infoExchange is an original resource that examines topics relating to suicide in a way that encourages conversation, written in an editorial style.


The best route to understanding suicide is directly through the study of human emotions described in plain English, in the words of the suicidal person –Edwin Shneidman,1996.

The most common pathway that researchers choose when studying the complexities of suicide is the objective, theoretical approach. In many cases, this means that they use general criteria to determine both who in the population might be at risk for suicide and the reasons why. In a previous issue, iE17: Why Do People Kill Themselves, we presented some of the prevailing academic theories about why people die by suicide. While taking an objective approach to suicide is often necessary and essential, specific elements drawn from individuals must be considered in order to form a true, comprehensive picture of the topic.

For example, the lived experience of Suicide Attempt Survivors (as well as others on the continuum of suicidal experience, such as those who have contemplated suicide but not attempted) is one source that could be examined more extensively. Their unique insights into the suicidal mind have been largely unexplored and historically undervalued. Their voices are often absent from studies of suicide and the formulation of suicide prevention policy (National Action Alliance for Suicide Prevention, 2014). Anecdotal evidence and powerful personal narratives provide an additional and crucial lens through which we can look to continue our attempt to comprehend the suicide phenomenon.

The American Association of Suicidology (AAS) estimates that there were more than 1,000,000 suicide attempts in the United States in 2013. 41,000+ of these attempts resulted in suicide (AAS, 2015).  Many who survive an attempt will try again.  So why have the experiences of these survivors been ignored for so long?

Stigma

The presence of stigma is one reason; individuals who have tried to die have feared how family, friends, school peers, and the local community will respond. As a result, they chose to remain silent. A study by Lester and Walker (2006) found that suicide and suicide attempters were subjected to more stigma than outwardly ostracized and marginalized ethnic and religious groups.

Front-line health care professionals have sometimes been cited for acting antagonistically toward attempters as well. Only a small percentage of those thinking of suicide – or those who attempt but do not end up in emergency services – ask for help for fear of being treated poorly. Those who do seek medical attention often do not receive the crucial, follow-up support that they need after emergency room exposure. Many suicide attempt survivors report negative experiences with emergency rooms, where they feel that they have encountered dismissive attitudes from staff. Some of these health care workers refuse to take suicide attempters seriously, and believe that they are merely “crying wolf” or exhibiting attention seeking behavior (Suicide Prevention Australia, 2008; Witte, 2010).

Suicide Attempt Survivors (possess) unique insights into the suicidal mind.

Man in sun

These traumatic experiences could cause victims to self-stigmatize and, as a result, they may begin to experience low self-esteem from self-inflicted isolation (Suicide Prevention Australia, 2008). If the attempter is male, there is a much greater chance that he will view himself in a negative way. Gender expectations in our society dictate that men be action-oriented, and that they “get things done”. Bizarrely, this extends to suicide too. Men who do not follow through with the suicidal act are prone to deeming themselves failures because of both their fragile mental health and their inability to kill themselves (Gold, 2012).

Even within the suicide prevention community, attempt survivors can find themselves marginalized and shunned because the term “survivor” is predominately associated with the bereavement community. To people who have lost a loved one, attempt survivors are often a living reminder of the person they have lost to suicide. To others, attempters may also be seen as a constant potential future suicide, should they attempt again.

Historically, attempters have often felt left out of the suicide prevention discourse. When they have participated, their perspectives were often considered less valid than those “of individuals who had survived the suicide of a loved one” (Litts, 2008).

Over the years, suicidologists have stressed the need for attempt survivors to have a strong voice. David Lester (2007) stated that there should be a network of support groups for suicide attempt survivors, and that their feelings, views, and actual shared experiences should influence prevention and education initiatives.

Although the change has been slow, suicide attempt survivors are telling their stories and relating their lived experiences in ever-increasing numbers. They are organizing, coming together and collectively finding their voice.

I would like to look at a number of ways that these personal narratives function. They allow for a personal catharsis for the storytellers themselves. They offer hope for those at risk for suicide. They add an essential portal of understanding into the suicidal mind. And – perhaps most important for those who choose to bravely share their experiences – they help reduce stigma by humanizing a taboo subject.

The Catharsis of Narrative Therapy

Some of the positive outcomes of constructing and sharing one’s story are seen in the psychological practice of Narrative Therapy. This approach was developed in the 1990s by an Australian named Michael White and a New Zealander named David Epston. Both men believe that individuals construct personal narratives in order to make sense of their lives. If these stories are based on a distorted and faulty self-perspective, however, an individual may internalize these misperceptions so absolutely that they negatively influence their most firmly entrenched beliefs. Narrative therapy allows for not only a re-telling and re-understanding of a person’s story, but also gives the client an opportunity to create alternatives to their personal narrative. Clients are encouraged to challenge those stories that limit the possibilities for positive change (White & Epston, 1990).

Another major technique used in this approach is externalizing one’s problems, and realizing that they are separate from the person. Ideally, a person is then able to see that s/he and his/her problems are separate entities (Carr, 1998).

Narrative therapy has been enormously successful in addressing a range of mental health issues from Post Traumatic Stress Disorder (PTSD) to Substance Use Disorder (SUD) to dealing with the grief of a suicide loss. Telling one’s story gives a person the opportunity to dissect aspects of it with a therapist, and collaboratively try to make sense of it all (Thompson, 2006). People can often see how past events might have influenced their ways of thinking. By identifying these events, they can try to alter these patterns of thought so that they do not influence future behaviors. Engaging in this process often helps people increase their confidence, self-esteem, and self-efficacy (Thompson, 2006).

 Hope and Understanding

Suicide Attempt Survivors are increasingly publishing their narratives in books, speaking at conferences, and revealing their experiences online. Their stories are offering hope to those at risk by showing them that they are not alone, and by exemplifying the fact that it is OK to engage in real conversation about suicidality.

Many case histories of those who have attempted have been documented in the past, but compared to the study of narratives of those who have actually died by suicide – through psychological autopsies, for example – the number of stories has been minimal. Fortunately, the early 21st Century has seen a sharp rise in published accounts of attempt survivors.

Suicide Attempt Survivors… are collectively finding their voice.

The story of Kevin Hines, for example, tells of his attempt to kill himself by jumping off the Golden Gate Bridge in San Francisco. Less than 5% of people who try this jump survive it. In his book Cracked, Not Broken, he tells of how the instant he stepped off the ledge he regretted his decision. The description of his downward descent is horrifying. But his ultimate survival is truly inspiring (Hines, 2014).

Memoirs like Craig Miller’s This is How it Feels and The Gospel According to Josh by Josh Rivedal, are two other excellent examples of attempt survivor accounts.

Attempt survivors and activists like journalist Cara Anna and photographer and blogger Des’Rae L. Sage have also done a great deal to advance the causes of attempters, most recently by hosting sites devoted to the stories of those who survive suicide attempts. Both are also regular guest speakers at mental health conferences.

Des’Rae L. Sage’s site livethroughthis.org is a gallery of faces of people who have tried to die. Clicking any one of the pictures displays a unique story that is as vivid and unforgettable as the next.

McMaster University and St. Joseph’s Health Care in Hamilton, Ontario collected anecdotes from 2008 to 2013 and posted them on a site called Reasons To Go On Living. Here is a randomly selected anecdote:

The betrayal I felt after the attempt, facing stigma and a lack of education from my family, could have been prevented. We could have made safety contracts, shared information, and worked together. I should have sought help and psychoeducation. Instead my parents covered their ears and I didn’t speak, until it became a trauma for all of us” (Reasons to go on living, 2013).

Cara Anna looks after the sites Talking About Suicide and What Happens Now?  The latter includes written accounts from those in the clinical professions who have posted anonymously about the added pressures they have encountered to keep silent in their field. Here is an excerpt from Bart Andrews, a psychologist:

That’s why we have to speak up, to tell our stories and reach out to those who are isolated

Had I attempted suicide? Yes!  Did I think about it, talk about it or acknowledge it?  Never… The depression got heavier and deeper until I constantly lived in a state of suicidal thoughts. Taking my own life was the only way I felt I could regain control of it… I wanted to talk about the importance of honoring “lived experience,” and I was going to honor that by sharing a bit of my own.  But I was scared.  I was afraid it could affect me professionally (Andrews, 2014).

The inclusion of the personal accounts of attempt survivors in the academic literature is still relatively scarce but the situation is improving. A study by Elliott, et al. (2014) interviewed 16 individuals who were hospitalized for attempted suicide. Their narrative data complement and support the theories and research on the predictors of suicidal behaviours, and make for a more robust analysis.  However, the authors feel that “Most research on suicide is quantitative… (and that) qualitative research is needed to reveal how individuals subjectively experience and account for suicidal behaviours” (p.1). Their study will hopefully encourage future research using similar, qualitative approaches.

Stigma Reduction: An Analogy

I would like to present an analogy to try and show the impact that personal narratives can have on the reduction of stigma.

In the late 1990s on Vancouver’s downtown east-side, there was a massive hard-drug epidemic. Even though addicts were overdosing at a rate of one per day, there was no societal appetite to improve their destitute living conditions. The prevailing attitudes of both the general public and those in power was that the addicts were subhuman and, therefore, not worth the effort.  Many thought that these “monsters” were doing it to themselves, and that if they were given help it would only make things worse for them (Hari, 2015).

This was a faction that was cruelly and unarguably marginalized and stigmatized.  If they wanted change in their day-to-day lives, it was clear that it would have to come from the addicts themselves. They had to band together and take action. And that is exactly what happened.

Activist addicts like poet Bud Osborn and former wealthy businessman turned addict, Dean Wilson, helped set up the Vancouver Area Network of Drug Users (VANDU), a group that instituted patrols who combed the city’s alleyways looking out for overdosing addicts (Mate, 2008). They tried to clean these areas of the many used syringes that were not properly disposed of, needle exchange programs were stepped up, and a lobby group was formed to push for more safe and affordable housing.  One of their demands, ultimately, made international headlines. This was their call for “a safe monitored place where people could inject their drugs without fear of dying” (Hari, 2015, p.), otherwise known as a safe (or supervised) injection site.  At the time, no one thought that such a demand would ever have a chance.

It was against all odds, then, that North America’s first safe injection site was opened in Vancouver’s downtown east-side in 2002. The aim of Insite was not only to save lives, but to reduce transmission of HIV and Hepatitis C, decrease the numbers of people injecting drugs in unsafe conditions, and to increase access to drug rehabilitation. Recent research at the facility has indicated improvement in all of these areas (Marshall, et al., 2011).

Of import to this analogy is that this victory only occurred because the obstacle of stigma against this group of people was hurdled. The antagonistic stance that many Vancouverites took toward the addicts was embodied in the persona of Vancouver’s mayor of the time, Philip Owen. He seriously believed that all addicts should be rounded up, locked up, and the key thrown away. At one point he proposed indefinite incarceration for drug offenders at an army base in nearby Chilliwack, B.C. Believe it or not, this was not considered an outrageous perspective to the general public of the time (Mate, 2008; Hari, 2015).

VANDU’s perseverance and determination eventually wore down Owen’s resistance, and he finally decided to find out for himself who these people actually were. He went incognito to the east-side of town, and spent hours hearing the addicts’ stories. He was “blown away” by their stories of suffering and pain, which helped him discover that these were not monsters but merely broken men and women who needed help as opposed to repression. Owen’s thinking was thus fundamentally and irreversibly changed. He became a fierce advocate for the addicts, and ultimately lent a major, political helping hand to making the injection site become a reality. The barriers of stigma and fixed ideas were thus eliminated because of one person’s conscious decision to engage with the flesh and blood anguish of real people and their real lives (Mate, 2008; Hari, 2015).

To be clear, I am not comparing the plight of drug addicts to those who attempt suicide. I am simply pointing out that similar changes in attitudes and a reduction of stigma toward issues like cancer in the 1960s, the AIDS epidemic in the 1980s, and same-sex marriage in the last decade have followed parallel trajectories when those affected have come together to give a face and a voice to a feared and misunderstood phenomenon.  When the face of the taboo belongs to a relative, a friend, or a colleague, it becomes increasingly difficult to fear or hate the familiar.

Stigmatized attempters of suicide are now achieving similar aims by telling their stories. They are humanizing a taboo subject, and slowly eliminating the fear that so often surrounds it.

The Future: Bringing Attempters to the Prevention Table

To date, impressive inroads have been made in the development of suicide prevention programs. The field will only be further improved by bringing Suicide Attempt Survivors to the table as stakeholders in the creation of new and improved suicide prevention strategies and solutions (National Action Alliance for Suicide Prevention, 2014).

Personal narratives…add an essential portal of understanding into the suicidal mind.

In 2009 Suicide Prevention Australia made explicit recommendations for Suicide Attempt Survivors as a distinct group within the prevention community. These included, among others an elimination of stigma toward suicide attempt survivors and the inclusion of their voices in the prevention and intervention conversation.

Recently, The American Association of Suicidology (AAS) created a chapter for Suicide Attempt Survivors. This is extremely significant because the survivor section of the organization was, until 2012, solely devoted to Loss Survivors – people bereaved by suicide. Now both groups share a space under the same heading of Suicide Survivors. This signals not only a new sense of cooperation and collaboration, but a visible realization of attempters finally finding their place in the suicide prevention community.

In 2014 a task force developed by the National Action Alliance for Suicide Prevention published The Way Forward, which advocates for attempt survivors in the United States. They proposed similar recommendations to those made in Australia, including inclusion of attempt survivors’ lived experience, reduction of stigma, engagement of family and friends, and collaboration and choice of care.

All of these developments represent significant gains for suicide prevention as a whole. The shared experiences of attempt survivors are truly reducing stigma and changing hearts and minds regarding suicide. Their stories are not only enlightening professionals who create policies or study the subject, but they are also transmitting all important hope to those at risk. Most important is the fact that they are helping to eradicate one of society’s most enduring taboos.

I feel the contributions of attempters will continue to grow and suicide prevention will benefit tremendously.

References

American Association of Suicidology. (2015). USA suicide: 2013 official data. Retrieved from http://www.suicidology.org/

Andrews, B. (2014, December 29). Providers willing to share. Retrieved from  http://attemptsurvivors.com/2014/12/29/providers-willing-to-share/

Anna, C. (2015).Talking about suicide. Because it’s not taboo. Retrieved from  http://talkingaboutsuicide.com/

Carr, A. (1998). Michael White’s narrative therapy. Contemporary family therapy, 20(4), 485-503.

Cerel, J., et al. (2014). The continuum of “survivorship: Definitional issues in the aftermath of suicide. Suicide and Life-Threatening Behavior, 44(6), 591-600.

Elliott, M., Naphan, D., and Kohlenburg, B. (2014). Suicidal behavior during economic hard time. International Journal of Social Psychiatry. doi: 10.1177/0020764014556391

Gold, L. (2012). Suicide and gender. In Simon, R. and Hales, R.(Eds). Textbook of suicide assessment and management, (pp.453-478). Washington, DC.: American Psychiatric Publishing.

Hari, J. (2015). Chasing the scream: The first and last days of the war on drugs. New York, NY.: Bloomsbury.

Hines, K. (2013). Cracked, not broken. Lanham, MD.: Rowan and Littlefield Publishers, Inc.

Leenaars. A. (1996). Suicide: A multidimensional malaise. Suicide and Life-Threatening Behaviour, 26(3), 221-236.

Lester, D. and Walker, R. (2006). The stigma for attempting suicide and the loss to suicide prevention efforts. Crisis, 27(3), 147-148.

Litts, D., Beautrais, A. and Lezine, D. (2008). First National Conference for Survivors of Suicide Attempts, Health Care Professionals, and Clergy and Laity: Summary of workgroup reports. Memphis, TN.

Marshall, et al. (2011). Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: A retrospective population-based study. The Lancet. Retrieved from http://www.bccja.com/images/Insite_ Report_2011.pdf  doi: 10.1016/S0140- 6736(11)60132-3

Mate, Gabor. (2008). In the realm of hungry ghosts: Close encounters with addiction. Toronto, On.: Vintage.

National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force. (2014). The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience. Washington, DC: Author.

Shneidman, E. (1996). The Suicidal mind. New York: Oxford University Press.

Suicide Prevention Australia. (2009). Position statement: Supporting suicide attempt survivors. Retrieved from http://suicidepreventionaust.org/wp-content/uploads/2012/01/ SPASuicideAttemptSurvivors- PositionStatement.pdf

Thompson, G. (2006). A long day’s journey into day: A psychobiography of Eugene O’Neill’s recovery from alcoholism. Abbotsford, BC.: INPM Press.

White, M. and Epston, D. (1990). Narrative means to therapeutic ends. New York: W.W. Norton and Co.

Witte, T., Smith, A. and Joiner, T. (2010). Reason for cautious optimism? Two studies suggesting reduced stigma against suicide. Journal of Clinical Psychology, 66(6), 611626.

 

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