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Why mental health advocates use the words 'died by suicide'

By changing the way we speak, we remove the culpability from the person who has lost their life.
Image: Designer Kate Spade Found Dead At 55 In Her Manhattan Apartment
City workers enter a building to retrieve the body of fashion designer Kate Spade who was found dead in her apartment of an apparent suicide on June 5, 2018 in New York City.Spencer Platt / Getty Images

With the news this week of the deaths of Kate Spade and Anthony Bourdain, reactions and commentary are pouring in on social media. People who never met them are grasping for answers as to why these icons could meet such a tragic end. Specifically they may be asking, “How could they do this?” It’s a common question in the aftermath of a suicide that, though typically innocent in nature, is loaded with crucial misunderstandings about suicide and, in some cases, mental illness.

What exactly is the problem? Partly it’s in the language. Asking “how someone could do this” puts responsibility on the victim, just as the phrase “committed suicide” suggests an almost criminal intent. Depression and other mental illnesses are leading risk factors for suicide. This is why mental health advocates usually employ the term “died by suicide,” as it removes culpability from the person who has lost their life and allows a discussion about the disease or disorder from which they were suffering.

That said, suicide is rarely caused by one single factor. According to a Vital Signs report, Centers for Disease Control (CDC) researchers found that 54 percent people who died by suicide were not known to have a mental illness diagnosis. While many cases of suicide are attributed to mental illness diagnoses, other issues like relationship and financial stress and substance abuse contribute to rising rates of suicide.

In the moment, what seems irrational can feel completely rational

“In interviewing people who have [survived] suicide, what becomes apparent is that suicide in the moment that they attempt to enact it seems to them a very logical solution to their problems,” says Dr. Anna Lembke, an associate professor of psychiatry and behavioral sciences (general psychiatry and psychology-adult) at Stanford University Medical Center. “Most often their problem is feeling profoundly unworthy, profoundly depressed and profoundly burdensome to others. What seems irrational from the outside in their mind is, in that moment, completely rational. And this thought of being a burden is a recurring theme that comes up again and again.”

Dr. Rebecca Bernert, a suicidologist and the director/founder of the suicide prevention research laboratory at Stanford School of Medicine adds that research suggests that people “at greatest risk for suicide may perceive themselves to be a burden or feel a lack of belongingness, even if this may be a harmful misperception.”

Because this feeling of being a burden is so strong, suicide can be viewed as “not a selfish act but almost a selfless act,” by its victims, Dr. Lembke explains. “There’s a gross underestimation of the psychological impact of what a suicide will be, even to loved ones, and an irrational sense that [one’s death] will help people, even those they love the most. This thinking is deeply informed by being in an altered mental state caused usually by depression or depression and psychosis.”

Not every depressed person develops suicidal thoughts and not every person who dies by suicide is depressed

Not everyone who suffers from depression will have suicidal thoughts. And not everyone who has suicidal thoughts will act on them. Why are some people more at risk than others? There’s no one answer for this complicated issue.

“Suicide is a complex outcome of medical illness and a diverse interplay of risk factors,” says Dr. Bernert. “Though a symptom of depression, suicidal behaviors exist on a continuum of risk, ranging in severity from suicidal thoughts to attempts to death by suicide. Only a small fraction of those with depression will go on to die by suicide.”

Dr. Urszula Klich, a clinical health psychologist who implemented suicide prevention training program in a previous role at Shepherd Center in Atlanta, Georgia, notes that in her current experience treating chronic pain patients (which she notes as a very high-risk category for suicide), “Some patients, no matter how depressed they are, never have suicidal thoughts and never does their depression manifest to their being at risk for suicide.”

Just as a depressed person may never become suicidal, a person who has never been depressed can become suicidal — seemingly out of the blue. But there is almost always, Dr. Klich says, some form of “working up to the act.” Sometimes a loved one can detect and intervene (successfully or not); sometimes they can’t.

“If we take a look at the acquired ability or the so-called ‘capability’ a person has when completing suicide, we know they work up to the act. We see some things unfolding. They may have talked about it with someone, and that person will later recall them saying something odd. But we also see suicidal patients doing some sort of rehearsals,” she says. “They may not even be planning suicide, but they’re playing around with the idea. Maybe, if they have a gun, they will take it out and load it and then unload it and put it away. Or, in the case of overdoses, they’ll take out pills and count them,” Dr. Kilch says.

These “planful behaviors,” as Dr. Bernert puts it, signal a heightened risk, “even if the act itself may appear differently.”

If you know someone at risk, get specific with your questions

To be clear, this doesn’t mean that survivors of loved ones who died by suicide missed warning signs, because you can’t miss signs if you don’t know they’re there; and as Dr. Klich points out, certain suicidal behaviors can only be aptly picked up on by trained professionals, especially in the case of those mentally rehearsing or visualizing — symptoms that can occur without the person’s full awareness that this is indeed a kind of suicidal thinking. Additionally, because millions of Americans have depression and don’t have with suicidal thoughts, it can be hard if not impossible to tell who is at risk and who is not.

But if you’re concerned about a loved one being at risk, you can possibly help by speaking up.

“Speak with your loved one about how they are feeling and encourage help-seeking by way of the many resources available, including the American Association for Suicide Prevention and American Association of Suicidology and confidential helplines,” says Dr. Bernert.

And be direct in your conversations when you can. Dr. Klich finds that because suicide is so stigmatized (and also, just a really tough thing to talk about), people tend to skirt around the issue, or even unintentionally steer victims of suicidal thoughts toward a reassuring answer.

“Very often people will say, ‘you won’t do anything, right?’” she says. “I see this even in the medical field. Professionals will say to patients, ‘you haven’t thought about self-harm or suicide, right?’ Who would answer positively in response to that? Not many people.”

Maybe a better way to ask is to leave it open-ended and nonjudgmental. You might want to say, “Are you having suicidal thoughts or imaginings?”

An ongoing struggle to understand

When we’re grieving this kind of death, we'll likely have questions. Even now, perfect strangers are trying to put together a puzzle of what happened to result in these celebrity deaths, of what they missed, of why we had no idea of their possible struggles (not that they are any of the public’s business).

But if someone you did know has died by suicide caused by a mental illness and are looking for a way to understand it, consider Dr. Lembke’s moving analogy.

“We talk about death with cancer and heart disease but not death when associated with mental illness,” says Dr. Lembke. “But some people do die from it. Suicide is like a massive heart attack of the brain.”

If you’re feeling triggered or at risk, please follow Dr. Bernert’s advice:

“Confidential support is available 24 hours a day, 7 days a week by way of the National Suicide Prevention Lifeline (1-800-273-TALK) or the Crisis Test Line,” she says. “These are available to anyone, whether in crisis or concerned about a loved one who is experiencing distress.”