Kangaroo Hearing: Congress & Technology CEOs

Kangaroo Hearing: Congress & Technology CEOs

This last week’s congressional hearing and grilling of Tech CEOs provides another example of a theatrical performance by the United States Congress. The hearing involved confronting the Tech CEOs with regard to harm for children, particularly public safety and sexual exploitation.
Parents held signs with pictures of their children who have been victims of sexual exploitation. The small crowd of victims dictated the tone of the hearing. When Senator Lindsey Graham told the CEOs they had “blood on their hands,” the audience applauded. This is the same senator who, along with other senators, refuses to regulate the sale of powerful weapons, which have killed thousands of children in schools. In Texas, the Uvalde shooter was 18 years old and purchased an AK-47. The seller cannot be sued by Indiana state law.
The hypocritical senators insisted the tech companies should be sued and held responsible. Didn’t we go through this with the video game industry? In a court, causality must be clear—that the games caused the actual violence. Of course, that is near impossible to prove.
Nor did the kangaroo hearing point out the tremendous benefits of social media. Teens are pretty familiar with internet/social use. According to Pew Research, 32% of teens said social media had a positive impact on them such as feeling connected—an incredibly important variable for teens. Further, Pew reports 59% of teens indicated that social media had no impact on them—positive or negative. Yet, they also report experiencing the drama and social extreme reactions including being excluded. Thus, despite public safety dangers, most teens seem pretty sanguine about social media.
Perhaps the problem might be the pre-teen ages, 11 and 12. It is probably too late for the argument they should not be allowed to use social media because they are too young and immature. No matter what is done, pedophilia, bullying, stalking and illicit/illegal activity will not go away. Should we try to do better for online platforms? Of course! Just as what I have written regarding suicide; we will never stop suicide, but it is our moral obligation to try with every effort and program that we can.
So how about a comprehensive solution because bashing the tech CEOs is not the best answer. Certainly, insisting Mark Zuckerberg apologize won’t solve the problem, though it would hopefully help address parental grief. We can’t count on Congress—they will just regulate in response to parental and societal pressure while they grandstand.
Rather than after the fact responses, what about preventative programs? Many communities require law enforcement professionals go into schools to address and inform youth of public safety issues of drugs or suicide. This can be expanded starting at the important age of 10 or 11 with regard to overall internet use. The underlying principle is to teach younger children that not everything you see on the internet is true. From this would be comprehensive school safety programs for internet dangers of pedophiles, bullying, violence, drug use and everything else—especially what to do (think triggers) when one encounters social media danger.
If the tech CEOS of Meta, X, Instagram, SnapChat and YouTube were smart, they would fund a social policy institute. From that structure, they could disburse funds to school districts which would implement preventative programs starting at the 4th or 5th grade. I can’t imagine any parent or teacher not in favor of such an approach. Imagine further the discussion material available for the classroom and with parents. Perhaps it can even help bring our communities together and depolarize our society.

Instead of waiting for Congress to do something, it's time for American parents to step and take charge.

Lance Crayon

Preventive programs can backfire. You end up with more of the problem when you focus on it because kids are so suggestible. We need to focus on healthy alternatives instead. By healthy I don't mean vegetables, I mean hobbies that build self-direction and self-agency. More on my parenting page https://innermammalinstitute.org/parentsteachers/ Especially my podcast episode on "Anti-Bullyism" https://www.spreaker.com/episode/anti-bullyism-makes-things-worse--42125475

Loretta Breuning, PhD

Preventative programs are a must given the stigma associated with conversations related to a child’s mental health and social media’s impact. Children are reluctant to speak about their experiences as it is; add to that other concerns related to mental health (anxiety, OCD, intrusive thoughts, etc.) and they likely will remain silent. Unless they become comfortable with the conversations that preventative programs could offer, which would encourage dialogue between children and professionals as well as children and their peers.

Karen L. M.

We cannot allow tech CEO’s to police themselves, they will err on the side of the financial bottom line. Therefore, legislators should legislate and write laws and procedures that look out for children and others who enter the vast wasteland of the Internet. I love how you went right after the gun manufacturers, you like most liberals are anti 2nd amendment. In addition powerful tech CEO’s like Zuckerberg should not be allowed to donate 400 million dollars to effect the out come of elections. I know he got around election law by giving to two non profits. Loopholes, and disgraceful.

William Cannon

Dr. Mazzucelli, I share your notable concern on the topic of gun violence and assault weapon accessibility issues; even with such regulatory policies being passed, I am afraid that bad actors wanting access to such weapons will still possess them. I believe identifying and mitigating the flow of such weapons, namely those that illegally flow in through our borders, should be considered when looking at this problem. One person killed and 20 others shot is insane, unacceptable, and should be a beckoning call for policy-makers and public policy experts to develop and provide thought leadership towards sensible gun-reform type policies that honor our right to bear arms via the 2nd Amendment, but also addresses the obvious risk associated with certain type of weapons being actively sold. As details of the investigation unfold, my heart and prayers are with the families of those impacted by this heinous attack, which some may even argue could be seen as terroristic.

Levino L. Johnson Jr., Ph.D., MSc, MPA

The violence in Kansas City on Saint Valentine’s Day speaks tragically, yet again, to what is required immediately in Congress: namely, the call by citizens of all ages for stronger regulation on the sale of assault weapons. Young Americans are particularly vulnerable in situations of gun violence, which threaten the safety of all in a community. The potential of social media to disseminate educational materials encouraging citizen support for limits on high-capacity magazines as well as robust background checks may be constructively tapped. The creative articulation of “voice” by citizens that urges Congressional legislation to ban assault weapons as a “proventive” measure requires the highest priority in agenda setting looking ahead at the start of 2024.

Prof. (Adj.) Amb. (Hon.) Colette Mazzucelli

A Message Regarding Inflation: It’s the Housing Costs, [Silly].

A Message Regarding Inflation: It’s the Housing Costs, [Silly].

While inflation has declined, Americans remain unrelieved from any reported declines in costs. Why? The answer is housing.

Housing is a primary cost and one we consumers cannot readily bargain our way through. If the price of chicken or eggs rises, I can try to find a substitute. I can also choose not to go out to eat at a restaurant. (However, it is obvious some restaurants have taken advantage of inflation to profiteer and raise prices higher than they need to be, while ostensibly making inflation or the government the bad guy.) Still, I can stay home and eat. I don’t have to pay $20 for a glass of wine. Of course, wealthy persons are not impacted by this.

When it comes to housing costs and rent, moving is not an easy decision. Besides the costs of moving, seeking a lower price often requires drastically downsizing or settling for a less desirable location. Unlike visiting a grocery store, where I can select from a variety of items and take advantage of sales to balance out higher prices on preferred products, moving does not offer such flexibility. I am left with no desirable options.

Where would I even move given the historic lack of housing supply? Few homeowners are selling since, according to Redfin, 91.8% of U.S. mortgaged homeowners enjoy a rate below 6%, with 82.4% benefiting from rates below 5%. This is certainly cause for increased frustration and anger.

Just consider your own experience over the years. Do you know anyone who ever had their rent lowered? It used to be in a loan mortgage application that your housing costs should not total more than 35% of your gross income. Keep in mind this 35% total is supposed to be inclusive of property tax and home insurance. This also does not consider your other debts, such as car loans or credit cards—”a debt to ratio” of your gross income. No wonder young adults live with their parents at increasing rates.

Economists seem aware of these loan requirements and the economic strain for young adults, but only give lip service to the dilemma. Parents are fully aware of the economic dynamics because they deal with the impact of their young adults who still live with them. Maybe this is like having an academic economic theory that does not match the reality of those who have to go out in the world and face reality. In the larger picture, economists seem in denial about the magnitude of the impact of housing costs on inflation.

So, let’s take economic data then. From June 2022 to March 2023, annual CPI inflation in the U.S. decreased from 9.1 percent to 5.0 percent. In June 2022, housing costs were one fifth of that amount and contributed 1.7 points. By March 2023, that contribution rose to 2.6%. This is slightly more than half of the 5.0 percent annual CPI inflation.

Now economists will wax and wane and tell you about the complexities—geography/location, the pandemic, decline in supply—all true but still missing the human impact that demands action and makes us very surly. That is, after you pay your housing costs, you have little left for anything else. Thus, an increase in gas, eggs, and chicken really hurts and makes you angry when you leave the grocery store.

The government should try to do something about housing costs if they want to help people and reduce street-level anger. The experts, politicians, and the economists don’t really get it. To paraphrase 1992 Clinton Presidential campaign strategist James Carville’s provocative slogan against incumbent George H.W. Bush: “It’s the housing costs, [silly].”

Dr. Jay Slosar, Psychologist, I always appreciate your articles, and your insights when you were a guest on my podcast last year were profound and meaningful. I was a homeowner in the past for about 10 years but have been a renter ever since. The rental market is outrageous in so many locations, and in places like Santa Fe, New Mexico where I currently live, it's no different. Many of us are paying far more than 35% of our monthly income on housing, and when you add the rising costs of food, utilities, gas, and healthcare, you have a complex picture of chronic economic struggle for millions. In municipalities where a certain percentage of "affordable" housing is mandated, I've heard of workarounds being manufactured wherein the number of affordable units ends up being woefully inadequate. As a healthcare provider, I believe that safe and affordable housing should be considered a public health issue. The lack of access to affordable housing can lead to all manner of socioeconomic and psychosocial ills, including homelessness, food insecurity, mental health issues, substance use disorders, and dare I say phenomena like spousal or child abuse. How we fix the problem is a complicated answer that I lack the savvy to answer.

Keith Carlson, BSN, RN, NC-BC

Good article. I have been in the housing finance industry for 50 years and have never seen anything quite like today's housing market. Mortgage rates have returned close to a median range and yet home sales are at lowest levels since 1995. Who's going to sell when the vast majority of homeowners have rates below 5%. I can't imagine a scenario where rates will fall below 5%. So it is going to take "life events" to cause existing home inventories to rise. What a time to be a builder.

David Lykken

The cost of housing will be the major financial issue for Gen Z and beyond. It wasn't that long ago - 2002 - when my wife and I started off our married lives. We were both elementary school teachers and found a starter home for $89,000! Granted, this was a smaller, two-bedroom house but was perfect for us. Where can someone find a house for that price right now? I am the father to a college sophomore and a high school junior and have come to realize that both of my girls will more likely than not live with us while starting their careers. I think this is something that parents should start planning for.

Danny Kofke

The link to the full article is in the description.

Scott Carson

People are struggling all over the country due to inflation and increased costs on everything besides rent or mortgage rates. Default rates are increasing on credit cards, auto debt, and all types of mortgage debt (both residential and commercial). We just highlighted the top 25 most financially distressed cities across the country that you might want to take a look at because many of our top cities were on the list and that came as a surprise to me. Check it out at https://youtube.com/live/nOyyrA21448

Scott Carson

I think housing cots is an extremely important issue, but not the central issue of the presidential election. For the Left it will be the ability to continue to take the ives of the unborn in the wake of the SCOTUS ruling on Roe v Wade. For Conservatives it will be the border. Just my opinion.

Mark Shiver

This is a great article Dr. Jay Slosar, thank you. There are a number of factors affecting affordability. While buyers are not able to control the market and many of the costs, they can educate themselves on the market and the options they have available to them currently. Purchasing your first home and potentially your second and third may have to be move up properties over time to get to the property they really want. Many of the costs of owning are increasing rapidly. Insurance, energy, water even sewer costs are out pacing inflation in many areas. Now is the time for homebuyers to educate themselves on the total cost of homeownership so they are not caught off guard. Budgeting is more important today than it has ever been. The government should move to lower energy costs as quickly as possible in order to stem the rising tide that is the root cause of inflation. Government intervention in the housing market is not always the solution. Government spending needs to be reined in to lower inflationary pressures as well.

Mike Litton

Great point doc. The growth in housing costs continue to prevent well meaning people in getting a home, having warm water, and a good nights rest. We must do better as a society.

Tim S.

Foreign investors have artificially raised the cost of housing by over paying for homes , renting those homes out at a high price making it nearly impossible to become a home owner. The USA may want to consider eliminating foreign real estate investors and make home ownership a reality again. The alternative could be making Americans succumb to inflation, foreign control and release of freedom. It’s very real to me and my community. Our neighborhood is owned by more investor’s than families.

Rev. Jodi Suson-Calhoun

Large corporations have bought up too many single family residences, forcing up the price to benefit investors. Perhaps protecting such properties from this kind of investing would be helpful. As for restaurants, the “Mom and Pop” model is hard pressed to support a working family anymore. The cost of employment (beyond the set minimum wage) is tough to navigate, especially if the space is leased, rather than owned. This is a complex problem, requiring cooperation at many levels, to solve it.

Marguerite Lorenz, MCIT, CLPF

As a business loan broker, this normally is not my area-residental housing but Dr. Jay asked me to comment. So this is my take on inflation and real estate investment. Inflation can have both positive and negative effects on real estate investments from a loan broker's perspective. On the positive side, real estate is often seen as a hedge against inflation, as property values and rents tend to increase with rising prices. This can potentially lead to higher returns for investors. However, inflation can also lead to higher borrowing costs, which may impact the affordability of taking out loans for real estate investments. Additionally, inflation could erode the purchasing power of rental income, potentially affecting the profitability of real estate investments. As a loan broker, it's important to consider the complex interplay between inflation, interest rates, and real estate values when advising clients on investment decisions.

Jacquelyn J.

This post is spot on and we are seeing the effects of the housing crunch here in Jacksonville, Florida, where rent prices have increased 46% over the last 5 years and a large proportion of homes are investor owned. Jax was a very affordable city compared to the usual metro areas people fled during the pandemic. But in the span of only a few years, soaring home/rental prices, high interest rates, low housing stock, and investor-owned properties have squeezed the market considerably. 

Josh Gellers

I'v been a homeowner for 24 years. I think of moving but my mortgage is less than most people's rents here for the same size house. Rents are out of control. So many houses and apartment buildings r owned by large corporations with no relationship to communities or people. With a holistic approach we could have affordable housing. It's in the interests and adds value to the community. Homelessness in my city is beyond belief. Many homeless people work, but still have to live in cars, vans etc. A high rate of mental health issues and addiction contribute to thousands of people living on the street, and high crime rate. Businesses close, people move and their houses are vacant, & in disrepair which invites, squatting, rats, etc. Build more housing, and less bombs, and weapons. Build more housing for everyone and housing with services for people with mental illness, more recovery homes for people with addictions. More government subsidized. housing for seniors and low income (the waiting lists here take years). How many houses, treatment centers, etc. can be built for the price of one bomb. We need more programs for lower income and seniors to make repairs on their homes which would keep people housed.

SIMMA Lieberman

Love this article. Housing is such a significant need and such an integral part of living in a safe and secure environment that it will become a more significant conversation in the years ahead. I have not seen a tremendous amount of success with government attempting to solve this problem, however I believe with advent of alternative technologies and solutions, this is a solvable problem. Any thoughts Alexander Cartwright?

Teá Damavandi MPH,MAIO

I have stage five renal failure. I am on dialysis, and am not able to work (ghostwriter) like I once could because of dialysis 20 hours a week (treatment and travel). Once I'm home, fatigue takes over and I can't work, or can only work limited hours. Health issues can impact anyone, but the worst part is, they impact our ability to pay rent. I'm facing eviction soon if I don't make up my rent ($2,500), from where I got behind because of hospitalization in January 2024. It's a race to stay ahead. Housing costs and help for the homeless, needy, elderly, and those impacted by severe health concerns still rise. The reason no one is talking about housing costs is no one wants to upset the landlords who are raking rents in hand over fists. Greed is our new national God. The government isn't going to step in with rent controls, or even tax advantages to landlords who lower rents because it's not sustainable. Low-income housing attracts the dregs of society (drug dealers, addicts, domestic violence, criminals) because a majority of those who live in low-income housing tend to be those who can't maintain high-paying jobs because of a lack of education, effort, culture, thug life, whatever. It's a clusterfuck on every level of government.

Becky B.

The reason any country builds bombs and goes to war is not ideological, but economic. Wars make money for the corporations who support them. If the "elite" had their way, wars would be never-ending. The only problem is they run out of people to train and kill who actually go to war. We could END homelessness and addiction if we threw the same money at housing, health, addiction, and mental health that we've thrown at Ukraine.

Becky B.

I went to a conference last year in Nashville, and the economist put it out very much as you said in this essay about how Gen Z‘s are staying home longer because of the increasing prices across the diaspora to live. As they are upcoming consumers, they are more socially aware and continue to push back on our narratives that doesn’t push the strategic plan forward as a whole. Unpopular opinion, they truly do care about quality of life and obtaining every goal that their parents sold them. Family, 2.5 kids and a house.

Charese Chambers

The cost of housing is indeed a major issue in the U.S. it is one of the major factors that contributes to generational poverty and widens the gap between the wealthy and everybody else. I’m glad we’re talking about it being an election issue for whoever is voted into office gets to decide how everybody lives, for richer or for poorer.

Jill Cox-Cordova

This is a dynamic and complicated problem, and not one with an easy solution that will satisfy tenants or landlords equitably. Government intervention will solve the high housing costs without creating other issues. Several cities in the US have agencies that regulate the cost of housing. NYC has the Rent Stabilization Association, commonly called the RSA. The RSA limits the amount of rent a landlord can charge for an apartment. Government-controlled rent rates sound like a good deal for tenants, and in many cases they are. But in NYC not all units are subject to RSA for a myriad of reasons and complicated factors. This means that non-RSA units can be rented at fair market rates. Regarding single-family homeownership, the pendulum of cost has swung from historically low rates to generationally high rates in a short amount of time. First-time buyers will struggle if they seek space, reasonable commute times, and quality public education. Existing homeowners are also challenged as there is little to no incentive to upgrade to a larger home. Unemployed professionals are also at a challenging crossroads if a new job requires relocation. There are solutions, but none are easy. Will the market self-adjust?

Steven Winkler

Test

The Ignored Personality Trait of Perfectionism and its Relationship to Suicide

The Ignored Personality Trait of Perfectionism and its Relationship to Suicide

The recent report that US surgeons and medical doctors have a higher suicide rate than the general population brings the issue of perfectionism into focus as an underlying factor.

Perfectionism is a personality trait related to suicide. It is surprising to me that this factor is not fully recognized within the fields of applied Clinical Psychology or Suicidology. I have already expressed in a previous post that perfectionism may help explain abrupt suicides. This interest started for me when FBI Quantico called for papers to address the increase in law enforcement suicide. This was way back in 1997. Many colleagues kept citing stress as a major factor in law enforcement suicide. However, my paper on perfectionism as a factor in law enforcement suicide was well received.

My awareness came from a seminal and important research article by Sidney Blatt: The destructiveness of perfectionism. Implications for the treatment of depression. The 1995 article was significant to me as it referenced three extremely talented individuals who abruptly took their lives. Blatt was analyzing data from the NIMH Treatment of Depression Collaborative Research Program (TDCRP). Strong or intense perfectionism was found to interfere with therapy especially in brief treatment models for depression. Blatt recommends long-term treatment if a person is perfectionistic and self- critical.

Perfectionism is a multidimensional construct. There are scales to measure the construct and researchers have identified several subtypes. Perfectionism is not a diagnostic category within clinical psychology, but perfectionistic components of intense self-criticism, excessive concern for mistakes, and high parental criticism and expectations are certainly embedded in anxiety and depressive disorders. As a trait that may be related to abrupt suicide, researchers have described a perfectionistic person as vulnerable to an experience of failure. In that moment of failure, their upward social and no-mistakes career climb can come crashing down.

As a clinician, I believe perfectionism is an important and neglected clinical factor. I am interested in responses from other clinicians, teachers, parents and all concerned.

Question for your commentary: What is the relation between perfectionism and suicide?

Dr. Slosar – thank you for your thought-provoking analysis of a complex and painful subject.

1. While I haven’t had direct experience with abrupt suicide, the tragic loss of prominent individuals like Stephen tWitch Boss serves as a stark reminder of how hidden this struggle can be. 2. Abrupt suicide may be linked to deeply personal and often concealed struggles that aren’t easily detectable by friends or family. This unique and hidden pain might lead to the ‘abrupt’ nature of the act. 3. As a society, we should foster open conversations around mental health and encourage those who are struggling to seek help without stigma. Creating environments where individuals feel safe to share their emotions could be a step towards preventing abrupt suicides. 4. I believe that warning signs may exist, but they can be incredibly subtle or easily misunderstood. Constant education, awareness, and empathy might be the key to identifying these signs.

Azim Khamisa

With my 20 years of experience as a crisis intervention expert-

I saw an incredible amount of ignorance, neglect, and fear in regard to the symptoms of possible suicidal ideation. Tere were always signs! Granted some of the signs were subtle–but the fear among clinicians of talking about and facing suicidal risk just exacerbated the whole problem. The slow suicide of drug and alcohol abuse, though, not abrupt–just as deadly.

Jim Nico

As someone who is currently in training (last year) and into trends...

I have found many things that I would love to research. I work with trauma and the SMI population. I have stopped my clients from attempting again and or cutting. I believe first and foremost I create a genuine connection (therapeutic alliance) but past the DSM, and the lingo/ and how we are trained or suppose to be. I treat them as a person. I also provide psychoeducaion on the data we found and ask them one important question. Are you trying to die or are you trying to stop the pain? I explain the stats which open many of my clients eyes. I track a daily card, essentially data for me . I am able to see that during suicide ideation , hopelessness, anxiety is high, wanting to hurt others is low, feelings of worthlessness is high, depression is low. My clients have stopped cutting and stopped attempting whether its long term I dont know, whether its something I am doing, i dont know that either. I believe we are missing anxiety and impulsively because we are so focused on the act of suicide itself and depression. I’m a big believer in it only takes one person to make someone feel cared for even if it’s your therapist. As humans we want to connect .

Diamond M.S.,Psy.D. Clinical Psychology Doctoral Trainee

As a possible solution...

I would make front line experience in dealing directly with suicidal patients as a must for clinicians. Not just training, they can get and ignore, but direct experience with suicidal patients/clients–.as a minimum–time on a suicide hotline should be required.

Jim Nico

In 2009, I lost my first wife to suicide.

Because of her mental state, I was aware of this possibility, but only a few signs of suicide described above were visible. We talked about it, she wasn’t giving away possessions, and there were levels of hope; however, she was ignoring her support system, she was frozen with indecision on the right next steps in her life, much less her day, and I had no idea how many meds were in her possession until after her death. In retrospect, I should have performed a complete search of the house for meds. Unfortunately, even with excellent training and knowing the signs of possible suicide, I don’t believe there’s any magic bullet here. Different people respond and react differently. I have discussed this with both professional therapists and as part of group therapy sessions with those who lost a loved one…. there is no true clear pattern. On the flip side, it feels like all suicides are “abrupt.” Nevertheless, I have seen through communication and education, plus open discussions like this, we are getting through to people who are either in a depressed state or know someone who needs help. Lives are absolutely being saved.

Michael Puldy

What is compelling to me is that being boots on the ground with teens for 20+ years,

I think the “means” has changed – In my suicide assessments of teens, previously overdosing was the most common method reported to me and a shift happened around 2010 where kids reported going to YouTube to learn how to “tie a noose” – remarkably, YouTube continues to keep the how to hang myself and how to tie a noose videos up despite the rising rates of suicide in young people by hanging. They are well aware of my concerns as I have repeatedly spoken to the YouTube team and members of Congress on this issue with Rep. Susan Wild leading the push against YouTube, having lost her partner to suicide in 2019. We know delaying access to the “means” will prevent impulsive suicides – how YouTube refuses to provide any reasonable action here is beyond comprehension. I do have experience with abrupt suicide losing a friend in high school which became much of the reason to become a therapist for teens and now built the Promly app for 13-19 year olds – (Promly.org) to help get ahead of the teen suicide and mental health crisis with an empowering social network that also provides accessible mental health support for all kids.

Jen Libby, MSW, LCSW

Acceptance from parents and society can feed the perfectionism. Sometimes I cringe when I hear parents or relatives describe their child/student as a straight A student. They are proud. Maybe I am overreacting?

Dr. Jay Slosar, Psychologist

Andrew Holter PhD, SHRM-CP As I noted my original paper and presentation on perfectionism was for law enforcement . I think morality is a factor of intensely wanting to do the right thing.Striving to do your absolute best and then having a poor or catastrophic outcome can be devastating. Perfectionistic tendencies can make things worse.

Dr. Jay Slosar, Psychologist

I don't know if perfection is a neglected factor in short- or long-term talk therapy but one insight about perfectionism and suicidal thoughts seems to be overlooked routinely: in my experience, depressed and anxious perfectionists spend an inordinate amount of time in the mind looking for a perfect solution, or at least a certain/guaranteed solution. And because nothing in the future can be certain, they spin out countless iterations of the future. It is exhausting. No rest. Until one solution appears that is guaranteed to end the experience of the problem - death. It is a comforting thought because the mind can rest on the certainty of death at least for brief moments, even though the mind can start up again about how to die, when to die, who would be hurt, etc. If the client/patient can see thoughts of death as an artifact of the exhaustion of rumination and obsessive thoughts, they are in a position to make some second-order change.

John Petersen, PsyD

Suicide mostly happens when someone feels hopeless, when there is no hope for change or help. When things have to be perfect and only one way, it is often hard to see other options. Suicide can become the only thing that helps. Being a perfectionist means you are often disappointed. Repeated disappointment can lead to a cycle of depression. Once that downward cycle begins, it is hard to come back without help. Perfectionists have a hard time with acceptance of the things they cannot control. That is a frustrating way to live. Acceptance can be learned; and believed. Just wanting things a certain way does not make you suicidal. Not accepting that you can't always have it the way you believe you need can, indeed, make you suicidal.  As therapists, we all believe this can be helped. Like any problem, it takes recognition of the problem and acknowledging the need for help and then asking for it.

Dennis Rozema

Perfectionism may be an additional component that increases the risk of suicide, what should not be forgotten however is the structural nature of medicine, and the philosophy of do no harm. Physicians are medical providers that are to trained enhance the quality of life of patients, alleviate symptoms and again do no harm the patient. Perfectionism, then plays a role here in which they want to do their job to the highest degree possible that will result in the most significant satisfaction and benefits for their patients. The perfectionism in and of itself may not actually be the determining factor to suicide as much as serving in medical systems that do not take into consideration, a patient centered approach, or take into consideration the welfare and well-being of the provider themselves. Doctors have a significant burn out rate, work in a stressful environment that often include harassment, discrimination, and retaliation practices, when accounted for altogether result in higher rates of suicide. Please do not blame the medical provider as being a perfectionist, which results in them killing themselves when you do not take into consideration the systemic structures and policies of medicine that are in play.

Kiana N.

Great article! Perfectionism is often something that goes ignored in relation to abrupt suicide. I’m so glad you’re bringing this to light. Let’s keep the discussion going.

Sonia Guilfoos, MSW, LCSW

It is a huge issue, I deal with perfectionists all the time in my practice. It is an offshoot characteristic of complex trauma. Clients who have it can learn to loosen their grip on performance and give themselves breathing room. The work of Pia Mellody is invaluable in learning how to go into recovery from it.

Becky Whetstone, Ph.D.

Approximately 10 years ago, after being in the field for 10 years at that point, I learned for the first time that Dentists had the highest rates of suicide of all professions. I did a little research and asked a few Dentists who all confirmed this as well as the fact that they are taught this fact in their dental programs. This was shocking that we as MH clinicians aren’t informed if this during our education or training. They confirmed what my research suggested as the main cause: Perfectionism. Based on all of my years working in the medical field and many different specialists throughout the medical community, perfectionism that entails expectations that few if any human can meet and maintain. The real question and cause for additional exploration and a deeper understanding of the underlying psychopathology regarding the development of perfectionism. For example, often times people with Narcissistic PD were often raised by mothers/caregivers who weren’t emotionally available and whose responses to their children was one of indifference, leaving the child to feel invisible & irrelevant. This is obviously a bare bones description but illustrates the point. Continued to #2

Susie Guffey

Perfectionism can sometimes lead an individual to be a high achiever given the constant drive for success, despite the tendency to downplay their own achievements. They may struggle to share their experience of inadequacy with others as this is further evidence for their own perception of a lack of perfection stemming from their inability to deal with “failure.” It is easy for outsiders to dismiss the possibility for distress given an assumption that success and a lack of observed or spoken suffering results in happiness. Lacking positive support can further feelings of loneliness and negative self-talk for perfectionistic individuals. This can lead to feelings of loneliness, increasing the risk of suicide. The all or nothing mentality associated with perfectionism becomes a chronic source of stress given the reality that perfection does not exist, no matter the time or resources given to a solution. Even if progress is made, it is not celebrated or acknowledged, but rather perceived as evidence for failing to meet a goal. Taken to the extreme, this pattern of thought can lead to a sense of hopelessness, an identified factor of suicide. Perfection is an all or nothing mentality, and suicide is an all or nothing solution.

Evan Neufeld

This is a great discussion to have. Perfectionism can as others have said be a component of Suicide and it can also be very isolating and interfere in relationships with other people. I've learned over the years that sometimes what we call laziness or procrastination also coincides with perfectionism. Because if someone feels they can't do it perfectly what's the point of doing it at all? I have many clients who strive to be "on" or "productive" all the time. I feel in my experience as a clinician and as a human being, even though some view perfectionism as positive and hard working it's also kind of said negatively. Usually, people who have high standards or perfectionism themselves don't give themselves a break and feel they have to present this aura of perfection all the time. As I saw in another post here, people whose perfection comes from anxiety or depression can set them up for disappointment because there may not be a perfect answer.

Irene Ramirez

This requires additional study and research in this area to build and capitalize on our current understanding afforded to us by the persistent work of pioneers in this field. This includes underlying individual psychopathology and family systems, etc. Based on research, we know that adverse childhood events are the biggest predictors of people experiencing MH/SA issues later on. We also know that if those underlying issues aren’t eventually addressed, the likelihood of people continuing to struggle with bouts of depression/anxiety going forward is high. The endless amounts of research and data have provided enough evidence showing the impact of childhood events on us developmentally, socially, psychologically, emotionally, etc. as well as the generational impact along with the impact of family dynamics, etc. as a domino effect if not addressed early on. Yet, very few people I’ve treated over the years have ever demonstrated a basic understanding of MH because they’ve never been educated. People can’t change what they don’t know and don’t understand. We have a responsibility to equip them with the vital knowledge and via every mode of transmission available to us.Perfectionism isn’t the issue. It’s a RESULT of the issue

Susie Guffey

It's an important point to note that strong perfectionism can be linked to impulsive suicide when a person's very high expectations for self are suddenly threatened, by an interpersonal or career crisis. However, I don't see perfectionism on its own as increasing suicidal risk. I find that perfectionism is much more often linked with high anxiety and vulnerability to panic attacks.

Christine Elliott

What an interesting article! I'm based in the Bay Area of California and with all of the innovation here, it is also a perfect hub to foster the trait(s) of perfectionism and undue pressure to succeed. I have primarily worked with pediatric patients over the past few years, and now with adults in my private practice. I've seen the tendency towards perfectionism over a large age range and also varying socioeconomic demographics. As far as suicidality and perfectionism, from what I have gathered, it's more challenging for some individuals to reach out for support, as they believe they should not need a therapist or outside support as this is a sign of weakness. This sign of weakness can feel very uncomfortable to them as this is outside of the scope of expectations (perfection) they have for themselves.

Kavita Nandra, LCSW

This is interesting....the dentists I have spoken to informed me they have chosen to become a dentist because either their parent was a dentist or they could not get into medical school. Perfectionism, as I recall studying it, can cause OCD (survival solutions) behaviors because the impracticality of not completing the task is too emotional for the mind to experience. Thus, the body must create a hidden backdoor excuse for an out that doesn't then have the mind think it failed. The trauma-produced experience developed into the ANS trauma strategy of getting out ahead of it. But unlike the kid who was bullied and later turned into the older kid now acting as the bully is not obvious because the person is bullying themselves. Ugh, I know! I remind myself and my clients that if my brain is working well, I'm going to be blind to it.

ms MISSY ms CMH Counselor and Trauma Prevention Advocate

Being a therapist myself and having had experienced suicidal thoughts in the past, I can see how perfectionism played a part. It's hard to see it as perfectionism but I can see how there were beliefs that I'm not showing up as "good enough" or "right" for my family and friends which increased or contributed to my suicidal thoughts at least. As I've worked with clients, I've heard many of the same things voiced. Specifically, that they feel they're not showing up well enough or that they're not showing up right for their loved ones.

Aaron I Anderson

Heidi Elias, LCSW, SEP (She/Her) serving NY, NJ and FL. I believe that there are a variety of causes of suicide, one of which is perfectionism. I consider suicide to be a person’s final act of ultimate control, when they have felt powerless and hopeless, with no other way out. I also view suicide as a culminating expression of anger, and in having the final word. Suicide offers relief from the depths of tormenting despair, in someone suffering from deep depression.  In my work as a Psychotherapist, I want to know the root causes of the behaviors that brought a client into therapy. Once identified, we then go about processing the unresolved thoughts and feelings utilizing both talk therapy, and Somatic Experiencing (SE), which works to heal the body.  I view perfectionism as a reaction to something that went wrong in the early years, in the family of origin, where perfectionism was used as a survival coping mechanism by the individual in order to keep safe. Once processed in psychotherapy, individuals are no longer stuck in old, outdated patterns that are no longer needed and no longer work, and can actually choose how they want to live going forward. heidielias.com

Heidi Elias

Perfectionism comes from parents who give conditional love depending on a child's performance in school and at work. It is this way for most Asian people, The younger generation complains about this way of internalized perfectionism and not feeling good enough due to these parents that favor money and prestige over character and only offer affection if a child performs well in school or makes a lot of money,

Georgina Nunez

Great article. As someone who works on suicidal prevention, I agree that more needs to be done to educate on the connections between suicide and perfectionism. The greatest predictor of suicide is a lack of hope. For a perfectionist who is disappointed in the lack of perfection in the world, it is surely overwhelming and they can easily loose hope. And personally the pressure to always produce at a perfectionistic level can lead to a loss of hope when they fail to succeed at that level. Let’s keep the dialog going on this connection of suicide and perfectionism! LCPC and owner of Capture Your Path Couseling

Geri Condon

Doctors I have known, work in a emotionally detached culture, where perfection in their work is an expectation, even under conditions of stress, fatigue or lack of rest. They receive little praise for their perfect performance, as it is an expectation and not something that they just happened to do well. They bring this detached state into their home life and it is very hard on their family or spouse; which in turn creates distance between them. This sometimes creates a state of personal depression, as their standard of living tells them that they must continue this cycle to maintain their family and home. There doesn't seem to be any way out of these expectations for them. A less than perfect event in their practice, threatens their whole way of life and also gives them a sense of hopelessness. They find it very hard to keep this standard of expected perfection up for a extended period of time, although they try to do so. Family also often put them under financial pressure to meet their extended needs, which only creates more stress and pressure in their life.

Gary Michael aka "Mick" Leach Lazer

In my clinical experience, perfectionism can be understood as a coping response to pathological shame. Early experiences of emotional neglect, harsh parental criticism, and disconnection in all of its forms can lead to core beliefs of defectiveness. Feeling never good enough most certainly can drive high achievement behaviors that are unrealistic and result in performance based self-esteem. When performance becomes the basis of self worth, being perfect becomes a preoccupation that preserves the ego. All can be lost in this precarious ego state. It makes a lot of sense to me that being a perfectionist can put someone at risk for suicide.

Lisa H. Brown, MA, LMFT

As a fellow psychologist, I understand perfectionism as being rooted in the desire for control. I wonder if one of the reasons why many become surgeons and medical doctors is precisely because they are seeking control. The more a person has a need for control, the more they are likely to subscribe to attitudes and engage in behaviors that are meant to grab control. Obviously, this is a risky game because there is only so much we can control. Imagine the disappointment when you're seeking control for so long only to come up short so frequently. It's disappointing, saddening, and perhaps even depressing. Suicide is a way out of that pain. Of perpetually falling short.

Dr. Raymond Nourmand

Perfectionism has nature and nurture components, and I have been fortunate to work with several physicians. In psychotherapy and neurotherapy sessions, family of origin and culture often have tremendous impacts in the genesis and growth of perfectionism. In the framework of growth mindset versus fixed mindset, the self-talk retraining toward growth mindset has clinically helped many previously perfectionist clients break free. This is an important topic and I glad to see discussion around such an important matter, and I hopeful that this will lead to further research.

Andrew Bindewald

Dr. John A Otte Licensed Clinical Psychologist Thank you Dr. Slosar. Perfectionism as a block to honest, open, accepting, and loving relationships is something most of us have encountered. I was not aware of the connection to suicide, so thank you for that insight. The relationship between perfectionism and obsessive and compulsive behavior - not necessarily OCD - has always intrigued me, mostly because there is almost a magical thinking to perfectionism. I have always thought of suicidal ideation and behavior as reflecting deep (intolerable to the person with SI) emotional pain and persistent, unrelenting perfectionism certainly can lead one to that experience. Thanks to all for your informational and insightful comments!

John Otte

In my clinical practice, I come across internalized shame in my clients on a regular basis. This often manifests in perfectionism, which many people interpret as "striving for greatness; settling for nothing less". While it's true that growth is an important process for all, perfectionism deviates from this goal. I've found that perfectionism is much more related to shame-avoidance than progress towards a goal. Perfectionism revolves around the idea that "if I meet my own/others' expectations of me, then I won't feel less-than" or "then I'll feel like I'm enough" in whichever capacity. Many individuals have a deeper insecurity about themselves/their own capabilities, and seek to soothe these distressful emotions by focusing on "how to do better" ad nauseum rather than coping with and moving through these understandably uncomfortable emotions. Suicide, unfortunately, can often be a symptom of individuals who have come to the conclusion that they "will never be enough". This distorted perception and conclusion does often take the form of suicide, which at the end of the day is a permanent solution to a temporary problem.

Aaron Herman MS, LCPC

Thank you for raising this very important topic for collaborative discussion. My specialty are is complex PTSD, including childhood emotional neglect, which is often overlooked or underestimated for its lasting effects. Children raised in environments in which acceptance, approval, and affection are withheld or ineffectively demonstrated will strive to prove themselves to "earn" the vitally important acceptance from their parents/guardians. Perfectionism, in this sense, is a survival response. This desperate attempt to win the love of an emotionally distant parent/guardian (upon whom the life of the child depends) shows up in other aspects of life as the child enters performance based realms of experience; academics, sports, music, etc. The grade, the goal, the applause are a temporary fix, but the nagging underlying belief that they still aren't good enough persists. The hopelessness of never being good enough, no matter how hard one tries, can cause a feeling of futility, unworthiness, and self hatred. In the absence of trauma treatment and support, maladaptive coping strategies like substance abuse and other self destructive behaviors can add to the fatal combination that makes suicide look like the only solution.

Jennifer McCarthy RN, MFT

I agree that perfectionism and suicide are not correlated enough. Hopelessness is a major driving force for suicide. I believe that individuals who struggle with perfectionism have a hard time coping with living up to the perfection they perceive others demand of them; which can perpetuate hopelessness. John Petersen, PsyD #suicide

Tara Emerick, LCSW

I would love to see more research done on this topic. I agree that there is a direct correlation between suicide and perfectionism. I have had clients whom have struggled with self-harm, suicidality, and perfectionism. In what I have observed, there is a correlation between a high ACES score and unrealistic expectations from their family of origin and if there is a culture of ridigity or fundamentalism. I believe that this is not only a problem in high-performing people who become professionals, Doctors and Police officers it is a problem that crosses various socioeconomic backgrounds.

Celine Elise Redfield (they/them)

My specialization is with misophonia, a neurological disorder with intense emotionality and complex family dynamics. Among the common traits of my mostly adolescent clients are perfectionism and straight As ... or often A+. We discuss Wabi Sabi, the Japanese art of appreciating the perfection of IMperfection, as well as their pottery technique of repairing cracks with gold lacquer rather than throwing out the broken piece. I ask how perfectionism is helpful to them, and also how it sometimes gets in the way. I give two examples that happen to be common in our lexicon: "Well, it isn't rocket science" or "it ain't brain surgery." I ask why perfection matters in those two examples. We look at examples of their own perfectionism (clothing has to be folded a certain way, or hung in closet in a certain manner, or books kept on shelves according to their own scheme, etc.) and i challenge them to do something "wrong" and tolerate the discomfort for a while, noticing that nothing bad happens, no one dies. We make the connection between perfectionism and the stress they create for themselves, and look for self-acceptance as a normal, imperfect human. That also goes for parents who have extremely high expectations.

Jaelline Jaffe PhD, LMFT

This could not be a more timely topic, Jay. Our society does not tolerate mistakes and miscalculations, thus many of us are inherently individualistic and perfectionistic (and often narcissistic, but that's another conversation). In these days of astronomical malpractice insurance costs, a highly litigious society, and near universal pressure to achieve perfection in all matters, it's no wonder physicians are taking their own lives in record number. Add to this the corporatization of healthcare and the ongoing pressure of the 15-minute visit for both specialists and primary care docs, it's no wonder that we have a shortage of physicians. And when we also consider the unreasonable expectations that our doctors be all-knowing superhumans with no room for error or simply not knowing the answers, we have a recipe for self-recrimination, self-hatred, and self-harm. Don't we owe our physicians a whole lot more?

Keith Carlson, BSN, RN, NC-BC

Interesting.

Katy G.

As a former firefighter/paramedic, I think we can absolutely look at perfectionism within this population as a possible root cause, but also forgotten is the impact of moral injury. I think combined, these two can be a knock out punch. Having personally experienced the impact of both, striving for perfection, and suffering constant moral injury in healthcare, you absolutely lose sight of reality and begin to look for an escape. I'm speaking more from personal experience and a candid place rather than a research informed one on this subject as this subject is more personal to me than others.

Dr. Andrew Holter

Dr. Jay Slosar, Psychologist I was recently discussing with a colleague that many parents need to see their children more holistically. They are much more than their grades. They may be kind and thoughtful people, with a passion for building, inventing, animals, nature etc. They may be really funny, or adventurous or patient, or a sensitive and deep thinker. A hard worker, persistent, a good leader, a good follower etc. So many more important things than being a straight A student.

Danielle Hanchett Friedman, LCSW

As I noted with Lisa's post this is so true. Its just getting the person to longer term therapy because short term models won't work.

Dr. Jay Slosar, Psychologist

OCD is in the DSM and gets diagnosed by the repetitiveness of behaviors--and rigidity. The movie as Good as it Gets with Jack Nicholson was the classic. Perfectionism is less identifiable in that sense and has an end point like success.

Dr. Jay Slosar, Psychologist

Dr. Jay Slosar, Psychologist I would argue that the perceived endpoint for perfectionism is not actually an endpoint as perfectionists seem to be constantly raising the bar on themselves or unlikely to be satisfied when then get to the “endpoint,” unfortunately.

Danielle Hanchett Friedman, LCSW

That is so true. Some professions are very demanding and controlling and may in fact attract people who have that in their nature. Military dynamics are quite recognized as authoritarian by design. Air traffic controllers are well documented in personality factors (16PF) as being controlling. There is a whole vocational needs theory that we choose our careers to math our emotional needs.

Dr. Jay Slosar, Psychologist

Thank you very much for this insight. I believe it is so true. It cuts to a core clinical issue and has been my experience also. As I noted above while it is a result, it still may interfere with treatment and response to treatment.

Dr. Jay Slosar, Psychologist

Working conditions seem to need a lot of attention. Perhaps all of us need to realize how much pressure medical professionals are under.

Dr. Jay Slosar, Psychologist

I have attended suicide CE classes with experts who do not mention perfectionism.

Dr. Jay Slosar, Psychologist

We value innovation and being an entrepreneur to excess. Sometimes I feel like there is this tremendous pressure to "think out of the box." I think we need more people who think well in the box.

Dr. Jay Slosar, Psychologist

Very good point. The depth/severity of symptoms always need to be considered and avoid overgeneralizations.

Dr. Jay Slosar, Psychologist

We know Adverse Childhood Experiences or ACES certainly has an impact on social,. emotional and cognitive development. This includes neurodevelopment as ACES interfere with the immune system and neuroendocrine systems. If the result is perfectionism, that person may not seek or stay in treatment. presenting with depression their perfectionism may result in stopping treatment as Blatt noted in the article I referenced. On a societal and day to day level it seems to me people get fixated and anxious and their coping mechanisms freeze up. Thus, an increase in rigid/perfectionistic tendencies. Education as you note is critical and I think that's our job, Hence, this post.

Dr. Jay Slosar, Psychologist

It is important to note that perfectionism gets things done. I think there is a difference between high levels of productivity and perfectionism. An over productive and driven person may overdo it and burnout but hopefully put on the brakes before that happens. They also probably are able to make corrections along the way and correct mistakes. Not so for a perfectionistic person who is driven to be flawless and collapses when they fail.

Dr. Jay Slosar, Psychologist

The all or nothing reflects the rigidity and a lack of support b;locks natural healthy responses.

Dr. Jay Slosar, Psychologist

I hope we can too.

Dr. Jay Slosar, Psychologist

The healthcare system and how it works can be extremely harmful. The way residents and interns have been treated is abusive. But the abuse also applies to nurses too. The MBI or Maslach Burnout Inventory was developed long ago when it was discovered that nurses had the highest burnout rates of all professions. The article features a surgeon who tells her story of a driven upbringing and the pressure of a surgeon who like the committed professional always puts patients first. I do not believe perfectionism is a causative factor for any suicide. In the medical field there are, as you note, too many systemic stressors. Especially, the stress of being a surgeon means you cannot make a mistake. If you do someone can die. Thus, the job demands itself breed the components of perfectionism.-- be perfect--be flawless-no mistakes.- and don't acknowledge any mistakes. Calling attention to the aspect of perfectionism overall and its relationship to suicide is an important discussion. -

Dr. Jay Slosar, Psychologist

I separate suicides from depression and hopelessness with an identifiable psychosocial stressor but your comment that hopelessness and depression are enhanced by perfectionism is certainly true. It is a form of rigidity that can become self destructive.

Dr. Jay Slosar, Psychologist

Within these internal thought processes of a perfect solution, I try to focus on one acknowledgement that is important. That is, an acknowledgment a person can make a mistake. Trying for the perfect solution may mean you try something and it doesn't work. So what? This is a key feature of a perfectionistic person--they cannot accept mistakes or learn from them.. I remember the APOOLO 13 movie and heroics --the message to the astronauts ---Failure is not an Option. But this heroic hopeful necessary message in the crisis became very popular. But its the worst message to pass on to kids. The better message is you will make mistakes and you learn from them. That's how you grow. When a perfectionist is the rising star and going to the top, a setback is not just a mistake. It is a complete failure. Then they can fall-- with an unexpected suicide.

Dr. Jay Slosar, Psychologist

John Petersen, PsyD I’m not an academic, but I’m an individual who has personally experienced this and been self-reflective enough to say your words are exactly how I’ve felt at time but didn’t know how to articulate it in a way that would be heard and not categorized. I’d love the opportunity to delve into this more with you.

Kristin Dowlut

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Abrupt Suicide: Discourse with Clinicians, Experts, and Researchers

Abrupt Suicide: Discourse with Clinicians, Experts, and Researchers

Abrupt suicides, such as the recent suicide of dancer Stephen tWitch Boss, startle society with the unresolved grief from deaths we can’t understand.

The abrupt suicide of someone we know, either as a family member, friend, or just acquaintance yearns for psychological treatment to address the unresolved grief. This is especially so when they appear, by all accounts, to be doing well. What went wrong? What did we miss? What can we do?

As a clinical and forensic psychologist, I have always maintained we will never stop all suicides, but our impossible goal should still be to try. It is a human and moral argument to seek zero suicides even based on the reality that it cannot be attained.

Overall, suicide has increased and especially in many segments of society. Extensive and prolific data and discourse are provided by Princeton economist Anne Case and Nobel Prize Winner Angus Deaton in describing deaths of despair:

Here are some basic signs that mental health professionals have learned from assessing suicide. Suicide is most likely to occur when:

  • the person’s depression lifts as they have more energy;
  • the person expresses feelings of hopelessness;
  • the person suddenly becomes more cheerful and reports everything is going to be fine;
  • the person gives away belongings;
  • the person stops doing things they really like to do;
  • the person has no support system;
  • the person has previously attempted suicide;
  • the person has access to pain meds and guns;
  • the person’s mood is unstable per a mood disorder or a serious mental health disease.

Here’s where you come in. We seek a public discourse with suicide researchers, clinicians, and experts.

Would you please respond with a comment in this LinkedIn post to address some or all of the questions below about suicide? We plan to share the results in as cohesive a format as we can.

1.    Have you had any type of experience with an abrupt suicide?

2.    Would you posit any reasons for an abrupt suicide, distinct from a suicide where there are warning signs?

3.    From your experience, direct or indirect, what can you recommend as a societal message with regard to abrupt suicides?

4.    Do you believe that, in general, there is always a warning sign for a suicide?

Dr. Slosar – thank you for your thought-provoking analysis of a complex and painful subject.

1. While I haven’t had direct experience with abrupt suicide, the tragic loss of prominent individuals like Stephen tWitch Boss serves as a stark reminder of how hidden this struggle can be. 2. Abrupt suicide may be linked to deeply personal and often concealed struggles that aren’t easily detectable by friends or family. This unique and hidden pain might lead to the ‘abrupt’ nature of the act. 3. As a society, we should foster open conversations around mental health and encourage those who are struggling to seek help without stigma. Creating environments where individuals feel safe to share their emotions could be a step towards preventing abrupt suicides. 4. I believe that warning signs may exist, but they can be incredibly subtle or easily misunderstood. Constant education, awareness, and empathy might be the key to identifying these signs.

Azim Khamisa

With my 20 years of experience as a crisis intervention expert-

I saw an incredible amount of ignorance, neglect, and fear in regard to the symptoms of possible suicidal ideation. Tere were always signs! Granted some of the signs were subtle–but the fear among clinicians of talking about and facing suicidal risk just exacerbated the whole problem. The slow suicide of drug and alcohol abuse, though, not abrupt–just as deadly.

Jim Nico

As someone who is currently in training (last year) and into trends...

I have found many things that I would love to research. I work with trauma and the SMI population. I have stopped my clients from attempting again and or cutting. I believe first and foremost I create a genuine connection (therapeutic alliance) but past the DSM, and the lingo/ and how we are trained or suppose to be. I treat them as a person. I also provide psychoeducaion on the data we found and ask them one important question. Are you trying to die or are you trying to stop the pain? I explain the stats which open many of my clients eyes. I track a daily card, essentially data for me . I am able to see that during suicide ideation , hopelessness, anxiety is high, wanting to hurt others is low, feelings of worthlessness is high, depression is low. My clients have stopped cutting and stopped attempting whether its long term I dont know, whether its something I am doing, i dont know that either. I believe we are missing anxiety and impulsively because we are so focused on the act of suicide itself and depression. I’m a big believer in it only takes one person to make someone feel cared for even if it’s your therapist. As humans we want to connect .

Diamond M.S.,Psy.D. Clinical Psychology Doctoral Trainee

As a possible solution...

I would make front line experience in dealing directly with suicidal patients as a must for clinicians. Not just training, they can get and ignore, but direct experience with suicidal patients/clients–.as a minimum–time on a suicide hotline should be required.

Jim Nico

In 2009, I lost my first wife to suicide.

Because of her mental state, I was aware of this possibility, but only a few signs of suicide described above were visible. We talked about it, she wasn’t giving away possessions, and there were levels of hope; however, she was ignoring her support system, she was frozen with indecision on the right next steps in her life, much less her day, and I had no idea how many meds were in her possession until after her death. In retrospect, I should have performed a complete search of the house for meds. Unfortunately, even with excellent training and knowing the signs of possible suicide, I don’t believe there’s any magic bullet here. Different people respond and react differently. I have discussed this with both professional therapists and as part of group therapy sessions with those who lost a loved one…. there is no true clear pattern. On the flip side, it feels like all suicides are “abrupt.” Nevertheless, I have seen through communication and education, plus open discussions like this, we are getting through to people who are either in a depressed state or know someone who needs help. Lives are absolutely being saved.

Michael Puldy

What is compelling to me is that being boots on the ground with teens for 20+ years,

I think the “means” has changed – In my suicide assessments of teens, previously overdosing was the most common method reported to me and a shift happened around 2010 where kids reported going to YouTube to learn how to “tie a noose” – remarkably, YouTube continues to keep the how to hang myself and how to tie a noose videos up despite the rising rates of suicide in young people by hanging. They are well aware of my concerns as I have repeatedly spoken to the YouTube team and members of Congress on this issue with Rep. Susan Wild leading the push against YouTube, having lost her partner to suicide in 2019. We know delaying access to the “means” will prevent impulsive suicides – how YouTube refuses to provide any reasonable action here is beyond comprehension. I do have experience with abrupt suicide losing a friend in high school which became much of the reason to become a therapist for teens and now built the Promly app for 13-19 year olds – (Promly.org) to help get ahead of the teen suicide and mental health crisis with an empowering social network that also provides accessible mental health support for all kids.

Jen Libby, MSW, LCSW

Dr. Slosar – thank you for your thought-provoking analysis of a complex and painful subject. 1. While I haven't had direct experience with abrupt suicide, the tragic loss of prominent individuals like Stephen tWitch Boss serves as a stark reminder of how hidden this struggle can be. 2. Abrupt suicide may be linked to deeply personal and often concealed struggles that aren't easily detectable by friends or family. This unique and hidden pain might lead to the 'abrupt' nature of the act. 3. As a society, we should foster open conversations around mental health and encourage those who are struggling to seek help without stigma. Creating environments where individuals feel safe to share their emotions could be a step towards preventing abrupt suicides. 4. I believe that warning signs may exist, but they can be incredibly subtle or easily misunderstood. Constant education, awareness, and empathy might be the key to identifying these signs.

Azim Khamisa

As a possible solution I would make front line experience in dealing directly with suicidal patients as a must for clinicians. Not just training, they can get and ignore, but direct experience with suicidal patients/clients--.as a minimum--time on a suicide hotline should be required.

Jim Nico

With my 20 years of experience as a crisis intervention expert--I saw an incredible amount of ignorance, neglect, and fear in regard to the symptoms of possible suicidal ideation. Tere were always signs! Granted some of the signs were subtle--but the fear among clinicians of talking about and facing suicidal risk just exacerbated the whole problem. The slow suicide of drug and alcohol abuse, though, not abrupt--just as deadly.

Jim Nico

As someone who is currently in training (last year) and into trends I have found many things that I would love to research. I work with trauma and the SMI population. I have stopped my clients from attempting again and or cutting. I believe first and foremost I create a genuine connection (therapeutic alliance) but past the DSM, and the lingo/ and how we are trained or suppose to be. I treat them as a person. I also provide psychoeducaion on the data we found and ask them one important question. Are you trying to die or are you trying to stop the pain? I explain the stats which open many of my clients eyes. I track a daily card, essentially data for me . I am able to see that during suicide ideation , hopelessness, anxiety is high, wanting to hurt others is low, feelings of worthlessness is high, depression is low. My clients have stopped cutting and stopped attempting whether its long term I dont know, whether its something I am doing, i dont know that either. I believe we are missing anxiety and impulsively because we are so focused on the act of suicide itself and depression. I'm a big believer in it only takes one person to make someone feel cared for even if it's your therapist. As humans we want to connect .

Diamond M.S.,Psy.D. Clinical Psychology Doctoral Trainee

In 2009, I lost my first wife to suicide. Because of her mental state, I was aware of this possibility, but only a few signs of suicide described above were visible. We talked about it, she wasn't giving away possessions, and there were levels of hope; however, she was ignoring her support system, she was frozen with indecision on the right next steps in her life, much less her day, and I had no idea how many meds were in her possession until after her death. In retrospect, I should have performed a complete search of the house for meds. Unfortunately, even with excellent training and knowing the signs of possible suicide, I don't believe there's any magic bullet here. Different people respond and react differently. I have discussed this with both professional therapists and as part of group therapy sessions with those who lost a loved one.... there is no true clear pattern. On the flip side, it feels like all suicides are "abrupt." Nevertheless, I have seen through communication and education, plus open discussions like this, we are getting through to people who are either in a depressed state or know someone who needs help. Lives are absolutely being saved.

Michael Puldy

What is compelling to me is that being boots on the ground with teens for 20+ years - I think the “means” has changed - In my suicide assessments of teens, previously overdosing was the most common method reported to me and a shift happened around 2010 where kids reported going to YouTube to learn how to “tie a noose” - remarkably, YouTube continues to keep the how to hang myself and how to tie a noose videos up despite the rising rates of suicide in young people by hanging. They are well aware of my concerns as I have repeatedly spoken to the YouTube team and members of Congress on this issue with Rep. Susan Wild leading the push against YouTube, having lost her partner to suicide in 2019. We know delaying access to the “means” will prevent impulsive suicides - how YouTube refuses to provide any reasonable action here is beyond comprehension. I do have experience with abrupt suicide losing a friend in high school which became much of the reason to become a therapist for teens and now built the Promly app for 13-19 year olds - (Promly.org) to help get ahead of the teen suicide and mental health crisis with an empowering social network that also provides accessible mental health support for all kids.

Jen Libby, MSW, LCSW

Most clinicians have had some experience with an abrupt suicide. It unfortunately comes with this field of practice. The reality is that if an individual wants to kill themselves & makes that choices there is nothing that will be able to stop that. Which is what leads to the abrupt suicide. The warnings come when people are ambivalent & that's why they have to be taken seriously. And since there are those that aren't ambivalent, when you have someone that is you are seeing someone that is asking for help. It's important to do that. Those people can be brought back from suicidal ideation.

The Psych Effect Podcast

I am a suicide survivor! Multiple ideations and attempts over a 20 year duration. None in last 10 years. Effective psychiatric care and family support are paramount! I owe a debt of gratitude to my VA Psychiatrist of over 11 years. She provided me with the former despite lack of the latter.

Tori M. Kelly OBHP

Hi, I will answer from my experience in Thanatology (Grief Counselor), btw, I'm happy to see the interest on this topic, and the importance of attending it before it's too late: 1. Yes, I have. 2. Every case is different, however, in some cases there is a specific trigger related with an unsolved issue, and when it is added to a previous suicide attempt, the effect of the trigger is stronger. 3.  They can be prevented with a strong social network. That's why it's important to leave the phone in the other room and provide time (real time), attention, active and honest listening, and empathy to those who surround us. You never know who faces a situation that may push them to an abrupt suicide. 4.  I don't believe that there is always a warning. In some cases there might be, however, sometimes individuals tend to become experts on hiding real feelings (sometimes it's related to the root of the problem). If there is, it may need a 24/7 follow-up to identify it, since we need to observe the day-to-day environment and the individual's response to it. Plus, there are cultural differences that we need to observe (i.e. LATAM vs. North America dynamics).

Paty Lopez

Thank you for your work, it’s highly important that we discuss suicide and that it gain more viability, specially in a social network about work. Where people only post succes content.

Agustín Alejandro Batto Carol

As a Grief Counselor, I've worked with those who have considered or survived suicide themselves, as well as the loved ones of those who have completed suicide. In both instances, I've found that what may seem like an "abrupt suicide" often isn't at all. At least it isn't an "abrupt" decision in the mind of the person making it, despite the fact that the completion of the act may seem abrupt to those around them. Here in the United States, we live in a death-denying, grief-phobic society which makes it difficult to talk to each other honestly about death in general, much less about suicide specifically. And yet, it is only in honest discussion that we can hope to identify the "warning signs" specific to each life, to each individual human being -- signs that go beyond any general list, however well-intended that list may be. What I've found to be in starting this discussion is asking not, "Are you having thoughts of suicide?", but rather, "Do you feel like you don't want to go on living?". A subtle difference or just a matter of semantics some may say, but I find that the latter leads to honest discourse more often than the former. And that is, at least, a good beginning.

Stephanie Rodriguez, GCCA-C

First and foremost, I believe we as a society have to get back to valuing life and promoting well being. We have to continue to link medical and mental health wellness and teach people the value and importance of the connection of the head and body, the heart and the brain, feelings/emotions and physical health. In my years of experience, it is this disconnect that pushes people into the state of confusion, despair, and the inability to see resolution to whatever “catastrophic” perception they are having at that moment … when they decide it is the end for them. The distortion of thought, personal disappointment, perception of weight of the world seem to be exacerbated by internal or external conflict, stressors and worries, poor nutrition, sleep deprivation, medication, other perception altering chemicals, combined with despair are the recipe for abrupt suicide. This is a complex human process filled with even more complexities for anyone trying to assess risk of harm - threat of death. Perhaps this is why I was trained to take all fantasies, threats, or actions toward suicide seriously and act accordingly; do the best one can to ensure safety. Even so, some people hide it so well their actions still surprise us.

Phyllis Mogielski Watson, MS, PsyD (AZ/IL/CO)

Personally I have experienced grief due to suicide death and professionally as a Thanatologist the study of suicide is very multi faceted and interesting. I do not view all deaths as abrupt as we can prepare and plan for a death that is anticipated. From what I have observed we have been taught as society to be aware of the signs and put in place prevention in order to disrupt the suicide which as you say is a good thing. Some people do not show "signs" of distress and may or may not show signs of their suicide intention through the behaviors mentioned which leaves the bereaved experiencing compounded grief: loss of the person and loss of not being aware. Suicide deaths and grief as a result of this type of loss is complex and therefore often difficult to talk about, learn about and teach about. Thanks for asking for my input.

Olga Nikolajev (she/her) RN, MA, FT

I think it's important to revisit psychologists Edwin Shneidman's concept of "psychache," the unrelenting mental anguish, that can be a driver of suicide. Also, psychiatrist Viktor Frankl's calling attention to the "existential vacuum" and loss of meaning as a contributor to one's self-destruction is important to keep in mind. Suicidologist Thomas Joiner's model of suicide - - with its emphasis on thwarted belongingness, acquired ability to enact lethal self-injury (by habituating to pain and overcoming fear of death), and perceived burdensomeness to others - - is likewise of relevance.

Brian S McCallum

From what I've observed... When someone seeks help from mental/medical health professionals, those professionals don’t often create the space to listen b/c they’re busy considering all the interrogating questions they need to ask in order to cover their butts just in case the person does harm themself. Ram Dass used to say that we should be able to answer the same questions we’d ask of our clients. But how many professionals do that? I don’t know anyone who hasn’t thought about suicide in some form or another, or felt safe to explore their thoughts with someone else out of fear they might be “sent away.” If we aren’t willing to openly speak about suicide, how are people considering suicide going to feel safe enough to share how they are feeling? I speak about suicide in grad psych classes I teach. If students hear about it in other classes, they're taught what they should do if they have a client who is “suicidal” but there’s no discussion about how to listen to someone who is considering suicide. Given all the challenges we’re dealing with today, isn’t it reasonable and perhaps even a “normal” response for some people to experience a psychache as Dr. Edwin Shneidman discussed in his work? Just my two cents…

Kriss Kevorkian, PhD, MSW

I experienced an an abrupt suicide attempt involving an older family member this past Feb. While there was talk of feeling depressed, as well as a previous attempt going back 30+ yrs. I never thought this person would ever attempt it again because they had received treatment, had ongoing access to treatment and medication, was physically active, and displayed a somewhat positive outlook. What I missed was the constant comparing to others in the same age bracket who seemed to be doing "better." Damned social media! I'm a fmr first reponder and now work in the first responder and veteran space. We are great at masking our emotions. But I believe there are always signs of some sort. From showing up late to work when usually punctual to someone's uniform being out of sorts when always neat. As trained observers, e need to take the time to "notice" our bothers, sisters, and battle buddies. Ask if the'ye doing okay pointing out the specifics of what's out of place and for goodness sakes if they respond with the words, "I'm fine," help them open up whatever it takes. "I'm fine" is code for "I'm not fine at all and I'm scared to say anything, but please help me."

A Badge of Honor Samantha Horwitz

This is an important although distressing topic because of the lack of answers. Even after all the research and prevention programs, we still don't know why suicide rates continue to increase since the turn of the century. We do know some ways to decrease suicide, but there is no conclusive evidence as to why it keeps going up. I'd like to offer some personal yet unpopular suggestions as to why suicide rates are increasing and how I believe we could dramatically reduce the amount of suicides especially among our teens. We know that that suicide usually occurs within a 90 day individual crisis period. If one who is contemplating suicide can get through that 90 day window, they are statistically far less likely to take their own life. What is missing in that 90 day window, however, is support and hope. With the rise of mothers working outside the home, more kids in day care, and the continuing decrease of faith in God, no wonder we see a rise in suicide. If kids feel neglected at home, and won't turn to God for help, feelings of isolation, loneliness, hopelessness, and unimportance can take over, and it's very difficult to reverse those thoughts and feelings.

Joseph Belliston

I have lots of experience transforming this in my patients. This is strictly and input-output issue that has the vagus nerve in mechanical lockdown so the brain cannot receive clear input and it slows the visceral motilities (in an osteopathic visceral mobility sense) making the person feel energetically dead - they are just trying to match on the outside what is happening on the inside. It is measurable biomechanically.

Melanie Weller

As a school psychologist I’ve unfortunately had several experiences with abrupt suicides involving youth. With teens and children it is difficult to know when a suicide will be completed as those who are troubled tend to threaten suicide frequently and all must be taken seriously. I’ve had to sit with parents who’ve lost their child from suicide and it is nothing short of devastating. Taking care of them and yourself is vitally important. I’ve seen suicides completed by youth where there were signs and some with no signs at all. Those who threaten suicide offer us a vital chance to intervene while we are often helpless in the face of a child’s abrupt suicide. I think the most important societal message is one of compassion towards todays youth and the mental health challenges they face. Having one caring adult in a child’s life can transform their life experience into that of feeling cared for and having importance. No I don’t believe there is always a warning sign making abrupt suicides tragic and a mystery with which to make sense.

Sarah Tomer

Sometimes there aren't any obvious signs or warnings in instances of abrupt suicide. Sometimes indicators and rationale become more apparent when performing a psychological autopsy. Everyone has their own limitations and threshold for psychological and emotional pain. What might seem tolerable to one individual may be too much to bear for another individual. I think there should be greater consideration of what Shneidman theorized regarding unresolved psychache and unfulfilled needs when seeking to understand abrupt suicide. Our societal message should be that any and every risk of suicide should be taken seriously. We all have the potential to save someone's life. Similarly, none of us are immune to death by suicide. We need to be more mindful that everyone has this capability and become more proactive in how we reduce the stigma surrounding suicide and the factors that drive its likelihood. Not everyone will exhibit the exact signs we associate with an increased risk of suicide and sometimes warnings manifest in ways that we might not anticipate. Likewise, there are many individuals who privately suffer from untreated psychiatric conditions, trauma, and unresolved pain while their social circle remains entirely unaware.

Elreacy D.

There are not always definitive warning signs for suicide, abrupt or otherwise. While it’s possible for those closest to the person who has completed suicide to reminisce and dissect interactions and circumstances, sometimes pain, despair, and hopelessness are known to that person alone. Through my experiences as a Certified Christian Life Coach, Thanatologist, and with further specialization in Pastoral Thanatology, I am reminded that those who are suicidal may or may not have their own timeline or agenda. Someone truly contemplating taking their life may be experiencing a mental health crisis, a crisis of faith, or a lack of lasting purpose. Experiencing an “epidemic of loneliness,” our society sometimes lacks true and lasting connections with each other. We cannot underscore the role of isolation, and the toll it takes on people – who may or may not exhibit outward signs or symptoms of needing help. This is when we are called to look inside to embrace mankind and take measures to share love, care, and serve those around us.

Veronica J. Kovach-Dodd

1.  Have you had any type of experience with an abrupt suicide?  Yes, I have had an experience. He was my class mate from college and school mate from university. 2.  Would you posit any reasons for an abrupt suicide, distinct from a suicide where there are warning signs? He was vessel machine engineer who was sailing during half of the year at least. In my opinion, working and life conditions without family support, at least on sailing. In this point I also would like to point out that recently perception management technics are quite popular and effect people life. These technics directly aim person social and business life. After regular continues application, person reach the loss of awareness and is not able see difference between reality and sensation. 3.  From your experience, direct or indirect, what can you recommend as a societal message with regard to abrupt suicides? Family support and of course mental support by medical professionals are very important. However , other reasons like perception management technics should be study by academically for preventing more losses. 4.  Do you believe that, in general, there is always a warning sign for a suicide? I don't believe, but signs possible.

Murat Arslanoglu

1. As an adult psych nurse practitioner, I frequently encounter folks in mental health crises and have experience with abrupt suicide. These instances are deeply distressing, impacting the professionals, families, and communities involved. 2. "Abrupt" suicides happen without clear warning signs or known suicidal ideation. Reasons could be individuals concealing their distress, impulsive decisions due to life events or substance use, or untreated mental health issues. Each situation is unique and complex. 3. It's crucial to promote open conversations about mental health. Encouraging individuals to seek help when needed, promoting mental wellness, increasing access to mental health resources, and reducing stigma are vital. Understanding that absence of signs doesn't guarantee mental well-being can prevent tragedies. 4. Warning signs often precede a suicide but might not always be present or recognized. People vary in behaviors, and some may hide their intentions. Recognizing potential warning signs is essential, but promoting mental wellness and accessible resources holds equal importance.

S. Frances Robbins

1.  Yes, my own daughter, a clinical psychologist, who plunged to her death when she was 34 years old. 2.   I don't believe it has been thought out by the individual. I believe it is either an impulsive choice by an act of being triggered by a past trauma or an episode related to undiagnosed depression or mania. This is often the case with teenagers. They take a temporary problem and solve it with a permanent solution 3.  In the case of my daughter, I spoke with her just two nights prior to her suicide. I asked her directly if she had any suicidal ideation. She firmly denied it. I thought she might have lied. Her psychiatrist did not believe Pam was suicidal, however, psychotic. I told the psychiatrist that she may have a delusional demand to kill herself. Pam never made it to her appointment. She jumped out of a window the morning that she was to see her. From my personal experience, I doubt we are capable of thwarting an abrupt suicide unless we are there in the moment of attempt. 4.  Yes, of course in most cases. In abrupt suicide, I think you have to be clairvoyant. I believe in the destiny of an individual. PS I had to delete your questions to provide adequate answers. I could not write my entire response.

Joan Childs, LCSW

As a mother of five, psychotherapist since 1978 and an author, I have had both personal and professional experience with abrupt suicide. My book, WHY SHE JUMP? My Daughter's Battle with Bipolar Disorder chronicles her struggle with bipolar disorder, her abrupt suicide and my grief. Pam was a clinical psychologist and thought to be a "wizard" therapist by her colleagues.

Joan Childs, LCSW

As a certified thanatologist working in a mortuary, I have experienced working with many families whose person suicided. It's interesting that, initially, families feel that the suicide was abrupt yet during an intentional conversation with them and asking about not only the death of but also the life of their person, they begin to share subtle warning signs. Regarding reasons for an abrupt suicide distinct from suicide with warning signs, there tends to be a recent significant loss (job, relationship, medical diagnosis) along with isolation and substance abuse. As far as a recommendation for a societal message, we need to stop the stigmatization of mental health issues and provide needed resources starting early. We need to help people realize that hope and hopelessness are not an "either/or" rather a "yes/and". Suicide, including abrupt suicide, can elevate the risk for complicated grief of the bereaved. They frequently report feelings of intense guilt, feeling unloved by their person who suicided, anger, and an intense loss of their assumptive world. At this point the work begins to help the bereaved "find their North" and learn to discover a new versions of themselves now that grief has touched their lives.

Becky Lomaka, MA, CT

In my thirty-plus years in practice, I have lost one then-ex-client to suicide.  She came from an extremely abusive family, and after years of suffering and hard work had finally settled into her body and a quieter mind, allowing herself nourishment, love and a partnership with a beautiful man who was deeply devoted. They had been on vacation, and having had a wonderful day, when he went out to pick up some dinner, she locked herself in their hotel room and killed herself. There had been so many times she had teetered full self-destruction, and now happier and healthier than she'd ever imagined possible for herself, I can only imagine wanted to go out on a high note, the end of a perfect day.  Her partner called me, frantic. She was gone and he was desperate. So, yes, abrupt suicide can come out of nowhere. On the best day. On the last day. No warning signs. Simply happy and not believing that could actually endure. Johanna Courtleigh, MA, LPC

Johanna Courtleigh, MA, LPC, CHT

Years ago, during the holidays, I received an unusual call from someone that was dealing with a divorce. To this day I cannot explain why I knew that they were in the final stage of committing suicide, but during the call I saw 'Red Flags'. I was out of town at the time, but was able to get a Sheriff headed to their location. Through the grace of god, a trusted friend, and a very calm and patient Deputy Sheriff, this individual agreed to voluntarily check themselves into the hospital. The help they received was instrumental in their mental recovery, and gave them the tools to live life. I am glad to say that they survived. Longest day of my life.

Anthony Hurley, MEP, CPP®, PCI®, PSP®, CPD, F.ISRM

When I think about messaging related to suicide or mental health in general, I focus on the need for what I would term a "personal safe space". As noted in one of the other comments, this is where you can be your authentic self. That may mean that you are honest to a fault with someone without feeling judged, or it may be a relationship in which you can say nothing and are not pushed to do so BUT that person knows your silences well enough to judge when they need to reach in instead of expecting you to reach out for help. We message so much that people need to "ask for help" or "I'm always here" but when you feel hopeless, the perception is often that those messages don't apply to you. We need to help the public understand that kindness and simple (authentic) questions around leaning in are vital to the support of individuals coping with mental health needs, especially depression.

Dana Milakovic PsyD

I agree with the indicators listed above but I'm surprised to see two glaring omissions. The two leading indicators of suicide, as stated in the National Strategy, are sleep disturbance and financial instability. Number three is the lack of community/purpose. For otherwise healthy adults, 1-2 nights of poor sleep quality provide some impact on daily activities. When a person begins to have 3+ consecutive nights of sleep disturbance, the person starts to lose their ability to problem solve. If it continues, nearly any problem can become 'unsolvable' and permanent solutions become more attractive with suicide as a real possibility. It really sucks when someone gets an unexpected bill of $150 and can think of no alternate solutions. I've been personally impacted by suicide 13 times. Those friends and colleagues chose to end their suffering and send shockwaves through their communities. As a veteran, suicide prevention is on all of our minds. Many of us have daily, weekly, monthly, and quarterly check-ins with other veterans, community, and family members. This helps us as veterans and helps us keep tabs on others who are important to us. How can you help? Engage with your community! Call or text 988 the suicide hotline!

Travis D. Johnson, MHR

1.    Have you had any type of experience with an abrupt suicide? Yes, as licensed clinician this has been an issue in my career, & with friends. It was shocking at the same time my colleagues and I were able to review and discuss the situation in a way that allowed for a deeper understanding of suicidal behavior, pain and suffering. 2.  Would you posit any reasons for an abrupt suicide, distinct from a suicide where there are warning signs? In my experience and in the research particularly regarding children and adolescents much of abrupt suicide is linked to impulsive behaviors. I definitely see suicidal thoughts and behaviors linked to impulsivity in practicing with youth. The research also posits a link to substance use and the connection to mood swings & brain development and emotional processing. 3.  From your experience, direct or indirect, what can you recommend as a societal message with regard to abrupt suicides? Develop an understanding that many people do provide risk factors, warning signs and protective factors. Be aware of potential risks of abrupt suicide, like impulsivity, substance use and warning signs. 4. Warning signs aren’t always there, so Ask directly. Are you thinking of killing yourself? Help- 988.

Leslie Baker MFT, NCC, RPT-S

1. Personally, I have not had  experience with an abrupt suicide but my mother attempted suicide 7 times. Professionally, I have experience with one of my student-client's stepfather. 2.  I would be incredibly hesitant to posit any reasons for an abrupt suicide, distinct from a suicide where there are warning signs. Dr. Midkiff once said that 'good' psychology often raises more questions than answers. 3.  Again, I'm hesitant to recommend a societal message with regard to abrupt suicides because I cannot guarantee the reliability of my experience to the rest of the world so to speak (i.e., my experience may not generalize because no two people are exactly the same and no two perspectives...even those of the most highly experience...may yield same, similar or reasonably consistent interpretations or insight.) 4.  I believe that there may be signs for a suicide but I don't believe I can definitively say the same are 'warning' signs.

Danny Ray Crum Jr.

Thanks for this post. So important. 1.  Yes. I lost my dad to suicide and had my own attempt in my 20s. I have regular suicidal ideations, yet the difference is now I know how to manage them. 2.  Sometimes yes, sometimes no. Here is the challenge: Hopelessness is the SINGLE consistent predictor of suicide. And the problem? We ALL experience moments of hopelessness all the time, it is how we manage the moments that matter. 3.  That we can end suicide. And must ensure every single person is taught what hopelessness is, and how to manage it. 4.  It is impossible to predict who will die by suicide, as we all experience moments of hopelessness. There are signs, sure, yet you will never really know. All we can do is teach the skills, the work is up to the individual. I can't save a person long-term, no matter how much I want to do so. Maybe for a moment, yet I must equip with skills. I can only truly save myself. We are taught to manage our blood sugar, regardless of if we have diabetes. Why are we not taught how to manage hopelessness? People don't want to die, they want hopelessness to end. Anyone has the power to do it, they just need to be taught how. What I call the 'how' of hope. #ShineHope

Kathryn L. Goetzke, MBA

As a neuroscience therapist dealing with community, health, law enforcement and military populations, what I learned is that when multiple stressors build up, ie from work, relationships, financial issues, family, etc. there is a much higher chance of client spiraling down the waterfall of depression into suicide. Key to preventing this is a “battle or life buddy” that you meet with regularly (weekly is best, virtually or in person) and be brutally honest about what’s going on in your life, good or not so good. I created the acronym “HELPS”, meaning talk about your purpose in life (and what you look forward to), emotional regulation, (have you been moody and why?), label negative emotion and create a plan to resolve and initiate plan (ie meet w/ Buddy, journal, walk the dog, call your therapist). Kindness and grace for others in routine interactions can also make a big difference as you never know what is going on with someone. Support groups are vital, whether that be a hiking, meet-up, church, mosque, temple, or other social group. We are made for connection and need it to survive and to be healthy. Re: Twitch’s abrupt suicide”, I don’t feel he committed suicide yet it was a sinister homicide as 2 people were in the room.

Moniqua C.

I do not believe that there is always a warning sign for suicide. I work in the Veteran field and many are very, very good about hiding what is going on inside them. There are few people that they can trust with their stories and feelings. They might be afraid that their fellow service members will think they are weak and they feel that civilians won't understand. They might let things bubble and bubble inside until they break down one day and die by suicide.

Dr. Daniel Roberts

My father died by suicide while I was in the hospital giving birth to triplets. The abrupt nature of a suicide can complicate the mourning process, bringing about disenfranchised grief. As a thanatologist, I recognize that all deaths are abrupt, no matter the manner of death. With suicide, in particular, it's abrupt, no matter how many warning signs or risk factors are known. The societal message about abrupt suicides is to ask the right questions concerning this stigmatized death and often ambiguous loss: Did the person who died perceive that they were a burden to their family? Did they come to a place in life where they felt that they no longer belonged? Did they no longer fear death? Clearly, suicide would not be a public health problem if there were always a warning sign. 

Barbara Rubel, Compassion Fatigue Speaker

Suicide is obviously incredibly complicated and complex. I believe that one of the most important issues in order to prevent the non-abrupt suicide attempts is to normalize conversations around suicide and mental health. The research shows that, on average, people live with depression for ten years before reaching out for support. We need to remove barriers and make it easier for people to reach out for help when struggling. I think, as in my own case, there can be a time of contemplation over suicide. People need to know how important it is to reach out for help when it gets to that point. I found myself, when deeply depressed, sitting in my dark bedroom, alone, with my laptop on my lap doing a google search on suicide. The very first site I go to showed a list of methods along with a chart to show how long until the impending death and how painful on a rating of 1-10. I slammed my laptop shut not understanding how I could have ever gotten to that point. Yet...I still didn't reach out for help at that point. As far as the abrupt-suicides, it seems to me, that in most cases (this is only anecdotal), many friends and relatives of those who have died seem to believe that there were surely signs when looking back.

Al Levin

I'm a licensed therapist who has done numerous suicide risk assessments and inpatient hospital admissions. I think the suicide feels abrupt to the loved ones of the person who completed suicide, but it's likely that person had been battling with depression or some other mental health concern for a very long time. Although it's improving, there is still a lot of stigma surrounding mental health concerns. I think the pandemic brought mental health treatment to the forefront of the conversation and has normalized it a lot more, but it takes time to change old belief systems. Many people don't feel comfortable seeking out mental health treatment to intervene before it reaches the point at which they contemplate suicide. The warning signs listed above are definitely things to look out for, but we can't always know what's going on for someone internally.

Kristen Jacobsen, LCPC

1.  Have you had any type of experience with an abrupt suicide? Yes. On several occasions as a clinician and most recently with an extended family member. 2.  Would you posit any reasons for an abrupt suicide, distinct from a suicide where there are warning signs? In my experience there are times that the individual offers NO signs of suicidal ideation or a plan to harm themselves. I also believe that sometimes individuals can act on an emotion in such an extreme way and have no long term intentions of actually dying by suicide. However, sometimes their efforts leave an undesired outcome. 3.  From your experience, direct or indirect, what can you recommend as a societal message with regard to abrupt suicides? Focus on developing a reliable support network in which you have at least one person that you can be raw and brutally honest with at all times. Also, be intentional about chasing your "Why?" and never be apologetic about self-care. 4.  Do you believe that, in general, there is always a warning sign for a suicide? No, I do not. I try to avoid thinking in extremes and "always" seems to most often "never" exist. ?

Brian Wall

Important topic, Jay. I have lived experience with suicidal ideation and it stemmed from a perceived lack of control and hopelessness. I went through a event that caused depression and poor coping strategies. I also was processing trauma from the military and policing. Add a dash of toxic levels of stress and it was a powder keg. Luckily, with the assistance of many I was able to recover. This is a passionate topic for me. It’s hard to put into words when I see someone with tons of potential that isn’t being developed and invested in. We are social creatures and without routine connection to things and people that are important to us, our emotional health suffers. That’s what happened with me. I felt more valuable to my family by not being alive because I was letting them down. That’s what I perceived, it’s flawed reasoning that I didn’t see in the middle of it. I was a peer support officer and that experience helped me tremendously. Thanks for starting these conversation. So important. I’m finishing a very personal and powerful book where I talk about this a lot so it’s cathartic for me. Thank you!

Chad Michael Bruckner

I'm not a clinician and haven't done much research into the issue of abrupt suicide but I think that there are usually signs that someone is contemplating taking their own life. In my job, I'm exposed to people who take their own life with some regularity and I always wonder why, even when colleagues (many who've become de-sensitized to it) just accept it as part of our job. Personally, I think it's usually a major, negative life event that triggers it (death of loved one, loss of job, divorce, etc.) but more than that it's people around the person in trouble fail to pay enough attention to the signs, which I think are usually there. Everyone is busy and has their own issues to deal with but sometimes, if we just pay closer attention to someone else's troubles, it might just save a life.

Alan Krawitz

1.  Have you had any ... experience with abrupt suicide?  I conducted psychological autopsies on ppl who died by suicide on railroads. Many who died on train tracks took alcohol and/or drugs (not all had substance use disorders but likely needed these for courage to die by suicide), lost love or didnt have love, had mental health issues (i.e. uni/bipolar depression), $ issues. 2.  Would you posit reasons for abrupt suicide, distinct from suicide w warning signs? I believe that losing love/not having love and changes in relationships is a major life issue that contributes to abrupt suicide. 3.  ... What can you recommend as a societal message with regard to abrupt suicides? Having love is essential to life like water. People can find support and work on themselves with or without love by having a life worth living with hobbies, passions, & relationships that are meaningful until finding love. 4.  Do you believe ... there is always a warning sign for a suicide? There are warning signs of hopelessness. Homelessness, loss of job, loss of a partner, & a lack of support, can be warning signs. It takes courage to die by suicide. It takes courage to ask tough questions if one is suicidal. Ask tough questions to prevent suicide.

Karina Kim, PhD, LCSW, LCADC, CCS

As a society we need to focus on collective grief associated to abrupt suicides.Systems are dysregulated,and we need to make a plan.Is it more about the acceptance of the world we thought we knew?Individuals can be egocentric.The more time that we invest in OUR need to understand abrupt suicide may be unrealistic.We are never going to know everything,we need to accept this. Maybe our time is better well spent on increasing our abilities in being more compassionate for suffering or the possibility that something greater then ourselves is operating here?Who are we to say,"What went wrong?"verses acceptance that they finally found their"peace".Our inquisitiveness is missing the opportunity together to connect to our experiences of grief to help normalize unknowns.We need to focus on what we can control,then what we can't.Is this about changing our words which will change our mindsets?Recognizing that our collective suffering in not having all the answers enables us to be together in those similar ways.Are we missing this point on all accounts?Aren't we all really grieving are own definitions of what is"normal"to us? Our brains are wired for connecting, who are we to say what people should be connected to or"how"people connect.

Christina Harrington-Stutzmann

Abrupt suicide may occur when a person comes face to face with major life-altering consequences like being served with divorce paperwork or getting the last in a series of DUIs that will result in major consequences. Those most likely to die by suicide are usually white male individuals with access to a firearm. Unfortunately, there are not always warning signs of someone’s plan to end their life by suicide. Also, grieving the loss of a loved one who died by suicide is usually much more complicated grief and even traumatic than grieving someone who died after a long fight with cancer or chronic health conditions.

Christy Kobe, LCSW EMDR Certified Trauma Therapist Polyvagal Theory Anxiety and Stress Therapist

I have worked as a consultant, trainer, supervisor, and psychotherapist in the clinical/community social work arena for over forty years. I have conducted dozens of suicide-risk assessments, I have treated scores of suicidal individuals, and have unfortunately been in the position as part of a team conducting psychological postmortems for suicide victims. I don't conceptualize the problem in terms of "abrupt suicide" separate from other kinds of suicide. I believe it is a profoundly sad and tragic event when a fellow human being takes their life. Yes, since the beginning of time human beings have been engaging in this behavior. But why do they continue to do it?-yesterday, today, and tomorrow. The solution?-because I wish to keep this comment brief I will say that it may sound like a cliche but we need a national, federally-supported commitment, supported by big bucks to expsnf services that will indirectly and directly address the multi-faceted causes of suicidal behavior (successful and unsuccessful) Peter Getoff, MA, MSW, LCSW Human Equation, Founder Consulting/Training/Clinical Services West Los Angeles Offices Remote services available nation-wide. Business cell 310 729-6460 www.humanequation.net [email protected]

Peter Getoff

In the 20+ years that I’ve been trying to understand suicide I’ve learned that there are 3 factors that put someone at the greatest risk for suicide. When we understand these 3 factors, we understand that it can happen to anyone as well as how to actually intervene and help someone in need. You can read more about it in the following blog post. https://www.allthatweare.com/post/the-3-factors-that-put-someone-at-greatest-risk-for-suicide

Jenny Thrasher

In my personal experience and extensive research, I have witnessed the despair that arises from broken systems and the frustrating tangles of bureaucracy. The lack of funding, affordable housing, shelters, and job opportunities has left countless individuals feeling trapped and hopeless. It's a harsh reality: Who will give a chance to the homeless or those who have fallen on hard times? Moreover, the closure of rehabilitative mental health facilities has only exacerbated the situation. The consequences of shutting down these facilities have been devastating, leaving vulnerable individuals without the crucial support they need. It's disheartening to admit that our government, politicians, non-profit organizations, and various institutions have failed their own country people. How can U.S. support other countries when our own country people are dying off in record numbers. I recall a profoundly disturbing conversation w/the U.S. Homeless Coalition, a few years ago who revealed homelessness has persisted for over 35 years. I experienced firsthand the apathy of those who could have made a difference. It became clear to me that, many suicide victims aren't strong enough to weather the storm, and will die off with no support!

Candance Camper

To answer questions 1 No 2. Ruminating thoughts, increased anxiety, impulsivity. 3.Societal message- Show more compassion we need to start validating people's pain and trauma. Start teaching coping strategies other than giving out a 1800 number. Also help them build a support system and find their purpose and use what they value (spirituality) etc. 4. I feel what some one feels about suicide is valid , that's all they see at the moment, but it's ineffective of course. I'm sure there are warnings signs we haven't found. We previously thought this about mild traumatic brain injuries and the research we did we believe also is a start to tracking biomarkers in the body. I believe the same is true for Suicides. Possibly low Vitamin D and hormones. We will never know unless we come together as professionals and start sharing what we know without trying to get credit for the input we gave. All we need to know is that it can save lives and that should be our motivation. After all that's what we signed up for to provide "hope" , even if it's one person.

Diamond M.S.,Psy.D. Clinical Psychology Doctoral Trainee

Two points here. First social networks are important --but today people think that means their online network. Loneliness has emerged as a rising factor and concern. Second, cultural differences and cultural awareness are extremely important. Certain situations have significant meanings in different cultures including divorce, losing a job and the famous slap in the face that caused a revolt in Tunisia.

Dr. Jay Slosar, Psychologist

Dr. Jay Slosar, Psychologist True. It is important to talk about social 'offline' networks.

Paty Lopez

We should be talking about it in the schools.

Dr. Jay Slosar, Psychologist

I have found that when I ask are you having thoughts of suicide, many often respond no but many times they don't feel like going on and don't care if anything would happen to them.. This does lead to honest discourse

Dr. Jay Slosar, Psychologist

Clinically, you can do a risk scale for suicide but that doesn't account for how the person is feeling who is in front of you--right now. Someone may not have history or risk factors but be in a really bad place. I see many young adults who are out there functioning every day and seem ok, but are lost, without feeling of purpose or direction and internally in bad shape.

Dr. Jay Slosar, Psychologist

These are great deeper references and models. Everyone should read--and I hope schools still recommend it--Frankl's Man's Search for Meaning and his model of Logotherapy. It makes me wonder today with all the deaths of despair if our society is in an existential vacuum.

Dr. Jay Slosar, Psychologist

I think self exploration about your own deeper feelings is essential to effectively responding to others.

Dr. Jay Slosar, Psychologist

A family loss as you had is something that really jolts you and sends you into deep introspection. With regard to social media there is a term for social media reaction that leads to anxiety and depression. FOMO--Fear of missing out.

Dr. Jay Slosar, Psychologist

School age children can be so unpredictable. Even of more concern is a contagion effect when after one student tries or commits suicide others follow.

Dr. Jay Slosar, Psychologist

Some people are very sensitive and reactive. They are more susceptible to attempt or carry out a suicide. Those are tough cases if you are working with them and cause for setting more safeguards.

Dr. Jay Slosar, Psychologist

yes the surgeon general speaking out about loneliness was eye opening. It seems to me all the digital "communication" does not connect us enough to still feel isolated and lonely. This has more to do with attachment and intimacy.

Dr. Jay Slosar, Psychologist

One's perception or outlook is significant and why therapy can be so helpful.

Dr. Jay Slosar, Psychologist

Open discussions are important. Many people are afraid to talk about and address suicide.

Dr. Jay Slosar, Psychologist

you can post a 2nd response if you want. Teens are especially difficult. You can have a great session on Thursday but then over the weekend something emotional happens and they attempt suicide. This impulsivity is developmental and separate from delusional psychotic voices or a manic episode. Hope you are coping ok.

Dr. Jay Slosar, Psychologist

Thank you so much for sharing this. Bipolar Disorder is often behind many tragic suicides, accidents and unexplainable aggressive outbursts. I am sure your story has been helpful for others. All the best, Jay Slosar

Dr. Jay Slosar, Psychologist

"finding their north" being able to move forward the hardest time is when the funeral is over and everyone leaves the guilt from a suicide is so hard and why professional help and support groups are invaluable,

Dr. Jay Slosar, Psychologist

Well said Becky. Best wishes.

Charles R. Nunn

so hard to cope with that for the loved ones.

Dr. Jay Slosar, Psychologist

That is a very encouraging story. Makes me want to be very proactive with heightened awareness. Thanks.

Dr. Jay Slosar, Psychologist

I think discussing about how to respond or what to do when having suicidal feelings/thoughts can be preventative and critically important. in moments of despair people often go to a place that has meaning for them.

Dr. Jay Slosar, Psychologist

This is VERY important regarding sleep and thank you so much for bringing it up. I use sleep as a barometer and measurement stick in treatment. When sleep improves, the person gets better. I have also seen when a person can't sleep because of pain, after a while they just have had it and commit suicide. Sleep quality is definitely correlated to suicide and an important risk factor. Financial instability relates closely to all the research by Case and Deaton as cited above--Deaths of Despair.

Dr. Jay Slosar, Psychologist

Directness and not avoidant is crucial.

Dr. Jay Slosar, Psychologist

I think some schools are having classes about mental health and suicide so kids can recognize, intervene and alert adults to a peer who is pre suicidal. I think all schools should put this in their curriculum.

Dr. Jay Slosar, Psychologist

community bonds and social connections as you point out are preventative.

Dr. Jay Slosar, Psychologist

yeah I felt uncomfortable as a civilian saying that --like maybe it was a cliche I'd more likely buy them a coffee or drink

Dr. Jay Slosar, Psychologist

Yes. I think the veterans also feel not just that "civilians" won't understand but they don't care. Its sort of an us vs them outlook. I do hear many people now saying "thank you for your service". I wonder how Veterans react to that.

Dr. Jay Slosar, Psychologist

Dr. Jay Slosar, Psychologist most veterans appreciate being thanked for their service. For some, who have guilt for what they were forced to do overseas, it can be like rubbing salt in the wound. It is a painful reminder of something they are trying to forget. There is no way a civilian can know that, which further increases the gulf between the veteran and civilians.

Dr. Daniel Roberts

wow what an experience from giving birth to a father's concurrent suicide. Its hard for me to grasp the experience.

Dr. Jay Slosar, Psychologist

Awareness of discontent building or low level depression in my experience may also be related to attaining a breaking point when life becomes stressful and more difficult. The risk factors we see--loss of job, financial failure, injury, divorce and similar.

Dr. Jay Slosar, Psychologist

So true, I don't think we have fully taken in the impact of the pandemic on anxiety, depression and suicide.

Dr. Jay Slosar, Psychologist

wow ten years did you develop social relationships or friendships with anyone in the group?

Dr. Jay Slosar, Psychologist

Brian I agree with you. I have had experience with both abrupt and not abrupt suicide. I don't think there are always warning signs. In fact it might be shocking in a sense that everything is going well in their life. In both abrupt cases they had a clear intention of dying as there would have been no possibility of survival. But I do agree with individuals acting on an emotion in an extreme way and not really having the desire to die, but more of a desire to make the pain, and negative thoughts go away. I like what you said about avoiding black or white thinking, in this case with "always". My societal message is to normalize asking someone if they are thinking about "killing themself." Being direct not saying things such as "are you wanting to harm yourself". People don't talk about wanting to kill themselves, in my opinion, because we as a society can't even use the language that is necessary. I worked for Marin Suicide Prevention about 23 years ago and that was an important takeaway.

Traci Ippolito M.S., MFT

Having someone you can bare all to is really important. I agree some suicidal acts are impulsive and without warning. There is some research evidence that perfectionistic persons can be suicide prone.

Dr. Jay Slosar, Psychologist

As far as having "at least one person with whom you can be raw and brutally honest", I am a huge believer in support groups. The day before I checked myself into a partial hospitalization program, I participated in a men's group for anxiety and depression. I cried my eyes out sharing, feeling that I finally had a space where I could share what I was going through without being judged. Ten years later, I still attend the support group every other week even though I have been quite mentally healthy since then.

Al Levin

Thank you! Ir sounds like a lot of things and cumulative factors but you reached out. Peer support groups in high risk professions are a great preventative approach. Good luck with your book. I am sure it will help others.

Dr. Jay Slosar, Psychologist

The increase in suicides is a call for a societal effort. There is some return of the 800 number hot lines that have been shown to be helpful and preventative.

Dr. Jay Slosar, Psychologist

thanks for info on psychological autopsies. I think there should be more of these conducted so we can learn more. Your last point identifies risk factors.

Dr. Jay Slosar, Psychologist

Drugs and Alcohol are coping mechanisms for many of people to run away from the pain or their situations. As well being a pharmaceutical researcher and certified homeless women's advocate; I've spoken with many whom stated if they can't get the prescription drugs they turn to the street drugs to cope. Any human being subjected to living outside in survival mode 24hrs a day, 365 days a year would become mentally unstable needing some type of numbing coping mechanism. As well; if your less fortunate and homeless and on prescribed medication, How can the medication work properly? The patient isn't eating, drinking water or bathing properly! Professionals should look deeper into the reasonings behind why people are increasingly wanting to commit suicide. Acknowledging a portion is due to systematic failures.

Candance Camper

Wow there is so much here. My thoughts in presenting this topic was to try to develop awareness and response and yes increase compassion. As I noted above the 800 numbers at least might be a lifeline for those in despair. But addressing the suffering and despair that is out there is a powerful point. The polarization we have today in society seems to me to end up for some as despair and a feeling no one cares. Or people just feel like failures. As for society overall--the deaths of despair by Case and Deaton look deeply at our society and the super powerful capitalistic world we live in every day. Thanks for this thoughtful response. https://press.princeton.edu/books/hardcover/9780691190785/deaths-of-despair-and-the-future-of-capitalism

Dr. Jay Slosar, Psychologist

The immediate trauma of losing it all is important. When one is arrested or at a point when they feel their life is ruined or over they take their lives. I think those in law enforcement recognize this when they arrest someone who feels their life is over and is faced with shame.

Dr. Jay Slosar, Psychologist

Yes, an individual feeling like they have lost everything is a key risk factor for someone dying by suicide. From what I’ve seen, I would like to see some law enforcement officers demonstrate more awareness and sensitivity around issues like this when an individual is being arrested or when someone is reaching out to police during a crisis.

Christy Kobe, LCSW EMDR Certified Trauma Therapist Polyvagal Theory Anxiety and Stress Therapist

Thank you Peter. You are right --the goal is to prevent suicide and a national call to action would be warranted. Thanks also for referencing unsuccessful suicides.

Dr. Jay Slosar, Psychologist

So true here is an increasing problem and a declining response!! And the problem is about life and death. As a society have we become immune or cold? Did all the COVID deaths make us immune to death?

Dr. Jay Slosar, Psychologist

As human beings; living a human experience we all deserve to live a fruitful happy, healthy, peaceful life, while here on earth. Society has become a deceitful, manipulative, self preservation society, having no sympathy nor regard for their fellow human being brothers and sisters, whom are less fortunate. America and some it's country people are dysfunctional, and not taking care of one another nor their home United States. Allowing America to burn from within; due to generational curses, ideologies, thought patterns that still plague our country. As well; covid or No covid No human being is immune from death! All human beings were born and we'll all leave the earth when it's our time to go! ....And we don't know when that day will come!! Unfortunately, in an attempt to deflect from their own discomfort, some individuals tend to resort to labeling and blaming the less fortunate for their circumstances, thereby looking down upon them and dehumanizing their experiences. Instead of supporting the less fortunate helping them to rehabilitate their lives, it's easier for people to consciously deflect to not have a guilty conscience.

Candance Camper

Allow me to emphasize that understanding the complexities of life goes beyond analyzing problems from an outsider's perspective. As the old saying goes, "If you haven't walked the walk, you can't talk the talk," and this wisdom extends far beyond formal education. True comprehension arises from lived experiences, genuine connections, and firsthand encounters with disparity, which cannot simply be found within the pages of a book.

Candance Camper

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Grieving and national trauma: Thoughts from Clinicians and Therapists

Grieving and national trauma: Thoughts from Clinicians and Therapists

Grieving and National Trauma: Thoughts from Clinicians and Therapists

I believe we are a society living with intense anxiety and fear of trauma.

Clinicians, are you seeing and feeling what I am?

Here are my initial thoughts as a clinical psychologist:

I never went through Kubler Ross’s bargaining phase when my mother died. I didn’t try to tell myself if I did something or acted differently she would not die from pancreatic cancer, or ask somehow to talk to her again. I did dial her phone number after she died to hear her voice mail message. And, since she liked cherry soda, each time I went to the grocery store from then on, I bought her favorite drink.

I think part of this non-bargaining is because I had closure. I was there with family at her side when she passed. I also had brought her to my house with hospice care. Even excruciating emotional despair resolves itself better when you have closure.

She helped create that closure, too. After her diagnosis and with limited time remaining, her brother and sisters all came out for one final visit. She summoned them in, one at a time. She asked each one if there were any unresolved issues in their relationships with her. Each came out of the room with either tears or a smile, but also great admiration for her.

Consider how different each of us grieves a parent or a loved one based on the relationship and factors of our attachment to them.  What if you weren’t that close to your mother? What if you do maintain major issues with your mother for past conflicts, from mistreatment, or while coping with her? All these types of factors make grief and grieving more complicated. All of this applies to the loss of any significant person in your life.

Next, consider far worse scenarios. The families of the victims of 9/11 lost their loved ones in a tragedy in which they didn’t even have any remains. Parents who lose their children in a school shooting face a loss so despairing the grief can feel insurmountable.

I submit that, because of the pervasive shootings and violent deaths our society faces, societal psychosocial despair is growing in a cumulative stress bomb that impacts every community in our country. In other words, I believe there is a collective societal prolonged grief that is affecting all of us on a daily basis.

It’s telling to this “national despair” viewpoint that the clinical psychology field has further developed diagnostic criteria for grief and has now added the diagnostic category of Prolonged Grief Disorder (PGD) in DSM-5 TR.

Here is the definition: DSM-5 PGD is present when, after the death of someone close at least 12 months earlier (Criterion A), a person experiences intense yearning or preoccupation (Criterion B), plus at least three of eight symptoms of: identity disruption, disbelief, avoidance, emotional pain, difficulties moving on, numbness, a sense that life is meaningless, and intense loneliness.

For a background and full discussion of PGD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473035/#:~:text=DSM%2D5%20PGD%20is%20present,a%20sense%20that%20life%20is

Prolonged grief disorder is experienced by up to 49% of people after an unnatural loss (such as the death of a child or deaths by accident, disaster, homicide, or suicide). https://www.sciencedirect.com/science/article/abs/pii/S0165032719315083?via%3Dihu

I should acknowledge that the criticism of the PGD diagnostic category is that it pathologizes the process of grieving.

My take is that emergence of the new PGD diagnostic category signifies the complex societal issues of persistent, ongoing and complex loss and trauma we are forced to live with everyday. The data that 49% of persons who endure an unnatural loss experience PGD is significant. This will probably increase with continued violence.

I believe we are a society living with intense anxiety and fear of trauma.

Are other clinicians seeing and feeling what I am?

Great post!

Jeremy L. F.

This is my exact experience in therapy sessions for the last few years. Much more so today than at any other point in my career. In my assessment and through what I am hearing, there is a lack of “hope” that society can see itself out of the troubles we hear about on a continuous bases. There is a lack of perceived safety causing a mistrust for others, increasing agoraphobia, & creating intense levels of fear and anxiety about life and others. There is a disbelief that life can and will get better, be less stressful, hold the days of promise for a better life, and return to a time when all levels of society were working together for the betterment of all. I hear a general sense of hopelessness and disillusionment of humanity in my client population. It is worrisome to me as I don’t believe medicating one’s self through this perception is the answer. More action and engagement is necessary. Advocacy and finding purpose again are some ways through this.

Phyllis Mogielski Watson, MS, PsyD (AZ/IL/CO)

There is a difference between grief counseling and grief therapy. The new DSM-5 PGD criteria has been instrumental in guiding me to differentiate between my treatment plan of grief counseling versus grief therapy. The field of grief therapy is exciting with new modalities such as Dr. Shear's evidence based trainings out of Columbia University. I also agree with other clinicians in that it allows for financial compensation and insurance reimbursement. Grievers benefit all around. Separately, anxiety is pervasive. I see in in all my of my clients, my family and myself. There is absolutely a collective anxiety humming in the background for all of us. This certainly affects our mental health.

Carolyn Gartner

I believe the literature supports that healthy grief is resolved through connection and communication -- both of which have declined substantially in the past decade. Our lingering, lonely grieving is likely a direct consequence of our loss of connection and safe communication with each other. Therapy is often the last refuge of both.

Adam Buhman-Wiggs

Frank, empathetic conversations about the complications of grief are important, so I appreciate this article. I also appreciate the framework of a social increase in anxiety and fear of trauma. In my practice, I have seen an uptick in the past 6-10 years of clients who are describing intense anxiety about safety in their daily lives--both physical and emotional safety. The collective, ongoing experiences of the COVID-19 pandemic seem to have intensified these concerns. I share the mixed feelings noted by others about the addition of PGD to the DSM-V-TR. I appreciate any step that makes therapeutic care more accessible, but I am concerned about pathologizing normal and appropriate human experiences. In my practice, I often see folks in acute grief for well over a year after a loss, even if the loss was expected. When loss is traumatic, it makes complete sense to me that intense grief symptoms would persist even longer. Thank you for the thought-provoking article.

Ann Becker-Schutte, Ph.D.

I think some of this holds true, and what was pointed out already here speaks to the surface level traumatic events that affect us and hold our attention. Having said that, I also see these events in contrast to our cultural expectations. Namely, the cultural rhetoric normalized in the wake of the sexual revolution that morphed into the yuppie capitalism of the 1980’s that capitalized on the more saccharine and idealized aspects of American culture. It hit a boiling point through the 90’s with the end of the Cold War and a preoccupation with feeling somehow everything was “getting figured out.” The idea that racism even existed at that point was considered, amongst many people, a social faux pas. Then, in 2001, we had a very rude awakening that made, understandably, very little immediate sense to anybody. What all of this says to me is that, during both euphoric and dysphoric cultural periods we tend to have a very short memory, much in the same way that someone with depression has the sense that they will always feel depressed, or in the way someone with bipolar will ride the euphoria of a manic episode believing, on some level, that it can be maintained. I have definitely noticed a collective malaise amongst people, and none of it is surprising to me considering the broader context it’s occurring in. That there’s been a major upheaval in what people can agree on in terms of leadership and a coherent national identity or dialogue is a symptom, not necessarily the fundamental cause of what’s going on. Lasting change in people, or any change, is typically spurned on by needing that change, something I think most of us can confirm is what is present in every intake we have with clients. When we’ve really had enough and the malaise can’t be enabled any longer, things will improve because there’s no other choice. Until that happens, in my view things will continue as they have been.

Michael Fiorini, PsyD

I think we as a nation had trouble with grief long before we were exposed to horrible events like recent mass school shootings.  As a culture, we live in collective denial; even when a loved one dies, many people do not take time to grieve.  Instead, what I have noticed is that people often turn to workaholism to avoid feeling loss, heading back to work within a day or two.  When you add societal trauma to personal trauma, it is no wonder that people experience prolonged grief.

Dr. Stephanie Buehler (she/hers)

Let's face it, we all treat grief and just diagnose it as an Adjustment Disorder so we can get paid! This is needed!

Dr. Stacy Wright

Jay, Thank you for your thoughts. When I think about the metaphor of grief applied to our national experience, I think it can guide us toward an important national discussion. First, when I think of what is healthy grief I think about an encounter I have many years ago with a father whose teenage son died unexpectedly from an allergic reaction to a food he consumed. The unexpected tragedy was very difficult for this father. As we worked together, I asked him a question: "If I could take away your pain and suffering, but it would mean that you no longer remembered your son, would you do it?" His immediate and emphatic response was "No!" This changed our conversation, because healthy grief is not about alleviating pain and suffering, it is about identifying what is truly important about the individual (or, in our metaphor, the nation) for whom we are grieving and preserving those memories as well as carrying forward in ways that honor the contributions of that person so that what is valuable is not lost. The national grief could be seen as a call to remember what is truly important about our experience as a country, letting go of those things that are trivial, and finding ways to fully honor our experience. I hope we can do that.

John Weaver

"Even excruciating emotional despair resolves itself better when you have closure" — I could not agree more, and I fully appreciate your take on these salient issues. You also wrote: "I submit that, because of the pervasive shootings and violent deaths our society faces, societal psychosocial despair is growing in a cumulative stress bomb that impacts every community in our country. In other words, I believe there is a collective societal prolonged grief that is affecting all of us on a daily basis." —  This "cumulative stress bomb" that you speak of is something we've collectively experienced at various periods throughout history, and I agree that we're currently in a time of extreme accumulation of grief and trauma that are tearing at the fabric of our culture and society. We need as many talented, thoughtful, and sensitive mental health clinicians as we can get, and I thank you for this very meaningful post.

Keith Carlson, BSN, RN, NC-BC

The points made by others here are things I've also witnessed in my thirty years of practice. In general, our Western culture seems to support avoidance and distraction from grief. How many times have I heard from those who've just gone through loss of some kind, "It seems like people expect me to be "fine." Unfortunately, giving prolonged grief a "diagnosis" seems to both a blessing and a curse - it means that its treatment can be covered by insurance and concurrently, it infers pathology. Very thoughtful article.

Dr. Margaret Rutherford

I feel that recognizing suffering as part of the process in life is post-traumatic growth, and movies and art can help us to better work through that pain and move into growth by suffering in a context by providing a model that has meaning and connection. By coming together through film discussions, group screenings, or collaborative film projects, community members can share their experiences of suffering and happiness, support each other's healing processes, and build a strong sense of empathy and resilience. This act of viewing films and engaging in discussions is called Cinematherapy, a concept coined by Dr. Gary Solomon, a social worker, psychotherapist, teacher, and movie doctor. https://filmandvideobasedtherapy.com/dr-solomon/ Groups like Veterans Media and Entertainment https://vmeconnect.org/ touch upon societal issues, personal struggles, and the complexities of human suffering, combining them with entertainment for an enjoyable experience. #FilmTherapy #CommunityBuilding #PostTraumaticGrowth #Happiness #WellBeing #EmotionalResilience #MediaPsychology #therapeuticadvertising

Joshua L Cohen

Grief needs to be categorized and seen as pathological.Their is a lot of misinformation out there on grief, and separating it from how mental illness is financially supported can be challenging. Unfortunately, living in society is getting more expensive, and resources can be limited without insurance companies' "support".The PGD diagnosis gives financial compensation for grieving patients and their systems, time off from work, and a break in responsibilities to heal from their loss.Individuals who are experiencing intense grief can have difficulties with sleep, miss payments and deadlines, disrupt relationships, and keep up with other responsibilities in their life during that time of intense loss. Recognizing intense grief this way can increase individual's assess to treatment longer and give them other extra support that are necessary for healing.As mental health providers, it is our responsibility not to disenfranchise their grief. Especially, as you point out here, there is more intense anxiety and fears of trauma in our society. We should not be adding to this by our own lack of awareness of how systems are operating here together and our own mortality personal views. Isn't this a national trauma? #emotionalliteracy

Christina Harrington-Stutzmann

I see this as global human burnout in addition to prolonged grief. As a clinician of kids, teens, and adults through the “pandemic time warp” (as I like to call it), the amount of relapse among clients, burnout of clinicians, healthcare workers, teachers, police officers, basically EVERYONE (yes I’m using an all-or-nothing term here ?) is unbelievable. It seems everyone is living in a post-war type of brain fog… the tik tokkers may loosely toss around the term “dissociation” to describe what I’m seeing as a mass societal numbness and demoralization. Like… What. Just. Happened?! The past few years were far from anything we’ve ever been through in this lifetime and we will continue to see the negative impact socially, emotionally, psychologically and culturally as we try to recover. Not only was it a pandemic, but wars have broken out, school shootings are out of control, distrust of the medical system and govt has erupted. Political battles are incessant not just in DC, but in our own classrooms, dining room tables, etc. Layer in some record-breaking earthquakes, fires, hurricanes, train derailments, media wars, and oh yah, a recession. The amount of overwhelming burnout and collective trauma is a Real. Big. Problem.

Kristen Markovich, Psy.D.

I am hearing about fears of shootings and stabbings by lone wolves, and that our society is fragmented and in danger of social upheaval or even civil war. People are avoiding malls, theaters, and other public places where there are large numbers of people. When vicarious trauma of violent deaths here and around the world are added in, our ability to process it all can overwhelmed. Our brains defer maintenance during stress, and in chronic stress the lack of maintenance shows in the form of blue mood, appetite problems, sleep problems, sexual problems, brain fog, and ultimately, clinical depression. Certain beliefs can help, such religious faith, or belief that humanity will find solutions to our troubles. Right now, we don't have a national or world forum for processing it all. Thank you for starting this thread, Jay

Lee Blackwell

I really appreciated this post! Prolonged grief disorder may at times be difficult to differentiate from major depressive disorder. Additionally, this diagnosis may unintentionally pathologize the natural process of grief and put a firm timeframe on how long a “healthy grieving process” may look. We understand that the healing process may vary on the individual and their unique characteristics. As clinicians it is essential that we consider how cultural factors (e.g., gender, race, upbringing, trauma history, environment, etc.) may impact how this diagnosis is conceptualized, assessed, and treated.

Ryan C. Warner, Ph.D.

I think what might be difficult to tease apart is the overlap In symptoms and experiences between prolonged grief and trauma (which can also be experienced at the national/societal level in addition to the individual). What are your thoughts on that?

Dr. Mira Brancu

We sure do--Thank you.

Dr. Jay Slosar, Psychologist

Yes it poses a dilemma. Once we create a DSM category, capitalism kicks in. Then look out. It can be discouraging. To me, though, setting the delineators or markers in the definition are helpful. I always answered the question how long does one have or feel grief and loss and I would just say from my own experience that after a year of special days without them somehow you get used to it. Or maybe immune to it? I always cringe and worry when a parent says about their child surviving a loss: “he/she is handling it so well.”

Dr. Jay Slosar, Psychologist

Per your comment about avoidance and distraction--- On the national level--, I am struck with 1 million people died from COVID more than all our wars combined. You know individually people had tremendous grief but we society just seems to say oh well.

Dr. Jay Slosar, Psychologist

This is an issue I discuss with my clients regularly. Collectively, even if we as individuals did not lose a loved one to COVID or gun violence or a natural disaster, we have faced an enormous series of losses. There appears to be an expectation that we just "move on," without holding much space to process these losses.

Ann Becker-Schutte, Ph.D.

Joshua thank you for providing all these resources.!!

Dr. Jay Slosar, Psychologist

Overall I think the PGD diagnosis is helpful and the criteria help us put into words how grief is impacting us and lends to therapeutic discussions. But grief is a part of life. However, as I note the unnatural deaths have overwhelmed us. But I have referenced in my book many years ago the book by Judith Viorst- Necessary Losses --self development is related to our coping with loss. https://www.amazon.com/Necessary-Losses-Illusions-Dependencies-Impossible-ebook/dp/B003L77W96#:~:text=She%20argues%20persuasively%20that%20through,and%20fuller%20wisdom%20about%20life.

Dr. Jay Slosar, Psychologist

Grief is not always negative; it's a part of life. Traumatic experiences disrupt our autonomic nervous system and result in suffering. Through the therapeutic use of films, individuals can explore and process their traumatic experiences, derive inspiration from stories of resilience and growth depicted on screen, and embark on a journey toward personal transformation and self-awareness while entertained. Paul Petshek, a film editor, member of the Director's Guild, and a Somatic Experiencing Practitioner, exemplifies how this process can be used in filmmaking to appreciate art and life.

Joshua L Cohen

By embracing the power of film and its potential to integrate ideas, foster community, promote post-traumatic growth, and deepen our understanding of suffering and happiness, we can cultivate a more balanced culture that embraces both trauma and healing while providing a fulfilling way of experiencing life through collaborative efforts. Film serves as a model for this process. Through the shared exploration of films, we can find healing, resilience, and a path toward greater understanding, happiness, and post-traumatic growth. Filmmaking and viewing enable us to build stronger communities that support each other's growth and well-being. 

Joshua L Cohen

Joshua I really do think art therapy has emerged as a vital therapeutic response to the grief and trauma an individual endures but also for us in general living under such fear and anxiety of ongoing shootings. I think art and art therapy should really be emphasized in schools especially with younger children.

Dr. Jay Slosar, Psychologist

I respectfully disagree that it would only be used with children. I've seen firsthand work with adults AND families in the military in reducing symptoms of post-traumatic stress. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234913/ This qualitative research study done by the grandson of General Patton and clinical psychologists from Israel shows how it reduces post-traumatic stress in military populations. Furthermore, virtual reality is also used by the military and documented in my book by the work of Dr. Skip Rizzo from the Institute of Creative Technology at the University of Southern California with the Army. When we are traumatized, we cannot access the language portion of the brain that makes talk therapy possible. Art, sports, kinesthetic, and sensory activities help regulate the autonomic nervous system, making talk therapy possible for any age at any talent level. This is backed up by research by Bessel Van der Kolk, Peter Levine, and many other body-based theorists stating that therapy is about the therapeutic relationship, which all evidence-based therapy is founded on at some level.

Joshua L Cohen

The power of interaction and connection should be considered. As esteemed art therapist Cathy Malchiodi emphasizes, the therapeutic relationship is crucial in healing. Whether with a therapist or fellow community members, genuine connections provide a safe and supportive space where individuals feel seen, heard, and understood. Through these relationships, individuals can navigate their healing journey, gain new insights, and find solace in the shared exploration of suffering and the pursuit of happiness.

Joshua L Cohen

Thanks Lee. Your conclusion points out solutions and a course of action.

Dr. Jay Slosar, Psychologist

Yes in the long process of developing PGD criteria the critique was it might pathologize grief. Certainly cultural and social factors are at play and each case is unique. The unnatural deaths component is important as to what is happening today leading to my premise. I do think the 8 criteria/components of PGD are helpful in describing the impact/effect on individuals and lends itself to elucidating therapeutic issues.

Dr. Jay Slosar, Psychologist

Sure if the PGD persists it then leads to possible PTSD diagnosis. The research showed the link between PGD with PTSD. My societal level and cumulative stress model is the idea that we are having visceral responses and vicarious reactions that are impacting all of us. This is the society we currently live in. Will we need to become immune to grief to psychologically function?

Dr. Jay Slosar, Psychologist