Talking About Suicide

Talking with Paul Quinnett


It took me far too long to come across “Suicide: The Forever Decision,” a book that psychologist and author Paul Quinnett allowed to be posted online. This is the first time I’ve ever seen a suicide prevention effort that includes a strong warning about the physical dangers of a suicide attempt. As the chapter title puts it, “What if You Don’t Succeed?”

“I had a long debate with myself about whether or not to write this chapter,” writes Quinnett, who has worked with hundreds of attempt survivors.

On the one hand, what I have to say to you here is both unpleasant and, some might argue, unnecessary. On the other hand, I promised you an honest book. Since most people who attempt suicide do not succeed, I feel I would be cheating you if I didn’t share what I know about what can happen if you try to kill yourself and fail to get the job done. So, I will keep my promise.

He gives more than a half-dozen examples of people who survived with serious physical problems and says he could give more. And he’s smart enough to know that some people reading his book will dismiss the warning as a scare tactic. He adds:

I know it is not enough just to warn people who want to kill themselves that, if they try, they may not succeed and some terrible unanticipated consequence may follow. But because I know that once you are in that terrible and lonely place and in the midst of that awful crisis of whether to live or die, you may convince yourself that the solution you seek will be neat and clean and tidy and final. This is part of the logic of suicide: that death will be quick and easy. But I will quote Murphy’s Law, “If a thing can go wrong, it will.” And Murphy’s Law, I’m afraid, applies just as well to suicide attempts as anything else.

I spoke with Quinnett last week about how his book came about, including its  conversational style and direct approach. (Other chapters include “Don’t I Have a Right to Die?” and “They Won’t Love You When You’re Gone, Either.”) Overall, the book is a refreshing, personal approach after the careful messaging of most suicide prevention efforts.

In our conversation, he also shares the results of a study he did on the health care costs of suicide attempts. It would be fascinating to see this done on a much larger scale, especially as so many attempts are classified as accidents instead, because of stigma or otherwise.

First, please introduce yourself. Who are you?

I’m Paul Quinnett, a clinical psychologist, professor, at least part time, and president and CEO of QPR Institute, an educational institute dedicated to suicide prevention education and saving lives.

It took me a long time to come across your book, and I’ve done a lot of Googling on this subject. How come it’s not more easily found out there?

Writing is easy, publishing is easy, marketing is hard. I’ve written seven books and a lot of magazine writing, and I’ve written outdoors and travel articles, fishing stories. I used to write for Audubon Magazine, a lot of fly-fishing magazines. I lead two lives, one as psychologist and another as outdoor writer. By the way, I just published all of my books on Kindle. So “The Forever Decision” book, the one you’re talking about, will soon be available for all e-readers. It’s available in several languages and is free from the QPR web site.
I think it’s $3 on Kindle. We just last month published Spanish translations of two of my books, including “The Forever Decision.”

I was very interested in your chapter about what happens if a suicide attempt doesn’t succeed, the possible injury involved. Why isn’t that message used more in suicide prevention?

I think people are terrified of the subject, first of all. To back up a little bit, the book was actually written to a patient of mine, an attempt survivor who had made three attempts. For years she was “on the edge.” I was working with her with a psychiatrist colleague. She had poor care from another psychiatrist who abused her sexually. It’s a long, complicated story. After her third overdose, she came to our mental health center and entered treatment. It took a while, including suing this psychiatrist and seeing to the removal of his medical license, but justice was finally served. In my view, injustice drives a lot of suicidal thinking. I call her Ann. When I was treating Ann, I realized there are lots of Anns out there. I really wrote the book to her, you know, in the second person, as if we were sitting across from one another in my office.

After the book was published, I met lots and lots of Anns because we had opened a conversation that had not happened before, at least not in that way. My work began to focus on suicidal folks, and I began to see more and more people who had made attempts. In my limited private practice I became known as the “suicide guy,” and other professionals began to refer their suicidal patients to me. I had a very exciting practice where I actually learned how, as near as I can understand, it feels to be suicidal. I think I had a mild mood disorder in my early 20s, but I never had an episode where I recall being actively suicidal. But I think I can begin to understand the psychological pain that drives that suicidal thinking. So the book was written to someone who had made several attempts, and who is now a successful grandmother. I saw her later at a Costco, and she looked great. The problem is, nobody feels they can talk about this. Some of the most important things I learned were from my patients. I didn’t get it from books. You have to get into the conversation and be willing to tolerate some pretty frightening stuff.

Why don’t more people talk like that, use your approach?

Thinking about suicide is one thing. Actually doing it, that final physical action, requires a great deal of courage and fearlessness. I’ve talked to hundreds of people who’ve attempted suicide. They don’t always die, obviously. The state of mind sometimes changes after an attempt, but sometimes it doesn’t. I had a patient, a brilliant young fellow with late-stage AIDS, homebound, basically dying. His physician agreed that he could get enough medication to kill himself. I worked with this fellow and couldn’t say to him, “You’ve got to stay alive and die painfully.” I wanted to go as far with him on the journey as I could, but not aid or abet his final decision. He took a massive overdose, and he didn’t die. He was revived at a hospital, and he went back to his apartment. I visited him, and he said, “I guess Jesus didn’t want me, and I was too much competition for the devil.” He went on to die naturally some months later.

I think a non-fatal attempt often reveals to suicidal people things they didn’t appreciate before making the attempt. There are people who survived the jump from the Golden Gate Bridge and who are happy to be among the living. I have a saying I sometimes used with my attempt survivor patients, usually toward the end of a first session: “You can learn so much from wanting to die, so perhaps a suicidal crisis is a terrible thing to waste.” So many people have gone through this moment of darkness and found the light on the other side. I recommend people read Shenk’s “Lincoln’s Melancholy” to see how close our greatest president came to ending his own life. I think all of this needs more discussion. I’m working with a filmmaker now who wants to make a documentary on this whole business to open up more conversations.

On which part?

I’m not sure, I’ve not seen the outline. Her father-in-law died by suicide. We have story after story. Bruce Springsteen just came out and talked about his attempt. [Note: The article mentions suicidal thoughts but not an attempt.] This is starting to happen. Where we have less information, and from whom we could learn a great deal, is from attempt survivors, because this conversation has been so taboo. And yet, people who are considering ending their lives need to hear these stories. Maybe these stories are told in therapists’ offices and confessionals, but the public can’t benefit from these discussions since they are all private.

Why isn’t it more open?

My theory, and we’re about to launch a national research study, is fear. Some colleagues and I put together a survey to determine how much fear is felt by health care providers when encountering a suicidal patient and, perhaps, what impact this fear has on the healing relationship. I see it all the time. Therapists cannot talk about this. They’re not educated; they’re fearful. A suicidal person goes in to talk about wanting to die and the therapist can’t even listen quietly. They fold their arms, look out the window and send all kinds of off-putting messages. If clinicians don’t deal with this fear, perhaps we are contributing to this continuing loss of life, even among the very people we are sworn to help. Years ago, I did a little study in my own clinic, trained my clinicians in how to do a suicide risk assessment and talk calmly about ideation and past attempts. Rather than ask the clinicians what they thought about the interview, I asked the patients. Did they feel comfortable? Did they feel more hopeful at the end of an interview? Talking about sex is easy, talking about suicide is hard. But just like a prostate exam, it’s potentially embarrassing and even a bit painful, but it’s needed and saves lives.

Why is there not more research on injuries caused by suicide attempts? Or have I just not found the studies?

I think it’s an excellent question. I’ve seen very few studies on the cost of nonfatal suicide attempts. And I think this is because of a couple of reasons. One is, many of the seriously injured people after, say, a single-car crash which was ruled an accident by the officers on the scene, will never been screened in an emergency department and asked, “Did you crash your car intentionally?” The result is that the medical costs associated with these frequent intentional suicidal self-injuries are considered accidents and, thus, not attributed to suicidal behaviors. I had a consult from a Montana hospital where a farmer had rolled a tractor on himself, and it cost $50,000 to $60,000, probably more, to put him back together again. The hospital staff called a psychiatrist friend of mine on staff and asked him to ask the farmer if he was suicidal. “Why don’t you ask him?” my friend asked. They said, “No, that’s a specialty question.” My guess is that hundreds, if not thousands, of falls, overdoses, car crashes and such are coded as accidents, not intentional injuries, and so we don’t have solid cost figures.

It’s not just the cost of attempts I’m interested in, but the number of injuries from attempts, the percentages …

I have worked up some suicide-related costs here in Spokane County. We tracked people who came into four of our six hospitals with nonfatal suicide attempts. We tracked numbers of days in the hospital. We didn’t know long-term costs, but we did know the direct medicinal costs. The medical costs for nonfatal suicide attempts exceeded $20,000 in the majority of cases. The costs are covered directly our health care plans. I’m not aware of the ongoing cost for continuing care, disability and nursing home placement if needed. I’ve had patients who suffered very serious injuries. They were in long-term care facilities. Spinal cord injury, gunshot wound to the head. Very, very tragic outcomes that, most of us believe, are preventable. [Note: The study looked at 1,100 emergency room visits and hospitalizations for suicide attempts for the year 2008 in Spokane County, Wash. In that time, the number of completed suicides was 70.]

Why is this not mentioned in suicide prevention efforts?

I don’t really know. When I wrote that chapter in the book, I debated: “Am I talking with someone who’s clear-headed and thinking rationally before taking an action?” I think probably not. People experiencing a great deal of suffering don’t always make great decisions.  And many people who make a suicide attempt decided to act in 20 minutes or less. At that moment, and if they are reading my book, at least we are reading and not attempting suicide. For many depressed suicidal people, and especially if they are beat down, not sleeping, and tired, and worn out, I doubt they’re going to sit down and read that chapter in the book and it will somehow change their mind.  But it might buy them a little time. I’d be happy with that. Just put off a suicide attempt one day. In one day, things can begin to turn around.

What many experts are thinking now is to move further upstream, go to the school years, ask, “Where does the thought of suicide come from, anyway? Did you see it in a movie? Did your mother take her life?” “Are you being bullied or abused?” These are known risk factor-producing experiences, and if they can be mitigated early on in the developmental
years, there’s good evidence suicidal behavior can be prevented. I don’t think there’s anything frightening about thinking academically about suicide as a sort of harmless thought experience. According to the Centers for Disease Control, eight million people in America will seriously think about suicide in the next 12 months. Seriously going to think about it. If people are thinking about it, why can’t they learn more about it, realize what it means, what that first thought means? The first suicidal thought is like a bad cut on your finger. If it doesn’t close up on its own, it may need a stitch or two. What do we do with badly cut fingers? Unless we’re Rambo, we get some help. The persistent idea that death is a solution to suffering can occur once and pass on as a non-option, or it can begin to recur, to haunt us. What we need now is a way to help people understand what suicidal thinking is, what it might mean, and what practical things they can do to manage these thoughts and move beyond them. According to the CDC study, 4.7 % of adults in my state, Washington, think seriously about suicide in a 12-month period. In my county alone, that’s 17,000 folks, and almost a quarter of a million in my state.

You haven’t had a suicide attempt. But for therapists who’ve had their own experience, should they mention it?

That’s what’s called self-disclosure. Is it useful? Is there a point when it would make a positive difference with a client to say you had made a suicide attempt yourself? There are some ethical guidelines about self-disclosure. I think that in some times and cases it may be helpful; at other times it might not. I can’t tell a practitioner when it’s time to bring up this personal historical fact. In recovery work, with addictions, lots of addiction counselors are front and center with their own recovery, but I’ve also seen some of them disclose too soon and cause the client to back away.

Is it healthy for people, not just therapists, but anyone, to self-disclose anyway? Or is it better to keep the experience quiet?

A very good question. I think the day is coming where disclosure will not matter. I did a lot of work for law enforcement over the years. I did fitness-of-duty evaluations and pre-employment psychological evaluations. Once I was evaluating a woman, 26 or 27 years old. Police officers have one of the highest suicide rates by profession, second only to the military. I always tried to determine if the candidate was exposed to suicide in his or her family, if he or she had ever been suicidal or made an attempt. When she was 18, the candidate I was examining was drinking heavily and had just broken up with her boyfriend, and was sitting in the bathtub. She cut her wrist with a razor, a superficial full-circle cut around her left wrist. She showed me the scar. She wore a wide wristband watch. She made a full recovery for her abusive drinking, was active in AA for six years or more and had her life together. She was psychologically fit to work in law enforcement, based on my extensive testing and interviewing. I recommended her to be hired. When the chief saw the report and that she had made a suicide attempt, I got a call. He wondered if I had lost my mind recommending an attempt survivor. I said, “Let me put it this way. She cut herself while intoxicated, an alcohol-related risk factor. She’s been sober many years now, there has been no recurrence of suicidal ideation or behavior. Of all the officers on the force right now, I can assure you that at least this one is not alcoholic or drinking excessively.”  The chief laughed, and they hired her. She’s been a great cop and promoted several times.

Are people going to stop listening to Bruce Springsteen because he had an attempt in the past? I don’t think so. Is the arc of revelations about having been suicidal at one time in one’s life ramping up? Yes. I know a major airline that hired back a pilot who twice was suicidally depressed. But he was well and on medication. He flew me and my friends around the Northwest after being seriously suicidal. What is the FAA doing now? Allowing pilots to say they’re taking anti-depressants. Before, if a pilot reported he or she was depressed and on medication, they took away their flight status. I think the arc of greater communication is forward. Having made and survived a suicide attempt is a long way from being a badge of honor for courage, but the sooner it’s part of the normal human experience, the better it will be for those headed down that dark road. Most people get over those thoughts. If not, action needs to be taken.

Is there anything that can be done to speed that arc along?

The National Council just published a magazine on suicide prevention. In this publication are multiple stories of hope. I recommend others find it online and read it. Stories of people who had made attempts, seriously suicidal, and so forth, who found a way forward in recovery. As I’d like to be quoted when it comes to experiencing a mental illness, “If recovery is possible, suicide is preventable.” Too many people wrongly believe of others, “They made an attempt, they’re going to die someday.” That’s nonsense.

The subject of suicide prevention and the subject of assisted suicide and the right to die, is there any common ground between them? Are they completely separate issues?

Well, that’s a big, long discussion. The field has tried to deal with it. There was a vote taken many years ago, maybe 10 or 15, among the membership of the American Association of Suicidology on this issue, and about half of the suicide prevention people said they supported right to die under special circumstances, and half said such laws should never pass.

I’m not actually that close to this issue or that familiar with the laws in Oregon and Washington. My fundamental concern is that many people are older people, which I am now one, and late-life depression is common. One of the drivers for late-life suicide is identified by Tom Joiner: burdensomeness. We have the largest cohort of people going into late life that the country’s ever had, and questions are arising about how to take care of them, how to help them through their last years. The problem is, the risk of suicide for them goes up with every decade of life. The highest rates are among the oldest groups, particularly white males, but almost nothing is being done in suicide prevention to address late-life deaths by suicide. What’s the cultural message for those headed toward what will, for some, be a burdensome, precarious lifestyle? Most don’t have sufficient savings, many are going to end up in dire poverty. If they see themselves psychologically and financially as a burden on the entire country, let alone their families, how will they deal with this?

If death by suicide with physician assistance or passive easy access to lethal means becomes culturally acceptable, I’m alarmed. I don’t want people dying to relieve the cost burdens our political system has created. And I’m adamant that I don’t want to see suicide made more convenient because it’s easier for us as a nation to deal with our deficits. I’ve been following some of the reports coming out of Washington and Oregon, and I’m not exactly comfortable that the law requires two physicians _ not mental health professionals _ concur before a fatal prescription is written.  Remember, these are the same doctors who can’t even talk comfortably about suicide with their patients. Most people who are receiving care when they die by suicide had last contact with their primary care doctor, not a mental health professional. But physicians get almost no training in suicide risk
detection, assessment, treatment, prevention or management and, what’s more, they push back when asked to get such training. Assisting medically ill, terminal suicidal patients in their desire to die is at best dicey and at worse criminal.  I’m no expert in this area, but Dr. Herbert Hendin, a psychiatrist and suicide prevention expert, has
written widely on this, and I’d recommend interested persons Google him if they wish to learn more.

Would making suicide safer, regulating it somehow, reduce the number of suicides? If people had peace of mind in knowing there was a sure way to go?

Well, that was the Greek method. But we have no data on the policy’s impact. In ancient Greece, you could make the case to die before the Senate and, if you were successful, you’d be given a prescription for, I believe, hemlock. Once people are terminally ill and make an application for self-administered death with dignity, many are relieved they have a way out, the stress goes down, and they choose to die naturally. In Oregon, the actual number who die after the application is completed is smaller than the number who apply. The book “Final Exit” came out at the same time as my book, and I can tell you, Derek Humphry’s sales were a lot better than mine.

I think what we know from imitative behavior is that if the methods of suicide are widely publicized, they become more accessible and acceptable for people in desperate straits and who may be seeking the mark of approval. We try to reduce that kind of contagion by making access to means difficult. If the means are not readily available, lives are saved, and the data is in on this intervention. The ambivalence of that moment of final action is tremendous, and if the suicidal person is provided an opportunity to see a new way forward, in my experience they will choose to live. Like the scene in “It’s a Wonderful Life” when Jimmy Stewart is about to jump to his death into a raging river. He is rescued by the angel, who jumps in just ahead of him. His greater humanity to care for the lives of others is appealed to by the drowning angel, and he forgets about his suicide and saves the
other fellow. Saving others gives life a broader meaning. It’s very interesting to me that two of America’s most-loved films are “It’s a Wonderful Life” and “Dances With Wolves.” The plot line is that people who made suicide attempts and don’t die open up a whole new life for themselves. You haven’t seen it? “Dances with Wolves” is about a solider who suffers a wound in combat in the Civil War and decides to end his life by having some rebel across the field of combat shoot him. They miss, he lives, travels west, keeps a journal, meets a woman attempting suicide after a great loss, he saves her, they fall in love and the two attempt survivors experience an entirely new and wonderful life together.  I
teach this film to students because people don’t see the underlying motivations of the characters, or that life can be wonderful if you don’t die in your suicide attempt.

That leads me to ask about media portrayals of suicide.

That’s big question, too. There are media guidelines, but they are often not followed. There’s no doubt about a contagion effect, additional suicides that occur after a first suicide. If you publicize suicide in a way that glorifies the person without providing the background issues that drove their behavior, and you show the method used _ “Here’s how you do it” _ you’re appealing to those thousands of people out there thinking about suicide today. We humans are “Monkey see, monkey do” learners. It’s how we acquire
important life lessons without having to do everything ourselves to learn something new. We watch other people. If you see a suicide and 15 minutes of fame as the outcome, people see that what happened to that person “might work for me.” It’s a modeling effect. It’s what I did my dissertation on. Some years ago, I wrote a letter to Richard Masur, then
the president of the Screen Actors Guild, who had just asked all actors not to smoke on screen if they could avoid it. I wrote to ask him to ask actors not to kill themselves onscreen. I never got a response, but it was worth a letter anyway.

When it comes to print media, I’d like someone to invent a software app that causes the reporter’s computer to freeze when he or she enters the word “suicide,” after which a pop-up would ask, “Have you read the safe messaging guidelines about how to report on suicide?”  A click of a mouse, and they could access the guidelines. Doesn’t mean they would follow them, but if they knew how they write their stories is a possible risk factor for suicide, perhaps they would think twice.

I feel I haven’t asked enough about your experiences with attempt survivors. In talking with them, what else have you learned? What surprised you?

I remember one of my male patients I saw over his summer break, the son of a professor. He had these terrible mood storms and was clinically depressed. He told me, “I like you, you seem like a good guy.” I was trying to work out a safety plan with him before he left for school.  He said that a plan was fine and even though I had asked him to call me and
he had agreed to, he said, “You know, I tell you now I would call you, but once I start down that tunnel, I’m not calling anybody.” He made two attempts and didn’t die before he saw me. He said, “Once the trance begins, once I get into that space, I don’t think about rescue, I just think about moving down the road toward that final decision. There is a relief in it.”

I’ve done a lot of work with people in recovery. The decision doesn’t begin with the decision to drink again, it starts with the decision to get in a cab and go get a bottle. How do we go upstream, backing up to what triggers this first thought of suicide, and fix it right then? Like
maintaining your car, how do we maintain our mental health? You can’t recover from alcohol or drugs by sleeping in a crack house. And so what I think, and what I’ve heard from more than one attempt survivor, is that we should not ask them to call us, but we should ask them if we can call them. In my practice for many years, I told my suicidal patients it was important to me to know they were doing OK. And I would say on our last session,” Is it OK if I call you later?” Nobody said no. Then would say, “I’ll call you between three and six months. How’s that?” No one said no. And I called every single one of them. A few were surprised, but most welcomed the call. Studies now show that staying connected reduces future suicide attempts and completions. It’s one of the things that actually works. The call says, “Hey, I want you to be around.”

This little practice was one of the more rewarding things I ever did as a psychologist. Knock on wood, I never lost anybody to suicide, at least that I’m aware of. Sometimes people would come back in for counseling: “I think I need a tune-up.” But we established a kind of a lifelong connection. I said, “I’m not moving, I’ll be right here.” But the real job of the therapist is a guide, not a pal or friend. The real job is to bridge the person to other caring people and to stay connected with them until they are safe on the other side.

Do you still call people?

No, I let them all know that I was closing my practice. I don’t see patients anymore. I encourage people to do these simple follow-ups. It costs almost nothing and can save lives. Now military research is doing the same via e-mail. And imagine what the support feels like.

Is there anything else you’d like to mention, anything you expected me to bring up?

Not right now. Maybe we can do this again sometime when we have data in our research. We’re trying to help create a tipping point in this country where people everywhere are talking about it and taking action.