. Who am I to impose my worldview on a friend who wants to kill themselves? The world is mysterious, and I think there's weight to the argument that doing so is a selfish imposition of my own discomfort with death. Yet, as you point out in your essay, many suicide attempts are impulsive – a forced intervention could conceivably be enacted while respecting a friend's interests. That said, I think all of the alternatives you outline in this essay are much better than drastic and forced measures. Thank you for writing about them.
I understand you're writing about your personal experiences and the experiences of your friends in this essay. Please don't take my critique of your presentation of these studies as a critique of your experiences. As you point out, every suicidal person is different, and ultimately, focusing on statistics erases those differences.
Thank you so much for taking the time to write this comment, Will. I appreciate when people care about rigor in reporting study results as I get irritated by shoddy statistical flubs and oversimplifications in writing about social science research all the time. In this case, I think the published work on the risks of institutionalization are a strong enough rebuke of psychiatry that it's important for us not to be coy.
The data is more than merely correlational, it also has a temporal element, linking risk of suicide to time after discharge along multiple time points. When you have both statistical association and a clear temporal link, you're entering the realm where drawing a cause and effect linkage is sensible, especially when you are trying to prevent something as catastrophic as a suicide in a person who had no serious ideation prior. Science moves at a glacial pace, and psychology and psychiatry are especially hesitant as institutions of knowledge to admit to the harms they've done -- but in this meta-analysis of numerous studies on the risks patients face post-discharge, we're clearly staring at a smoking gun. In my work I often suggest alternate interpretations of published data that the study authors have not considered due to their institutional biases, and this is definitely one.
As for the data on the risk police pose to persons with mental illness, I think we have even more of an obligation not to mince words. The data clearly illustrates that the police present a risk, and even more to the point, we already know as abolitionists that they have no legal obligation to help persons in crisis, and that providing aid is not what police departments are designed to do. It is definitional to policing that they present a greater risk to vulnerable people than they do a source of aid -- there's the data that the police state collects and reports on itself, and then there's our leftist analysis of authoritarian institutions and how they function that inform this conclusion. And you can imagine which one carries more weight here. Though it's interesting and noteworthy that even in policing institutions' own data, they admit to doing a terrible job at responding to mental health crises.
This is a very thoughtful piece and I have a lot to say about it, which I'll eventually do on my own Substack. My tl:dr: Being told to "support the suicidal no matter what" needs the caveat: unless that person is abusive or manipulative.
I appreciated this essay and it is making me think about a conflict I haven't quite worked out for myself yet and I'm curious about the thoughts of people here.
It seems to me that a natural extension of these ideas is support for assisted suicide. Personally I support assisted suicide and have grandparents who I wish had had it as an available alternative to the ways that they died. However I read criticisms of assisted suicide laws from some disability advocates who worry that increasing its availability will cause more disabled people to die prematurely. The argument is often predicated on the idea that society may make death more accessible than accomodation and support. I understand that advocates do not see death accomodations as opposed to accomodations for a dignified life, and that both are possible, but I also am sympathetic to the concern, so I'm curious how others have grappled with it.
Thank you so much for writing this! It echoes so many beliefs, stances, and conflicts I have as a therapist and person who has lived with thoughts of suicide. I’m heartened to see more of a shift to understanding and responding to suicidal thoughts this way in the last handful of years, and I hope it continues. I can’t tell you how many people have told me they have been so harmed by therapists’ responses to even vague mentions of suicide without any intent, that they now fear or loathe the idea of getting support from mental health professionals. I hope we will see the day that this field reckons with and takes accountability for the harm it’s caused to the people seeking help at their most vulnerable points.
Beautifully well-written. It's always bothered me the way popular society has developed a set of action plans around the disclosure of suicidality that all have the result of foisting the pain off on somebody else to deal with. Tell people to call a crisis line. Tell them to speak to a professional. Call 911 on them. When in practice, in my personal experience, the things that have helped my suicidal friends the most are simple, consistent companionship, and the promise of confidentiality. The thing you put yourself at risk to give. There's been one exception: I have known one periodically suicidal person who religiously calls crisis lines and believes strongly in professional intervention even against a person's will. But that only serves to underline the importance of respecting people's inherent humanity and free will, their right to make decisions about their own care. Thank you so much for laying out this essay. I think it will help a lot of people.
Thank you for writing this! I read the book Every Cradle is a Grave a few years ago, which is a work of philosophy that takes a more morality-grounded approach to suicide harm reduction. But that book radically changed my perspective on the matter and reading it at a time when I myself was actively suicidal was, somewhat surprisingly to me, immensely comforting. Ever since, I have always been invested in this harm reductionist model and sought to find more texts on the subject. This article along with the zine cited will be good resources! I’d also recommend the article from Ayesha Khan / wokescientist called Destigmatize Suicide. <3
I have recently been reading Undoing Suicidism by Alexandre Baril (https://www.jstor.org/stable/jj.5104041) which explores many of these ideas and proposes a policy/society wide approach to suicide that is consistent with supporting autonomy. It is a long, sometimes dense, read but a valuable one I feel. Thank you for considering so many of the same ideas, and producing such a clear and emotionally connected piece.
Thank you for the rec!
This essay is incredible, thank you so so much for writing it. The more I think about it, the more sense this makes. And as I think through my interactions that I’ve had with suicidal people in the past, I can see that a lot of my reactions were counterproductive, and I want to make sure to do better in the future.
Man I wish harm-reduction was more disseminated about suicidality (and by extension self-injury.) I deal with pretty severe NSSI but only recently have I really realized how hard it is for me to talk about the suicidality I experience.
I unfortunately can't avoid interfacing with emergency services when I get necessary medical treatment, so it becomes something I'm pretty vigilant about. I carefully screen clinicians I work with for their attitudes towards mandatory reporting and will have frank and explicit conversations about their threshold for reporting. I acknowledge I have a lot of privilege in being able to vet and choose clinicians like that.
Something that is less commonly disseminated is that psychiatrists, even if they 'determine' that someone meets the 'legal' standard for 'involuntary admission' (incarceration), do not have to admit that person. Unfortunately you get a lot of CYA attitudes w/ doctors, but with proper documentation the risk is overblown. Of course its ideal that people experiencing suicidality don't get to the point of being assessed, but if it gets there, assessing psychiatrists/other drs can (and should...) resist the pressures to incarcerate and instead respect autonomy.
I'm thankful (low bar) that my psychiatrist and those at the hospital I go to understand that involuntary 'admission' will be "counter-productive" and actively harmful, even when presenting with potentially life threatening conditions, but that's always in the absence of suicidal ideation. Its hard to talk about any potential suicidality, even to friends, since i fear they will be more afraid because of my history with NSSI. Its really isolating.
I really hope that more and more non-carceral responses to suicidality will become understood as the ideal, and to center nuance and autonomy over all.
This is- brilliant!!!! I loved every single bit of it and I also appreciate the way you’ve articulated all of it. As someone who has a hx of being suicidal before, and attempted it as well in the past, but (mostly) healed, I couldn’t help but feel so seen and supported. I’m a doctor by profession now and a lot of people in my circle unfortunately don’t echo my emotions wrt the people committing suicide and their need for bodily autonomy and freedom. It is indeed a very disheartening sight to see people making it about themselves instead of offering support to the people who’re suicidal/just being there. It’s articles like these that help destigmatise mental health struggles for what they are and give a very raw, and real perspective on life as a whole. Thank you for sharing!! X
Carly Boyce’s zine is an incredible tool and it feels so important for it be extending its reach through this essay!
Thank you for your writing! Your challenge to the narrative that “suicide is selfish” is helping me figure out some stuff.
If you want to talk about the link between psychiatrists, the police, and care work I HIGHLY recommend Ismatu Gwendolyn’s “Therapists Are Also the Police”, on the newsletter Threadings on this app.
Thank you for writing and sharing this. It’s very validating, both as someone who has contemplated suicide and as someone who tried, in this sort of manner, to provide support to a partner who did end up committing suicide. The dominant views around suicide and suicidal persons, and the related expectations regarding how to deal with suicidal persons, have contributed to my grief journey being particularly difficult. The guilt and self-doubt have been horrendous and there’s been almost no one I can discuss it with for fear of being blamed or seen as a monster for all the things I did or did not do. Reading this has been really reassuring.
Thank you for writing such a compassionate piece on suicide. I largely agree with it but want to comment that you’re misrepresenting the studies/data that suggest institutionalization increases the risk for suicide.
The “suicide rates after discharge” study finds that people admitted for reasons other than suicidal ideation are 100 times more likely to attempt suicide than the general population. Those admitted for suicidal ideation are 200 times more likely. These rates are unsurprising, given that people being institutionalized are presumably experiencing much greater suffering than the general population. The authors of the study do not claim, as you report, that “being held in a psychiatric institution has been shown to raise a person’s risk of suicide by 100 fold." Rather, those who are institutionalized have an increased risk of suicide. This study also does not distinguish between voluntary and forced institutionalization. The limited conclusion of this study is that post-discharge is a high-risk time for suicide in patients.
The "Perceived Coercion" study finds that perceived coercion in hospitalization is associated with increased suicide attempts after discharge. Of those who attempted suicide after discharge, 66% perceived coercion. It's worth noting that those who are bipolar or psychotic are much more likely to report perceived coercion in hospitalization. Bipolar patients are more likely to be institutionalized when behaving erratically in a manic episode and are more likely to kill themselves during the despair and hopelessness of a depressive episode. Recent self-harm, involvement in treatment after discharge, depression diagnosis, and borderline diagnosis also predict post-discharge suicide attempts. What is clear is that forced hospitalization can be an extremely traumatic measure that should not be taken lightly. I don’t doubt that many people are worse off after such experiences than they were before.
Neither of these studies claims that the data suggest that hospitalization was the causal factor in post-discharge suicide attempts. I believe that it very well could be in some cases, but it's irresponsible to point to these studies as data to back this up. Conversely, forced hospitalization could have been the life-saving measure in many of these cases. The best we can do is say that forced hospitalization is harmful to some and beneficial/necessary to others, but it's hard to draw more specific conclusions. Obviously, we can't control for such studies to get good data. There is no "abundant" research, as you write, that forcing suicidal people into institutions only results in them becoming more suicidal and traumatized.
The Washington Post article does not support your summary that police are "far more likely" to kill a person in distress than help them, as you write. What is clear is that a large portion of people killed by police are having mental crises. This is a problem. I do not advocate for calling the police to deal with such situations, but I do not think misrepresenting this information is helpful.
There is no doubt that the history of psychiatric institutions is full of literal horror stories and instances of "treatment" that can only be accurately described as torture. It is safe to assume that this history has left millions of victims in its wake. Yet the quality of care in psychiatric institutions worldwide varies widely. Just like you say every suicidal person is different, it would be wrong to say that they are all the same or that there is no place for psychiatric institutions in our world. We need to take a nuanced approach to psychiatric care and be rigorous in our approach to analyzing the data that informs how we treat mental suffering.
I'm very sympathetic to arguments for body autonomy. Who am I to impose my worldview on a friend who wants to kill themselves? The world is mysterious, and I think there's weight to the argument that doing so is a selfish imposition of my own discomfort with death. Yet, as you point out in your essay, many suicide attempts are impulsive – a forced intervention could conceivably be enacted while respecting a friend's interests. That said, I think all of the alternatives you outline in this essay are much better than drastic and forced measures. Thank you for writing about them.
I understand you're writing about your personal experiences and the experiences of your friends in this essay. Please don't take my critique of your presentation of these studies as a critique of your experiences. As you point out, every suicidal person is different, and ultimately, focusing on statistics erases those differences.
Thank you so much for taking the time to write this comment, Will. I appreciate when people care about rigor in reporting study results as I get irritated by shoddy statistical flubs and oversimplifications in writing about social science research all the time. In this case, I think the published work on the risks of institutionalization are a strong enough rebuke of psychiatry that it's important for us not to be coy.
The data is more than merely correlational, it also has a temporal element, linking risk of suicide to time after discharge along multiple time points. When you have both statistical association and a clear temporal link, you're entering the realm where drawing a cause and effect linkage is sensible, especially when you are trying to prevent something as catastrophic as a suicide in a person who had no serious ideation prior. Science moves at a glacial pace, and psychology and psychiatry are especially hesitant as institutions of knowledge to admit to the harms they've done -- but in this meta-analysis of numerous studies on the risks patients face post-discharge, we're clearly staring at a smoking gun. In my work I often suggest alternate interpretations of published data that the study authors have not considered due to their institutional biases, and this is definitely one.
As for the data on the risk police pose to persons with mental illness, I think we have even more of an obligation not to mince words. The data clearly illustrates that the police present a risk, and even more to the point, we already know as abolitionists that they have no legal obligation to help persons in crisis, and that providing aid is not what police departments are designed to do. It is definitional to policing that they present a greater risk to vulnerable people than they do a source of aid -- there's the data that the police state collects and reports on itself, and then there's our leftist analysis of authoritarian institutions and how they function that inform this conclusion. And you can imagine which one carries more weight here. Though it's interesting and noteworthy that even in policing institutions' own data, they admit to doing a terrible job at responding to mental health crises.
This is a very thoughtful piece and I have a lot to say about it, which I'll eventually do on my own Substack. My tl:dr: Being told to "support the suicidal no matter what" needs the caveat: unless that person is abusive or manipulative.
One of the best, no-bullshit essays I've seen on this topic. Breath of fresh air. Thank you. 🖤
I appreciated this essay and it is making me think about a conflict I haven't quite worked out for myself yet and I'm curious about the thoughts of people here.
It seems to me that a natural extension of these ideas is support for assisted suicide. Personally I support assisted suicide and have grandparents who I wish had had it as an available alternative to the ways that they died. However I read criticisms of assisted suicide laws from some disability advocates who worry that increasing its availability will cause more disabled people to die prematurely. The argument is often predicated on the idea that society may make death more accessible than accomodation and support. I understand that advocates do not see death accomodations as opposed to accomodations for a dignified life, and that both are possible, but I also am sympathetic to the concern, so I'm curious how others have grappled with it.
This whole article is amazing
As a future therapist I found this to be very valuable and insightful. Thank you!