It is my mission with this project to delve into the most relevant scientific disciplines where suicide was studied, the customers/users/survivors’ movements of mental suffering people, and try to bridge the gaps between them. Only then it will be possible to understand in which circumstances lifting can be a positive and in which it can be a negative influence over the suicidal person.
1. Introduction: Who lifts the barbell and who does the barbell lift
2. Let's talk about these people
3. What is suicide and how can we classify it
4. Approaches and types of suicide
.....Pre-scientific ideas of suicide
.....The medicalization of madness, suicide and the asylum culture
.....Durkheim and the sociology of suicide
.....Freud and psychology
.....Other theories of suicide
.....The escape theory of suicide
.....The rational suicide
.....The pharmacological revolution
5. Can we predict and prevent suicide?
.....The window of opportunity
.....The revolt of the madmen
.....The neurodiversity movement
.....“Hear them out” - the problem of inclusive prevention and treatment: co-production of knowledge
6. Anti-psychiatry, Post-psychiatry and Mad Studies
.....Democratic psychiatry and political psychiatry
7. Stigma and the law
8. "There was nothing you could do"
9. What suicide is not
.....Hopelessness and despair
.....What is hope
.....Where does hope come from?
11. Lifting, mental well-being, and mental suffering
.....Can lifting help a suicidal person out of
.....Conditions to make lifting a suicide prevention
.....Can lifting be harmful to the suicidal person
12. How far down the rabbit hole do you want to go?
13. False beliefs (lay theories) about suicide
Writing to such different audiences as gatekeepers, other scholars, lived-experience movement leaders and a general readership concerned with public health and suicide is a challenge. One of the first concerns I have addressed is to avoid the use of any jargon. After all, to promote interdisciplinarity, one has to negotiate common terms to even start a conversation. To integrate the contributions of lived-experience movements, even more critical terminology negotiation must take place. A conversation between psychiatrists, as unconventional as they may be, with lived-experience movement leaders who question the validity of psychiatric nosology, is a first very hard step to take.
If the reader is someone dealing with their own suicidal challenges, a jargon-laden book would be of very little use.
The book was written in a certain order for the sake of the argument but it can be read according to the order that best satisfies the reader’s needs. Here are some suggestions for different types of readers.
I am assuming a loose form of Quinnett's gatekeeper concept, used on Chapter 5 ("Can we predict and prevent suicide?"), in "The Window of Opportunity," as "people who may be strategically positioned to identify distress in the community and could be trained as gatekeepers" (Quinnett 2013). These would be all those mentioned by Quinnett minus lived-experience movement leaders. They are at a qualitatively different situation concerning the identification of red flags and their interest in the topics covered by this group. Gatekeepers are coaches, teachers, community leaders, spiritual leaders, and civil rights movement leaders. For this reading guide, anyone in the position of, the interest in and the curiosity to learn about preventing suicide at the grassroots level is a gatekeeper.
I suggest you read the next three chapters, “Introduction”, “Let’s Talk About These People,” and “What is Suicide and How Can We Classify it,” and then skim through the burgundy text until you reach “Can we predict and prevent suicide?” In this chapter, read the first topic (“The Window of Opportunity”). “Stigma and the Law” is particularly important and from there you can follow the burgundy text until you reach the chapter about “Lifting, Mental Well-being, and Mental Suffering."
Even if you are not implementing a lifting-based program at your community, this chapter should provide you with insight about potentially helpful and unhelpful components of any program or environment and ways to promote the first and mitigate the latter.
The burgundy paragraphs are summaries or takeaways of a larger segment. Through them, you can decide to read the whole topic or chapter or move on.
Whatever your field is, there’s a chance you may be frustrated with the lack of depth into it. My point here was to use the outlines of each to highlight the interdisciplinary gaps as a bas-relief or a negative photograph of a landscape. Moreover, I wanted to stress the need for a social, rather than purely individual approach to suicide and mental suffering in general. There are an environmental chicken and a phenotypical egg. Getting our eggs from the grocery store for years may have had an impact on younger generations of scholars who may not be familiar with who laid that egg.
I especially invite you to read the chapter on "Lifting, Mental Well-being, and Mental Suffering" and appreciate how the absence of interdisciplinary and critical approaches to suicide makes it difficult to make sense of data and to devise policies. The idea that many, if not most of the time, we are proposing approaches that will "probably work" based on by-proxy data and concepts tested in other conditions is far from optimal. That’s what we have to work, though. This is as close as I get to a call to action to test approaches and programs.
For Lived-Experience Movement Leaders
I hope you feel inclined to read the book cover-to-cover. I am one of you and although there is not a single paragraph about my experience in this book, I am convinced you will recognize the identifying marks of a survivor-author. Other readers probably won’t and they will only learn the author is a survivor because I mention it at the Preface. I know that we look at reality differently and we identify hidden elements that are not visible to those who haven't got skin in the game, who haven't been out there, and exposed the things we are supposed to never talk about and also the non-neutral nature of knowledge construction.
For some of you, there may be chapters about issues you are too familiar with. Everything except the first ten topics and the chapter on lifting, proper, is related to the history of lived-experience movements. There are still the burgundy paragraphs and you may choose to skip them or not.
For Someone in Mental Suffering and/or Dealing with Your Own Prevention or Postvention:
I would like to suggest that you consider this book as a collection of resources that you can go back and explore as frequently as you need. You can skim through the burgundy text and decide where you want to read more. Depending on where you are in your process, I would go directly to the end of the book, on Chapter 9, “What Suicide is Not”, Chapter 13, “False Beliefs,” and then back to Chapter 10, “Hope."
After that, even if you have never lifted in your life and are not familiar with the strength gym culture, I would go to Chapter 10, “Lifting, Mental Well-being, and Mental Suffering." There are several items that you will recognize as similar to other sub-cultures that you are familiar with.
Introduction: Who lifts the barbell and who does the barbell lift?
Is lifting weights something that can help people struggling with suicide—whether experiencing extreme mental suffering or having just survived a suicide attempt? Can it help vulnerable populations protect themselves from suicide conducive factors? Is there something about lifting weights or about lifting weights with others that can help these people out of their dark cave of despair or confusion?
Evidence suggests that it can be both positive and negative.
The first step to answering the question in the first line and developing the argument is to establish what we are talking about. If a common definition cannot be found, it's important to understand why and what working assumptions to use.
Deep down, we don't know what the disorders associated with mental suffering are. At the mechanism level of things, depression, anxiety, personality disorder, or autism remain elusive. We have symptomatic descriptions and typologies but we don't know what causes them or even if they are one thing or many that look alike. In science, there is an important distinction between association and causation. For example, in 1850, Ignaz Semmelweis observed a high association between puerperal death and physicians not washing their hands before a delivery. In 1862, Louis Pasteur, often referred to as the “father of microbiology," supported the germ theory of disease. However, actual evidence that germs caused infections that led to death came only in 1876 with Robert Koch’s discovery of the anthrax bacillus (Schlich 2012, Blevins & Bronze 2010). That is a classic example in the history of science and if we move back, there were lay theories about disease based on associations as well. Unfortunately, that’s not the case with behavioral or mental phenomena. Psychiatrists may have names and some consistent associations concerning a certain behavior but they have no clue about what is causing the patient’s suffering. Yet, they have to do something about it and so do we. Suicide falls exactly into this category.
Critical psychiatrists, and psychiatric researchers, have been insisting on this knowledge insufficiency in recent years. Most of them suggest a more comprehensive approach including societal-level mechanisms (Stein et al 2013). They point out that psychiatry is struggling more, not less, to provide prevention, treatment, and prognosis (McGorry et al 2006). Nosology, or the classification of diseases, is harder in psychiatry than in almost any other medical field. Is a certain behavior a discrete clinical condition? Is it an arbitrary segment along the dimensions of human functioning (Widiger et al 2005)? The DSM-5 (Diagnostic and statistical manual of mental disorders) and the ICD-11 (International Classification of Diseases 11th Revision) are works in progress in terms of diagnostic guidelines, far from the effectiveness needed on the front-line battle with mental suffering, whether it is a disease or not.
Although most scholars believe that suicide is preventable, they also agree that we are still failing in our attempts to prevent it. Not only that, but there is a major concern with the constant rise in suicide rates in the past decades in certain social segments, for example among military veterans, young adults, and middle-aged white males in the USA. Several countries have experienced a rise in suicide rates and have felt the need to promote applied research towards the development of preventive measures.
I believe that the failure to effectively promote suicide prediction and prevention is the interdisciplinary wall of silence. Suicide, as an object, lies at the intersection of many disciplines: sociology, psychiatry, psychology, anthropology, law, toxicology, urban planning, political science, and management, to name a few. By not actively engaging in interdisciplinary work, we end up not even agreeing about the definition of suicide. And that is just to mention the sciences. An even thicker wall exists between all social institutions, science included, and the (surviving) victims. Knowledge and questions don't cross this wall. Surviving victims of suicide are not only the suicide attempt survivors, who, if not carefully listened to, have a high chance of repeating the attempt and succeeding. Suicide victims are also surviving relatives, friends, and whole communities.
A suicide is not only an individual act of medical consequences. It is also, and frequently mostly, a social act of social consequences and a manifestation of social pathologies.
Something has been changing in the interdisciplinary and community-based direction. Recently, the number of publications on social aspects of suicide as well as those attempting to bridge the scientific gap are growing. Timidly but steadily. One of the reasons for that is that there is an institutional push for that from way up the health science and policy hierarchy: the World Health Organization.
On May 27th, 2013, during the 66th World Health Assembly, consisting of Ministers of Health of 194 Member States, the World Health Organization adopted an almost decennial mental health action plan. As pointed out by Saxena and collaborators on The Lancet (WHO 2013, Saxena et al 2013), as a result of many years of debate, the WHO moved away “from a wholly medical model”, incorporating approaches developed throughout the world towards “community-based care." White and Sashidharan have called it a “more nuanced” approach (White & Sashidharan 2014).
The plan’s four major objectives are: More effective leadership and governance for mental health; the provision of comprehensive, integrated mental health and social care services in community-based settings; implementation of strategies for promotion and prevention; and strengthened information systems, evidence, and research. We all agree on this: The way it was, it was either not helping or making things worse. If a strengthened evidence-based information system in integrated mental and social care services at community-based settings grow roots, maybe we will be able to promote suicide preventive conditions and avoid suicide conducive conditions.
What does that mean in practice? For starters, going back to the classics, such as Durkheim (1897), and updating the model by collecting modern data on suicide. Other important measures are to identify the bottlenecks to prediction and prevention, such as heavy religious influence combined with a non-mandatory autopsy, leading to sub-notification of suicides (Ohayi 2019, Dine 2019); theocratic laws punishing suicidal individuals (Arensman 2017); or inability to force health insurance companies to cover self-inflicted injuries which are the first red flags for suicide risk, making the bulk of these important signs for prevention invisible (Chapter 6).
Most of all, though, it is important to use the available research and theory to create a few practical guidelines for decision-makers, community leaders, and individuals in a supervising position: Teachers, coaches, and, why not, co-workers and friends. The qualitative change in perspective that can lead to actual prevention is one that reframes the responsibility for suicide towards the collective rather than the individual. While individual choice must be respected, such as "rational suicide" or euthanasia, and suicide-risk dissociative or psychotic states must be dealt with by others because the victim is not equipped to assess reality, the bulk of suicides are determined by social variables that can be changed.
Bullying, domestic abuse, discrimination, social isolation, and intolerance are associated with suicide. A lifting gym or training environment that welcomes these behaviors is conducive to suicide while those that oppose them may be preventive of suicide.
My argument is that lifting may have either a positive (preventive) or negative (conducive) influence on the suicidal person or the suicide survivor: It depends on the social setting where lifting takes place. Only by examining different approaches and concepts involving suicide can we provide any useful guidelines.
Considering that the best predictor of individual suicide is hopelessness, my other challenge is to find the common thread of how hope is lost and gained back.
Let’s talk about these people
Before we examine the different conceptual tools developed to study and intervene on suicide, I will introduce you to a few cases that I observed, directly or indirectly. This is an exercise that anyone can do and will probably reveal overlooked surprises because that is the advantage of memory—it provides distance. Aaron Swartz, Egbert (not his real name), my bipolar cousin, my schizophrenic friend, my terminal muscular dystrophy professor, the department outcast, the foreign grad student, child psychology pioneer Bruno Bettelheim and, ironically, Sigmund Freud himself died of suicide. These deaths have only one thing in common: The decision and active measures that led to death were made by the victims. Everything else is different.
On January 11, 2013, Aaron Swartz ("Aaron Swartz" 2020) died by suicide. Aaron was a normal, happy child prodigy who grew up to be one of the major figures in the activism for free access to information. Among other things, Aaron was a co-founder of Creative Commons, Open Library, Demand Progress, Reddit, and received several awards for his web inventions. He was a friend of knowledge, science, and believed in the power of the internet to bring social justice.
In late 2010 and 2011, Aaron downloaded a large number of academic journals from the MIT network while at MIT. Powerful companies had been hunting Aaron for a while and on a joint federal and state action, he was charged and prosecuted (“UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS” 2011) with the help of JSTOR ("JSTOR Swartz Evidence All Docs" 2010), MIT and other organizations. The Federal Government decided to make an example out of Swartz by punishing him to the full extent of the law and some. Even with the help of the community, Aaron’s personal and family resources were exhausted. As nine new charges were added to the lawsuit, his parents were getting a second mortgage on the house. At this point, Aaron realized that they had no chance since the prosecution was determined to not negotiate. The corporate and government political war against him was hurting his family and his causes. He ended it all by hanging himself.
I remember as if it was today. Like others in the scientific community, I was struck by pain and anger. On that day I wrote four letters: to the Office of the Attorney General, to Carmen Ortiz, Massachusetts Attorney General, and chief prosecutor, to the MIT and to JSTOR. In each one of them, I wrote, in no uncertain terms, that Aaron Swartz was forced to commit suicide by them and that they had blood on their hands. Carmen Ortiz was the object of a petition signed by 60,000 people demanding that she step down ("White House Must Respond to Petition to Remove U.S. Attorney in Aaron Swartz Case” 2013). Carmen was ambitious and ruthless. She was Obama’s choice for Massachusetts democratic governor candidate. With Aaron’s death, her career was over. She tried teaching for a while and joined a law firm living in the lowest possible profile. She will never have a political career or hold public office again, she probably looks over her shoulder to this day and for the rest of her life. Aaron’s death resulted in a legal probe but nothing came out of it ("Aaron Swartz' Death Fuels MIT Probe, White House Petition to Oust Prosecutor", 2013).
Aaron died of suicide but the public perception was that of a murder. He became a martyr of all the noble causes he championed. His self-sacrifice seems to have significantly influenced the history of the Open Access movement ("Scientific Reports Overtakes PLOS ONE As Largest Megajournal" 2017, "History of the Open Access Movement" 2020). As of May 2018, there were 1.4 billion works licensed under the various Creative Commons licenses ("State of the Commons" 2020).
The dirt that came out concerning corporate interests after the suicide intimidated the MIT, JSTOR, and all the big academic publishing companies. The MIT denied involvement, JSTOR, whose involvement became public, offered their full library to open access (which they canceled years later).
Aaron died on January 11, 2013. On June 4, Research Gate ("Bill Gates, Benchmark And More Pour $35M Into ResearchGate, The Social Network For Scientists – TechCrunch" 2013) closed Series C financing arrangements for $35M from investors including Bill Gates. In September 2013, Academia.edu ("A Social Networking Site is Not an Open Access Repository" 2018) raised $11.1 million from Khosla Ventures, True Ventures, Spark Ventures, Spark Capital and Rupert Pennant-Ream. The growth of PLOS (Public Library of Science), a nonprofit open-access science, technology, and medicine publisher, follows a similar timeline ("PLOS" 2020).
I suspect that Aaron’s thoughts as he hung himself were only to protect his family and escape the torture of a trial with a pre-established result. It was strictly impossible to envision a positive outcome in the future which is the definition of hope (Chapter 9). He couldn’t predict the social consequences of his death. However, martyrdom often promotes social change. In this case, it did.
Egbert was a shy boy. Hard worker on his job, at school, and at the gym, where he lifted. He showed signs of mental suffering early in his teenage years but only got help when he was an adult and educated himself on the matter. He talked to me about his issues. Like so many in his condition, he was easy prey for manipulative types who frequently dragged him deeper and deeper in the circle of drug abuse and depression. He received poor mental health assistance and had few people to talk about the discomfort of mood-stabilizing drugs, particularly lithium. He felt sick and, as so many, discontinued and resumed pharmacological treatment again and again.
Like most successful suicides, Egbert rehearsed them: I knew of at least three attempts. As is the rule on self-inflicted wounds, he duct-taped them as best as he could because there is no medical coverage for that. It didn’t work well, he bled publicly and one would assume that his need for help was obvious. About a month later he was found dead from an overdose of something I was never told.
Also like so many suicidal patients, the month before his final and successful attempt, he seemed calm, in control, and publicly encouraged all his social networks to openly talk about suicide. That was the last red flag. He was 23 years old when he died of suicide.
Egbert was a white middle-class young man from an American Midwest state. His social environment was predominantly evangelical, with heavy drug users, unsupportive of educational pursuit and part of these people were "gym cultists": Bullies, contemptuous of anyone who was not a strength athlete, group-thinkers.
I never knew my cousin. My parents told me he was a mathematical genius like at least two of his siblings, except even more so. One of his siblings has all the features of the savant. He's an adorable man with some cognitive impairment. He found his place in society because he communicates well: Mathematical challenges are obvious to him and he managed to make people see them that way. He became an amazing private math teacher and leads a simple, supervised life. The cousin who died of suicide had violent mood swings, scary euphoric and psychotic episodes, and depression. One day he shot his mouth, missed the brain, did not die immediately, and crawled to his parents' room (suicide ambivalence). He died minutes after that, leaving a nonsensical suicide note. All I know about this note is that he cheered his favorite soccer team as a goodbye.
In college, I met several people who died of suicide. The first was one of our buddies. He had been diagnosed with schizophrenia but his family was neglectful. He abused recreational drugs and we didn't know what psychiatric medications he took. His episodes could happen in the middle of a class or during a party. One day he jumped into an unprotected elevator well at the students’ dorm. We were confused, felt guilty, and never talk about it.
A couple of professors died of suicide. One was at the end stages of muscular dystrophy. He was brilliant, funny, somewhat cynical, and caring. I miss him. Another was a young and promising woman back from her postdoc abroad. She was an international authority on her subject, extremely committed to causes in a world that only made sense to her as a crusader. She was hired in one of the less productive, most mediocre, and ethically questionable departments of the university. During a couple of months, other faculty members treated her with passive aggressiveness and made her feel like an outcast. Suddenly, her demeanor changed, and she plunged into what looked like depression or a longing for something lost. Months passed and again, suddenly she changed into a calm and polite person, apparently conformed with the circumstances. She was found many days after her death by suicide because of the smell from her apartment. In her office, neat piles of books with instructions to return to the library or donate. She had worked all her life to make a difference in the world as a scientist. What should be her long-term professional life stopped making sense to her.
As I recall it, the graduate student from Chile wasn't so unlike the young female professor. He obtained a scholarship to work on his dissertation in one of the best laboratories at one of the best departments in the world. I was an undergraduate research assistant then. He was the poster child of enthusiasm and the belief in the power of science to improve the world. After a few months, he hadn't made friends. The pathologically competitive environment created cliques of graduate students according to academic accomplishment and the student from Chile wasn't accepted in any of them. They weren't particularly interested in changing the world. Nobody invited that student for Christmas and his body was found after New Year's day as neighbors called about the smell.
Sigmund Freud, founder of psychoanalysis and one of the founding fathers of psychology died on September 23, 1939, from a lethal morphine dose administered by his doctor Felix Deutsch. Freud suffered from inoperable cancer of the jaw and his “contract” with Deutsch established that when pain and suffering became unbearable, that the friend should help him die. It is assumed that it all happened according to Freud's plans for a dignified death. However, up to this day, there are doubts about that (Gifford 2017). Another prominent psychologist, Bruno Bettelheim, ended his life through asphyxiation with a plastic bag in 1990 when the suffering from his degenerating health after a stroke became unbearable (Finn 1997).
My point with these examples is to show how multi-faceted suicide is in practice and how each one of us already knows it. How were Aaron's mind and brain when he hung himself? I'm sure it would be possible to detect abnormal activity and a very disturbed state of mind. But his motivation for the act was instrumental and altruistic. My college friend and my cousin experienced reality through the lens of psychosis. The negligent family environment my friend lived in and the strict religious one my cousin had may or may not have been strong factors in their deaths. The two scientists may or may not have been chronically depressed but what we do know is that their suicides happened in the context of a dramatic erosion of meaning in their lives. Freud and Bettelheim were ill and in pain. It is possible that Freud passed in complete peace, a transcendent man satisfied with having left the world a wiser place and, of course, enjoying the simultaneous fading out of pain and life. Bettelheim survived the horrors of the Dachau and Buchenwald concentration camps where he was brutally treated, suggesting PTSD. He struggled with depression for a long time. Still, he left extraordinary contributions to the wellbeing of others. Bettelheim died in isolation and misery, under growing harsh criticism. He didn’t pass in peace or with pain relief. Egbert was diagnosed and medicated for bipolar disorder and depression. It’s hard to overlook the fact that he fits perfectly in the demographic that currently manifests the phenomenon of “deaths of despair.” He was immersed in a social circle that is struggling with a historical thinning of life purpose and meaning added to grim perspectives of life choices for personal development.
What is suicide and how can we classify it?
There's no consensus definition of suicide. The minimum common denominator is "death resulting from intentional measures taken by the individual."
The stigma and taboo about suicide come from different institutional sources and historical threads but the result is the same: We can’t seem to have an organized public conversation about suicide. Whether it is because the sciences can’t agree on a definition, or because in most countries, even those officially secular, the law reflects religious views that end up punishing individuals who attempt suicide, or because every cultural niche expresses in its own way contempt and hate towards those who either die or almost die of suicide, and finally, because the voices of the victims are silenced, there is no consensus on what it is.
If we don’t agree on what suicide is, how can we be expected to predict and prevent it? Even if we decide to fall in line behind the mental health initiatives, grudgingly embracing the mental illness approach to suicide, how do we know where to look? Whether certain behaviors should be considered pathological or not is as much a medical as a philosophical choice (Canguilhem 2012). What defines a behavior as pathological? Dysfunctionality in life? Suffering?
Several conditions considered as mental illnesses and listed on the DSM-5 don’t cause suffering. A serial killer, who may have several co-morbidities besides one of the Cluster-B personality disorders, won’t walk into a psychiatrist’s office and ask to be treated because he is in pain. Quite the opposite: He gets sexual pleasure out of inflicting pain in others. Yet, it is a consensus that serial killers and mass murderers have a mental illness.
PTSD is a big enigma (Hendin & Haas 1991, McKinney et al 2017, Brake et al 2017, Locci & Pinna 2019, Brake et al 2019): Nobody knows what exactly causes it except that trauma is a pre-condition. On several individuals, trauma can irreversibly alter not only the behavior but the brain structure itself. It causes extreme suffering and is highly associated with suicide.
A confounding factor today is the increase in drug overdose deaths. There is evidence that a good part of "unintentional drug overdose deaths" are suicides (Bohnert & Ilgen 2019). As we will see, Freud and other authors discussing suicide with a psychoanalytic perspective classified long-term self-destructive behaviors as suicides. If we add the questionably "unintentional drug overdose deaths" and long-term self-destructive behaviors (Menninger 1938) such as drug and alcohol abuse (Suokas & Lönnqvist 1995), suicide will account for much more than the share of deaths than it does today.
Table 1. Rates of Death from Suicide and Overdose in the United States, According to Year
Source: Bohnert & Ilgen (2019). Categories were determined on the basis of the codes of the International Statistical Classification of Diseases and Related Problems, 10th Revision, that were obtained from death records. Suicide deaths were those with an underlying cause of death coded as X60 through X84, Y87.0, or *U03. Unintentional overdose deaths were those with an underlying cause of death coded as X40 through X45. Deaths involving opioids were those with multiple causes of death codes recorded as T40.0 through T40.4 or T40.6. Data were obtained from the Centers for Disease Control and Prevention.
Figure 1. Mortality rates for U.S. white women and men, 1980-2013
Source: Masters et al 2017. Mortality rates for US white women (left) and men (right) aged 45-54 from “extrinsic” causes of death, 1980-2013. Original source: NCHS, Multiple Cause-of-Death Files (1980-2013); CDC, Bridged-Race Population Estimates (1990-2013); and Census Bureau, Quarterly Population Estimates (1980-1990). Note: Mortality rates estimated at age 50 years.
The self-destructiveness continuum, of which death by hanging, shooting, asphyxiation, and other means identified as suicides would represent a point in the intention scale (Firestone & Seiden 1990, Maltsberger 2008, Henderson 1976) raises questions about what effective suicide prevention is. If the behaviors characterized by self-neglect and self-destructiveness are placed under the suicide umbrella, then we’re possibly talking about the first cause of death in modern industrial societies. The methodological problem is where to draw the line and provide guidelines as to at which point self-neglect and recklessness are red flags for suicide (or a long-term suicide taking place).
There are several things that we do know about suicide, many of them already pointed out by Durkheim (1897) and his followers. We know suicide is a stable phenomenon in a given society and that the best predictor of suicide rates is the previous year's suicide rate within that social group. Rates change slowly and when there is an abrupt change it is correlated with dramatic disruption in society.
2. Suicide rates (deaths per 100,000) by sex, Switzerland, 1881-2000 (rough rates, 5-year moving averages)
Figure 3. US crude suicide rates, overall and by sex 1933-2010
Source: Phillips 2014. US crude suicide rates, overall and by sex 1933-2010. Original Source: US National Center for Health Statistics (http://mypage.iu.edu/~jmcintod/SuicideStats.html)
Figure 4. Suicide rate in 1990 vs. 2017.
Source: "Suicide Rate in 1990 Vs. 2017” 2020. Original Source: IHME, Global Burden of Disease. OurWorldInData.org/suicide.
Even the recent increases in suicide rates among certain segments of American society, among traditional societies disrupted during colonization or among former Soviet countries after the fall of the Berlin Wall, are slow if compared to a transmissible pathogen epidemic such as COVID-19.
Changes in suicide rates are comparatively slow.
Suicide rates are comparatively high as compared to other causes of death even at present sub-notification levels.
Changing suicide trends for the better also take a much longer time than mitigating measures directed at other causes of death.
Phillips (2014) suggested that the (slow) changes observed in American suicide epidemiology can be attributed to "weakened forms of social integration and regulation among postwar cohorts." As a predominantly social phenomenon and unlike a transmissible pathogen, suicide rates vary according to cohort, sex, ethnicity, income strata, religion, region, and, of course, trauma, abuse (physical, emotional, and sexual), economic inequality and insecurity.
Figure 5. Male and female age-standardized suicide rates and unemployment rates, 1907-1990.
Source: Morrell et al 1993.
When we break up epidemiological data by social segment, specific high suicide rate trends become visible. For example, the disproportionate suicide rates among young native Americans: In an overall suicide rate chart they are invisible because of the relatively small size of their population.
Figure 6. Suicide Rate by Age for American Indian/Alaska Native Compared to United States (Average 200-2013).
Source: Substance Abuse and Mental Health Services Administration 2017. Original source: Suicide Prevention Resource Center (SPRC): http://www.sprc.org/basics/scope/disparities
Suicide impacts different social groups differently. However, it is always one of the major causes of death. Suicide rates are high and have been high for a long time.
Suicide is the hidden face of brutality, oppression, inequality, abuse, rape, bullying, and mental illness, the latter being frequently also the result of those social factors.
The challenge has always been with us and we failed to deal with it. Whether it is because of the oppressive forces of religions, theocracies, or normative (reproachful) pathologization, suicide has been and still is a major killer and the single undeniable manifestation of hopelessness and despair in our societies.
During the past many thousands of years of human history, we have been trying to de-normalize suffering, cruelty, oppression, violence, and murder. In the Middle Ages, half of the children died before one year of age, infectious diseases could have catastrophic incidence in the form of epidemics and wipe out from 10-60 percent of whole nations and hunger was a major killer until the beginning of this century. The reason why we should face the suicide challenge seriously is that many of its determinants are manageable. Suicide may have never been dealt with seriously because it is still normalized: Something that happens to people who are born "sick in the head." It is not.
If we look at the chart of the leading causes of death for 2017, all the non-accidental causes receive significant research and treatment funding, and there is a genuine belief that they can be decreased. The difference is that society still sees those who die from these causes of death—malignant neoplasms, heart disease, diabetes, and chronic lower respiratory disease – as victims whereas suicide is predominantly considered “their fault." It is not.
People who die of suicide are victims of suicide. This is why it is time to denormalize death by suicide:
Table 2. Leading Causes of Death in the United States (2016)
Source: "NIMH » Suicide" 2020. Original source: CDC.
Figure 7. Number of deaths by cause, World, 2017
Source: "Suicide" Our World in Data 2020. Original source: IHME, Global Burden of Disease.
Worldwide, suicide kills more than malaria, homicide, hunger, or war.
Figure 8. Summary of Suicide Trends
Source: "Suicide" Our World in Data 2020.
Approaches and types of suicide
Suicide is the self-directed lethal act that results in death. The intentionality, the self-awareness and consciousness, and the motivator for the act (whether economic duress, pain, self-sacrifice, mental illness, or a state of overwhelming hopelessness resulting from a given social context or pathology) are as varied as the suicide forms.
There is a global unprecedented increase in suicide rates overall and more so in specific groups. The mantra of "mental illness" repeated in chorus a million times to explain the rise in suicides and rampage shootings is worn, old, and useless. Human behavior has been swinging between two extremes since it became a subject of scientific interest and even before that ("it's all determined by external causes, it's all nurture," versus "it's all determined by internal causes, it's all nature"). Ideas such as, "The apple never falls far from the tree" have been available since time immemorial to explain violence, cheating, theft, and suicide. "Some people are just born that way" (an "all nature" example). The idea of the intrinsically benign human nature that becomes corrupted by society has also been around (an “all nurture” example). The idea of the “noble savage” has been entertained since ancient times (Dudley 1972).
Pre-scientific ideas of suicide
Sometimes the past is not in the past. Most of our society is scientifically illiterate and shares ideas and values concerning suicide inherited from ancient beliefs crystallized in religions. Kay Jamison, an academic leader in suicidology, has mapped traditional conceptions about suicide in her books, most detailed in "Night falls fast: Understanding suicide" (Jamison 2011). Abrahamic and even polytheistic reincarnationist religions strongly object to suicide. For these cultures, it represents a major transgression of divine codes and for this reason, people who died of suicide were not even buried in holy ground. Despite legally being secular states, many countries deny treatment to patients with self-inflicted injuries resulting from or not from suicide attempts ("Despite Law, Health Plans Refuse Medical Claims Related To Suicide." 2014). This is a situation where modern institutions are still contaminated with pre-scientific prejudices and ideas.
Why does this matter now? Because many of the people that will handle a suicidal person in distress still espouse these ancient damaging beliefs. Their interaction with the suicidal person may increase their feelings of hopelessness, shame, and guilt, and farther push them into taking their lives.
There is no consensus as to whether suicide grew in prevalence or not as it crossed different forms of social disapproval. All the written records we have correspond to societies that had already developed social classes or casts, with intra-societal oppression, patriarchal organization, female oppression, forced marriages, rape, and slavery. In other words, all the social pathological determinants of suicide were at work. Durkheim suggests that social disapproval of suicide increased as more emphasis was placed on individual dignity. Marra and Orrù (1991) disagree and argue otherwise. Recent studies about the association between forced marriage and suicide among women with no psychiatric diagnose (Saxby & Walter 2013) suggest that this is an important clue: Many of the forces identified by the social sciences and psychology as conducive to suicide were present or could be provided during episodes of the endemic war.
The medicalization of madness, suicide and the asylum culture
When madness was added to the menu of subjects under the domain of medicine, deviant behaviors were pathologized. This is the other thread that informs much of the modern views on these behaviors today, including suicide. Reclassifying them as a disease did not reduce the stigma and discrimination. On the contrary, it led to the "Great Confinement." From the Renaissance to the modern age, Foucault argues, those considered mad, originally tolerated, were increasingly excluded from society until complete confinement in the modern age. They were then institutionalized, "treated," punished, and tortured with the justification that those were the methods to reverse their moral weakness (Foucault 1988).
Why does this matter now? 1. Because the strong emphasis on natural and individual causes for suicide (mental illness) and its public representation as a deficiency and a weakness are some of the most serious enemies of suicide prevention; 2. Because society still disqualifies those diagnosed as mentally ill from decision-making and self-assessment; 3. Because a mental illness diagnosis is an important foundation for discrimination.
Psychiatry’s first patients were the deviant and the undesirable. In the XVIIIth century, they were blamed for their condition. Assuming that they caused it, justified the methods used to force them to revert to normality, or “cure” them. Instead of a moral flaw to be punished, these deviants carried an illness to be cured. The illness, however, was their fault, which made their treatment an actual punishment. No cruelty was spared to cure the insane.
In suicide, it meant submitting individuals who survived a suicide attempt to extreme forms of torture instead of sentencing them to death as theocracies did.
Durkheim and the sociology of suicide
Suicide has been defined and judged for a very long time and there are written records of it since ancient times. It has been systematically studied only recently. The first empirical study and scientific conceptualization of suicide are attributed to Émile Durkheim (1897). Eghigian (2018) pointed out that Durkheim's work might have been more the product than the trigger in the scientific study of suicide since at least one contemporary author adopted a methodologically similar approach: Enrico Morselli, author of Suicide: An Essay on Comparative Moral Statistics (1881). That is the nature of scientific inquiry: It is always a product of the intellectual context.
Durkheim's suicide typology relies on his model about integration in the social group's "conscious collective" which we could roughly relate to our modern concept of predominant culture in a complex society. The conscious collective is the set of values, beliefs, moral and ethical standards, and forms of reasoning prevalent in a given social group.
Integration can be understood as either as having a place in the social group’s structure and functioning or having shared cultural references.
We could think about somebody with weak or no social ties (no family or being estranged from one’s family, no stable employment or school, no community of shared interests) or with a weak or loose self-referenced symbolic system (no shared ethical or moral system, no shared beliefs over which to build expectations and goals, or shared descriptors of reality). We all met thousands of them. We just don’t see them.
Considering integration and regulation, Durkheim identified four types of suicide:
- Egoistic suicide is a response to a state of loose or no ties to any social group, resulting in a sense of not belonging. In the integration spectrum, this would be the pathological social condition of no integration. Meaninglessness and hopelessness are associated with this condition and are both conducive to suicide.
- Altruistic suicide would be the exact opposite: The level of social integration is so holistic that individuals see themselves as less important than the group. Durkheim considered that this would be a social scenario not conducive to suicide except for self-sacrifice as in the military. Much has been discussed concerning this with the advent of suicide bombers.
- Anomic suicide is the result of extensive cultural disruption so that the moral regulatory system is practically absent. Individuals lack the substrate to build expectations and self-expectations.
- Fatalistic suicide would be the result of a social scenario opposite to the former: A rigid system exerting oppressive discipline over individuals may lead to a state of hopelessness that results in suicide.
In this perspective suicides are manifestations of social pathologies: For example, societies that fail to offer routes of integration to its members, societies that have been deeply disrupted by internal or external conflict, disintegrating ethnic groups or tribes under the excessive regulation with oppressive discipline. They would result in egoistic and fatalistic suicides, respectively.
Bullying, for example, may reflect the absence of moral and ethical regulation and the result is an increase in suicide among the outcasts. Children, still evolving their integration in the social group, if left unsupervised, tend to manifest anti-social and damaging behaviors. It is no surprise that there is a strong association between suicide and bullying victimization (Kim & Leventhal 2008, Bauman et al 2013, Koyanagi et al 2019, Hinduja & Patchin 2019). Alternatively, among adults, when authority figures do not enjoy trust and respect, violent abuse among the group's members may take place as a form of power dispute. Violence of this type is frequently inspired by shared beliefs from other, external social groups or ideologies and takes the form of bullying, assault, or murder. Suicide rates increase in such situations. They could be seen as anomic and fatalistic suicides respectively.
We can think about school environments in which adults do not enjoy true authority and trust. The students may then engage in violent and immoral behaviors disapproved by the school's nominal authorities, expecting no reprimand. In the second case, we can think about abuse in the military where bullying, rape, and other forms of abuse take place despite being strongly, but not effectively, disapproved by the command (Monteith et al 2019, Gross et al 2020). The relationship between abusers and victims in both cases frequently reflect power relations in the major society: Victims will frequently be women, ethnic minorities, gay or transgender people, the poor, the deviant, the "mad," or those who don't share the dominant religion.
Suicides among indigenous populations that experience violence and disruption in their encounter with European colonizers (or the major society) have been documented. We would think that these suicides could be interpreted as egoistic or anomic since both belonging and regulation are compromised with cultural disruption. Hamlin and Brym (2006) suggest that Durkheim’s model is insufficient to provide a proper interpretation of preliterate (traditional) societies. They studied the Guarani-Kaiowá indigenous Brazilian society, one of the most suicide-prone groups in the world. According to the authors, the inclusion of cultural and social-psychological considerations resolves Durkheim’s model insufficiency. The rates compiled in their study make any other “suicide epidemic” pale in comparison:
Table 3. Characteristics of Suicide Among the Indigenous Peoples in Mato Grosso do Sul, 1991-1995 and 2001-2003 (n=230)
Source: Hamlin and Brym 2006. Original source: compiled from Ministério da Saúde (2003, 2002, 2001) and Instituto Socioambiental (1995). “These data undoubtedly exclude suicides among Guarani who are either isolated (living far from government offices) and dispersed (who refuse to leave their ancestral lands and live on reservations). Nonetheless, we believe they are sufficiently comprehensive to establish the broad patterns that interest us.”
What Hamlin and Brym's work seems to suggest is that a model that attributes a more significant role for culture as a causal explanation for suicide and accepts multi-causal suicides has better explanatory power. The Guarani-Kaiowá mass suicides are highly specific in method, age, and most of all, actual motivation. For the Guarani- Kaiowá, leaving the “Land of Evil” and the quest for the “Land without Evil” is a cultural (social) imperative. The search, turned inevitable and permanent by the violent contact with Brazilian society, involves an attempt to reach an individual state of lightness or transcendence. It involves food restriction, singing, dancing, but ultimately, as the state of mind known as nhemyrõ is achieved ("a mixture of ferocity, anger, despair, and sadness" which drives a ‘‘diffuse aspiration toward transcendence’’), death by self-strangulation. According to Hamlin and Brym, a thorough consideration of a group’s culture solves the apparent contradiction in Durkheim’s model by which equal states of anomie cause different suicide rate responses.
Unfortunately, the similar phenomena of young suicide clusters among North American Native Americans have not received such a detailed cultural analysis. The emerging picture is one of generic, unpredictable, Durkheimian anomic suicides.
Table 4. American Indians/Alaskan Natives Risk Factors for Suicide Clusters
Source: Substance Abuse and Mental Health Services Administration 2017
The same can be said about studies of other social groups displaying a rapid increase in suicide rates. One example is the increase in suicides immediately after the fall of the Berlin Wall and the end of the Soviet Union in former socialist countries. The author considers economic (hyperinflation, unemployment) and sociologic (family disruption, changes in the labor market) factors but not cultural ones (Brainerd 2001). The fact that the suicide "epidemic" in a group of former socialist countries preferentially affects older males suggests that this cohort was more sensitive to the post-1990 cultural disruption.
Figure 9. Suicide rates per 100,000 between 1985-1998 in former socialist countries
Source: Brainer 2001.
It is not surprising that the recent increase in suicide deaths among “non-Hispanic American whites of low education," known as “deaths of despair," is far from a consensual interpretation: Although most authors focus on economic factors affecting the psychological wellbeing of this population (Scutchfield & Keck 2017, Shanahan et al 2019, Cherlin 2018), there are those who simply dismiss it as a reflex of an increase in cheap illegal opioids in the black market (Botelho et al 2017). The latter reflects poor methodology since by now it is clear to scholars that deaths by suicide, by drug overdose and by alcohol-abuse-related liver disease are associated. The three share a pattern of self-destructiveness that must be interpreted.
Figure 10. Potential Moderators of Pathways: timing of economic stagnation, sociodemographic group, sex, previous adversity, vulnerability/protective factors.
Source: Shanahan et al 2019
If cultural factors combined with social disintegration are driving deaths of despair among "middle-aged non-Hispanic American whites of low education," wouldn't it be expected to affect their children as well? Yes, and it is: Younger "non-Hispanic American whites of low education" are dying of suicide proportionally more than other ethnic groups in the same cohort except for Native Americans, which by far lead suicide rates among the young (Han et al 2018).
Why does this matter? Because the factors that are driving these people to suicide are frequently the same ones that lead them to the gym. Sometimes lifting and being part of the gym environment will turn them away from suicide and sometimes it will not. The factors are at work all the same. The difference may be what happens inside the gym.
A social group's coherence or homogeneity depends on the extent to which its members share cultural items (Abrutyn et al 2018): Language, values, beliefs, world views, and explanations. In complex industrial countries, the larger society has low coherence and is usually highly heterogeneous. In fact, the modern nation-states (countries) are not "a" society, but a legally integrated collection of societies. For this reason, individuals will seek smaller cultures that exist inside the larger society, especially in urban environments. They will usually inherit part of their belonging and value system from their family. As individuals grow into adulthood and personal autonomy, they tend to adopt new symbolic items and, frequently, new belongings (new social groups). For example, they may question the family's religion and church community but they will share the same ethical standards as their parents. They may not be with their parents and siblings every day but they still share weekends and holidays. One of the adults may take up their father's profession and will be the manager at "Robertson and Sons" welding and plumbing, or the next Dr. Robertson at Robertson Family Practice. This is the absolute most favorable scenario: There is quasi-perfect social and cultural belonging, and smooth social continuity.
We can think about someone born into poverty, with the father out of the picture, an abusive uneducated alcoholic mother living in an abusive adult environment. He or she grows up with no social expectation, loose (contradictory, ambivalent, or ambiguous) moral values and soon drops out of school. The closest thing to a coherent social group is the local gang. Before long he or she is in the prison system where there is absolutely no space for personal choice in belonging or action.
Alternatively, we can think about someone born in a formerly colonized country shattered by war, their family is murdered and the closest thing to a social group is the warlord's organized crime unit.
Between the two extremes, there is an infinite array of cultural scenarios, social integration, and regulation.
Freud and psychology
The other path that leads us away from the predictive self-fulfilling mental disease understanding of suicide in psychiatry ("If it is a suicide, then there was a mental disorder.") is to be found, ironically, in psychology. The starting point is naturally Sigmund Freud. Freud himself died of suicide, a type which today we would probably classify as “rational suicide” since it was a well-planned action for when everything else failed on his fight against cancer, and pain made his life unbearable.
The main concept from which Freud’s model of suicide stems is the “death drive." The “death drive” itself is an elaboration over the “pleasure principle” by which Freud introduced a foundational tension in human existence, forever at work in the unconscious.
The pleasure principle is foundational to all of Freud’s work. It refers to the human instinct to permanently seek pleasure and avoid pain. In Freud’s early work, the pleasure principle explained the construction of individual life purpose. In contrast to it was the principle of reality. While the pleasure principle would generate a permanent drive for self-gratification, the cognitive assessment of the external world and its restraints would oppose it. The reality principle would confer man the ability to defer gratification. Behavior would be a result of the tension of these two foundational principles (Freud, "Formulations on the two principles of mental functioning.", 1911).
Based on that, Freud hypothesized that suicide was frequently the expression of the repressed destructive drive towards an external element. Because it is repressed, the destructive drive is turned towards the individual himself, resulting in suicide or other self-destructive outcomes (Freud, “Mourning and melancholia”, 1918, in the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 1957). For that reason, some of the relevant motives identified by psychoanalysts for suicide are anger, resentment, or hate.
The elaborated version of the death drive as the tensional principle in dynamic opposition to the pleasure principle appeared later, on Freud's "Beyond the Pleasure Principle," from 1920, and later on in "Civilization and its Discontents," from 1929 (Freud 2015a and b). The death drive encompasses destructive as well as regressive forces, fantasies about a return to the womb, or to a state free of tension (Soreanu 2017).
According to this perspective, all human beings exist within the unconscious tension between the "erotic (or life) drive" and the death drive. All humans: Not only the sick ones, not only the bad ones. Moreover, if it weren't for that tension, according to Freud, we wouldn't have Civilization. We wouldn't even have the earliest manifestations of human culture because all of it is a result of the sublimation of those fundamental drives (or instincts) into useful or productive action. In this view, guilt and "neurotic repression" is the price we all pay to share the love and belonging that society may only bestow on those who relinquish their drives.
Why does this matter? Because if all individuals have the same unconscious tensional structure, we are all capable of happiness, creation, and transcendence, as well as hopelessness, darkness, and destruction (self-destruction or destruction of others). Suicide takes place when something disturbs this balance.
Karl Menninger (1938), an influential American psychiatrist, listed many behaviors that, according to this model, are attenuated forms of suicide: Chronic drug abuse, unexplainable life choices that lead to ruin or reckless exposure to risks. They would be suicidal actions without the willingness to embrace agency or responsibility for the outcome. The farther into denial, the less death looks like suicide: For example, strange accidents or unexplainable diseases. As we've seen, these behaviors can transform into one another and a heavy drug user may, at one point, deliberately overdose.
As later elaborated by Menninger, suicidal motivation is necessarily made of three different independent intentions: To kill, to be killed, and to die. These are three very different actions in intent and purpose. To kill someone is a pure expression of aggression and destruction regardless of whom it is directed. Killing is highly associated with poor executive function, which is the neural mechanism of impulse control (Bredemeier & Miller 2015, Paschall & Fishbein 2002). Being killed is a much more passive act and not an uncommon predominant component in violent death ("suicide by cop"). Dying is the complete absence of action and total passivity. Suicide involves the full spectrum that goes from complete agency (I kill) to having someone with agency doing something to the person (someone kills me), to the absence of action (death happens to me).
The feelings associated with each act are anger, resentment, and guilt which feed into each other in a destructive spiral that eventually results in death by suicide. There is little consensus about what emotions comprise the suicidal state. Anger, sadness, self-loathing, resentment, and guilt are usually identified, interacting, and evolving into one another. Perceived wrongdoing, adversity, or thwarting may lead to unendurable resentment. Resentment may encompass hate as related to revenge or envy and hostility towards someone or something. Repressed resentment is directed inward and may overtax the individual's resources for assimilation, resulting in suicide. We go back to the idea that unmastered self-destructive impulses either insufficiently directed outward or insufficiently gratified by external opportunities result in self-destructive action.
The most significant contribution of psychology to the understanding and intervention over suicide was to blur the line that separates the “normal” from the “pathological." With this, a road to suicide prevention by manipulating suicidal forces and components in each person becomes possible.
The shattering of the self is considered, by some psychoanalysts, the point of no-return in the progression self-destructiveness. Maltsberger argues that the suicidal self, as a sub-structure of the ego, can become frail and vulnerable to powerful destructive forces. Not only it is under attack from the superego but the ego itself undergoes failure and disarticulation of self-representation. The individual is injured at the core of their identity. At this point, there is no more control over the “affective flooding:" Anguish, self-loathing, anger, aloneness sweep through the mind and cause excruciating pain. When the helpless self gives in to hopelessness it begins to break up (Maltsberger 2004, 2008).
Other theories of suicide
Several other theories of suicide offer to bridge the path between a specific context for suicidal intent and a successful attempt.
Table 5. Three theories of suicide positioned within the ideation-to-action framework
Source: Klonsky et al 2016.
To kill, to be killed and to die, the three basic motivators proposed by psychoanalysis, are contradictory and hard to orchestrate. It makes sense that suicides are rehearsed and preceded by non-lethal self-inflicted attacks. According to the interpersonal theory of suicide, individuals must first develop the capability for suicide by overcoming fear of death and reluctance to suffer self-inflicted pain (George et al 2016).
That is an important fact for those in any position of identifying suicidal risk or helping a suicidal person: They have probably tried it before. Also, despite some disagreement, there is a larger consensus over the fact that there is a progression from suicide ideation to suicide completion.
Source: Klonsky et al 2016
Data from public statistics show that among those with suicidal ideation, 15.6 percent will make an attempt within the following year while 31.8 percent will progress to an attempt at some point in their lifetime. Most of these attempts (60 percent) happen during the first year after the onset of suicidal ideation. One of the determinant factors for this is the development of a suicidal plan, doubling its chance. Among those who attempt suicide, an estimated 16 percent will make a second suicide attempt within the following year. Completed suicides are distributed as follows: About two percent during the following year, five percent after nine years, and up to 13 percent detected after 37 years (O'Connor et al 2013). Significantly, a prior suicide attempt is the single most important risk factor for suicide in the general population (WHO "Preventing suicide" 2014). From these admittedly incomplete and sub-notified data, some practical guidelines can be inferred:
Suicide is rehearsed and there is a progression between suicidal ideation and completion. If someone shares hopelessness with you, you have a red flag. They may be hurting themselves in more or less obvious ways. Visible self-inflicted injuries are a serious red flag and this person is not seeking attention: They are rehearsing their death by suicide. The single most important risk factor for suicide is a previous suicide attempt.
Suicide, like other non-transmissible causes of death, is something that evolves slowly, most likely years. The original determining elements are usually lost in a person's history.
The first red flag is when there is the highest chance of helping the suicidal person. Maybe you (and the social network) can directly prevent the progression by providing “fixes” to social pathological factors that resulted in that suicidal behavior. Maybe you cannot: If suicidal behavior is a result of chronic untreated pain, for example, someone else has to be mobilized to help.
The documented progression from suicidal ideation to completion also led a group of cognitive researchers to propose that suicidal thoughts are the primary antecedents of suicidal behaviors (Nock et al. 2008). The self-loathing emotion, strongly related to the feeling of hopelessness, may be a result of perceived failure (the thought “I failed," “I am a failure”), usually failure to meet some standard. Suicide often comes to mind immediately after failure (Chatard & Selimbegović 2011).
From experiencing a situation or event (lack of professional opportunities, poverty, social disruption, social oppression, abuse, etc.), to becoming increasingly conscious of them and producing a thought (through more rational or more irrational thought processes), and finally verbalizing them may be fast if pre-conditioned (“I am a failure” following failing a task), or very slow (“I am worthless,” “I am shameful” following many years of abuse).
Verbalized suicidal thoughts can come disguised as jokes or comments embedded in layers of context. For example:
“Not worth it. I’d never be approved anyway.”
“Such a nice house. Not for me, I’ll never have one.”
“I didn’t pass. It was a waste of my parents’ money. I’m not worthy of them, I’m a total failure and a burden.”
“You need to fail? I can do that for you, it’s my specialty.”
“I don’t think we should continue. It’s a waste of your time, I’m clearly not making any progress. I never had any talent anyway.”
“I think I’ll just change my name, put on a hat and shades and disappear after this.”
Understanding a person's sense of belonging and social integration, their lived experience of oppression and regulation, the importance of repressed negative emotions, and the cycle of negative emotions and self-destruction can help you identify red flags before the suicidal behavior becomes more serious.
According to the different combination of the studies and theories introduced here, different suicide risk assessment instruments and scales were elaborated. They have been validated through a series of tests. The result is some variation of the "suicide risk barometer" (Harris et al 2015).
Figure 12. The suicidal barometer model
Source: Harris et al 2015. The suicidal barometer model with descriptions of suicidality levels based on item response theory analyses. WTL=wish to live, WTD=wish to die.
These instruments have pretty straightforward questions such as “Have you been thinking about suicide lately?” Some suicidal individuals won’t admit to such thoughts and others are stuck in a dark ocean of suppressed emotions. Emotional suppression and invalidation are highly associated with suicidal behavior (Kaplow et al 2014, Yen et al 2015).
They may just want to escape all the bad memories, the bad context, the bad feelings, and emotions.
The escape theory of suicide
The escape theory of suicide is one of the results of interdisciplinary projects. Integrating and building over more recent contributions from social-psychology, escape theory is significantly influenced by the original Durkheimian propositions. The main assumption from which escape theory builds its causal arguments is that individuals' most important motive to attempt suicide is to escape from self (Baumeister 1990, Chatard 2011). Escape happens in a deconstructed state, not unlike that described by Maltsberger (2004, 2008). As a result of the desire to escape from the self, suicide would involve a six-step progression:
- Major failure-related disappointment—a discrepancy between the standard and reality is very important here although external problems (or a combination of both) can be a cause.
- Self-blame, negative implications about the self.
- Aversive state of high self-awareness (feelings of inadequacy, incompetence, guilt).
- Negative feelings and affect (self-loathing, self-hate).
- A state of cognitive deconstruction as an escape from the painful trajectory. As attempts to escape are insufficient to divert the aversive thoughts and feelings, more attempts to escape and numbing the pain are made.
- Cognitive deconstruction conducive to suicide, such as a lack of inhibitions, rejection of meaning, and irrationality.
This six-step progression is a decision-tree structure: At each step, something can happen that will lead to an outcome other than suicide. A decision tree is a flowchart-like structure. Each node represents an attribute test and two options may result. “Decision” tree doesn’t mean an actual decision, but a route among two or more possible ones.
That means not only that at each step the individual has the potential to reinforce their inner resources or the opposite. It also means that at each step, there is an opportunity for suicide prevention. Since at each step the individual is increasingly trapped inside their irrational process, increasingly isolated from others and less communicative, there is a chance to interfere and empower the individual towards the "other" road: The one that doesn't lead to suicide.
An environment that handles competition positively and constructively, confronting perceptions of failure with more nuanced appraisals of the situation are suicide preventive. A destructive and hostile competitive environment can be conducive to suicide. That is when the sports community must assume responsibility for what kind of environment it is promoting.
The rational suicide
Rational suicide is a controversial concept. First, a significant part of the medical and scientific community assumes that, by definition, if there is suicidal behavior it is determined by mental illness. If the individual is interrupted in a suicide attempt, it is automatically assumed they are not competent to make decisions and their autonomy is taken from them. They will be hospitalized or controlled by other adults at home. Suicide prevention policies include detaining and hospitalizing all suicidal agents caught in the suicidal process.
Critical psychiatrists, suicide researchers, and even official public health organizations assume that there might be a much larger proportion of rational suicides than it is assumed.
With the present surveillance tools, health policies, and prevalence of mainstream psychiatry's tautological assumption that if it is a suicide attempt, then it is irrational, driven by mental illness, rendering the agent legally incompetent, we don't know the proportion of rational suicides.
Biel (2019) assumes that not only euthanasia patients but other suicidal agents are rational and competent and that policies should reflect this assumption. Once the rationality and competence of an apprehended patient are established, they would not be subjected to forced hospitalization or post-treatment.
It still begs the question of how to determine the rationality of suicidal action. If detailed planning is adopted as a criterion for rationality or competence, it still doesn't mean that suicide is the only option for that individual: It means that, without significant action from third parties, it is.
Some authors have been pointing out the competence of suicidal agents for decades (Mayo 1986). Others observe that the suicidal agent might be rational and competent, as many elderly individuals. However, their decision to die is derived from the social context which they cannot change (Dzeng & Pantilat 2018).
With better data providing a realistic picture of suicidal acts predominantly contextualized in a scenario of inescapable and excruciating chronic pain, or social circumstances that promote isolation and no prospect for improvement, the understanding of rational suicides may provide suicide prevention stakeholders with a better understanding of helpless situations (as opposed to just helpless individuals) and of the social circumstances that need intervention.
As for the individual, although impulsive acts with a window of opportunity call for intervention, their autonomy should always be respected. The response to individuals expressing the wish to die must be framed by the concepts of understandability and respect (Clarke 1999).
Euthanasia or physician-assisted suicide is legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada. Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s, ranging between 47 percent and 69 percent (Emanuel et al 2016).
Still, most of the literature about rational suicide is concerned with showing that they are actually irrational, a research agenda that borders the irrational. It is irrational to find irrationality on the wish to die of someone forced to live under unbearable conditions and even worse, force them to continue to live.
Sometimes, a cigar is just a cigar. Freud died of suicide because of all the options available—it was the only one that beats living in excruciating pain. Many suicides among the elderly are rational. Pain, inability to maintain minimum living standards and dignity, hunger, or any other extremely debilitating condition with no perspective of change leads to rational suicide.
Bohnert and Ilgen (2019) claim that "pain causes alterations in the neurocircuitry related to reward, which results in vulnerability to suicide and potentially to riskier use of opioids. This biologic mechanism is supported by epidemiologic data that have shown that chronic-pain diagnoses are linked to suicide." This line of inquiry is not helpful. There is no need to appeal to reward neural mechanisms to explain rational suicide from chronic pain: There is a point in which the scale balancing enduring pain and meaningful experiences in the world tilt towards death. Living just stops making sense. Maybe for this reason chronic pain suicides are such a controversial subject. At this point, the decision is nobody's business except the person deciding to live or die.
Efforts to prevent suicide come hand in hand with de-pathologizing it. The high association between a positive diagnostic of mental illness and suicide doesn’t tell us anything about the chicken and the egg. Mental illness is highly associated with negative environmental conditions (Mulder et al 1998, Amone-P’Olak et al 2018, Curran et al 2016). It is also tautological because suicide is considered an expression of mental illness, and because we don’t know which came first: If the negative environmental conditions chicken or the mental illness egg. (Baumeister 1990).
The natural corollary to the assumption that suicide may be competent and rational is that it must be respected if so. This opens two cans of worms: The euthanasia debate, where ethics and health scholars face the religious stonewall and chronic pain.
Chronic pain is associated with suicide (Petrosky et al 2018, Racine 2018). There has been a dramatic increase in chronic pain sufferers denied pain treatment after the radical anti-opioid measures adopted by the CDC (Sade 2020, Pergolizzi et al 2019). The war on opioids and the questionable interpretation of epidemiologic data are a result of many other factors beyond what is known as the "opiate crisis" (Jones et al 2018). Without a health care system that adopts a comprehensive approach to treatments and interventions and addresses patients' needs, individuals will self-medicate. Chronic pain patients, estimated in approximately 25 million people in the USA, have always self-medicated. If not with alcohol, with laudanum; if not with laudanum, with poppy tea, if not with poppy tea, with opium. Since prescriptions with indefinite refills for opiate pain-killers were available, they became self-medication's first choice. That happened long ago. However, the "opiate scare," or the acknowledgment that the number of individuals addicted to prescription drugs was very high, is recent. It became a political platform issue after the late 1990s ("The Opioid Crisis" 2020). The first federal measures started in 2000 in the USA. The increase in synthetic opioid-related deaths was exposed as an "epidemic." It was depicted as the natural progression from prescription opioid use for a "legitimate" reason to drug abuse and overdose death ("The Opioid Crisis" 2020, Lisa & Halverson 2018). Several emotion-laden stories reached the mainstream media. Conveniently, the fact that the majority of deaths are by street drugs, heroin and fentanyl in particular ("Where Does Fentanyl Come From?" 2020, "Fentanyl Has Taken over America's Drug Market" 2018) was and is omitted. As more restrictive measures were adopted to limit the access of individuals to legal opioids, the more the opioid-related deaths increased. A simple look at the charts and a google search for "opioid-crisis-smuggling-fentanyl" is enough to understand its structure (ironically even in DEA official documents: US Drug Enforcement Administration 2018): China's fentanyl smuggling is a high investment for the Triad and the first notorious Transnational Criminal Organizations' (TCOs) consortium operation. Fentanyl is produced in China, transported to Mexico, where the Cartels manage distribution in the USA. The more restrictive the measures, the more clients for the black market, and as of now, fentanyl overdoses are the leading cause of drug-related death.
The measures adopted by the CDC and other agencies are sloppy, excessive, violent, and unscientific (Pergolizzi et al 2019). Opioid addiction is bad but untreated pain is even worse. The number of suicides related to the official measures adopted by the government to combat the "opioid epidemic" is high (Kline 2019). First, a good part of the opioid overdoses are suicides but end up as "accidental overdoses" in the public records. Second, untreated pain is a high-risk factor for suicide and it is rational to try to die if life is reduced to excruciating, unending pain. Third, people who never had access to the recreational black market are pushed in its direction out of an urgency to control their pain. These naïve drug users are typical victims of drug overdose: Neither the Triad nor the Cartels are known to apply precise quality control on their merchandise and someone might end up ingesting 80mg of oxycodone when they only tolerate 20mg.
That's a picture where everything is wrong: While the majority of people being prescribed opioids for pain up to the mid-2010s were older than 45 with a large portion over 65 yrs. Opioid-related deaths affect younger users (Samet & Kertesz 2018). With so many restrictions, stigmatization of opioid users ("legitimate" or not), and treatment denial, this demographic is experiencing an increase in suicides. The younger and middle-aged adults are dying "deaths of despair" that involve drug overdoses, alcohol, and liver damage. With the aggravated social factors driving this demographic to suicidal behavior, more of them will seek out a welcoming black market with powerful drugs. With increased deaths, the regulatory agencies adopt even stricter control over health providers. Pain clinics are shut down ("Why I Am Closing My Pain Practice" 2018). Many Family or General Practice physicians don't prescribe opioids anymore. Drug companies are sued. It is a strange scenario where everybody seems to be losing and that is hardly the case in a market economy. Someone is not losing. We know that the TCOs are profiting from this state of affairs. However, they never operate alone. Someone else is also happy: Whoever negotiated with the TCOs to squeeze out legal opioid prescriptions and gear people in pain in their direction. It's not a person. It's a whole malfunctioning regulatory system.
If we go back to the original question as to whether opioid pain-killers should be prescribed long term to patients suffering from chronic pain, the unbiased answer is "Yes." Not only that, but it must be done within the public health system where low-income individuals can be seen and benefit from affordable medication (Christo 2020, de Leon-Casasola 2013).
How should we see suicide among chronic pain patients? What if they rationally decide that they can’t enjoy life anymore with that pain and decide to die (as so many of them do)? Were these deaths preventable? Should they be prevented?
I leave you with the questions.
The pharmacological revolution
The "pharmacological revolution" is the short period in which a new approach to deviant or atypical behavior, cognition, and emotion was adopted. This new approach was based on the assumption that those atypical or deviant behaviors were pharmacologically treatable illnesses of neurologic origin. It started in 1950 when the drug chlorpromazine was employed as an anti-psychotic. This is still the dominant approach in psychiatry although intellectual (lack of causative explanations), ethical (hyper or incorrect medication), and practical (failure to solve problems at the individual and social level) discomfort with it has always been a matter of contention for critical psychiatry.
By their sheer weight on social representations of suicide and other so-called deviant behaviors, a project such as the one you are reading now would begin with mainstream psychiatry. Not by scientific standards (the scientific study of suicide began with sociology) and not by chronology, since the historical continuity between pre “Pharmacological Revolution” psychiatry and post 1950s psychiatry is at least questionable (Baumeister & Hawkins 2005). Before World War II, psychiatry had the intellectual structure inherited from asylum psychiatry where it was practiced (Scull 2011), something increasingly less acceptable that resembled some sadistic form of pseudo-science. At the same time, physicians who specialized in psychiatry were seduced by psychoanalysis, which offered a complex model of human behavior and a code of ethics. Under psychoanalysis, patients were human beings at an unfortunate point in the psychic structure spectrums. Psychoanalysis-based psychiatry was called "the dynamic approach" in the USA where it was dominant for decades (Menand 2020, Tuck 2014).
Eventually, the pharmacological "paradigm" (Healy 1987) became hegemonic in psychiatry and any psychiatric intervention. For over half a century, behavior, cognition, and emotion were psychiatry's legitimate objects of study and power. Wherever possible, the idea of a mind issue was substituted by the idea of a brain issue. The social and psychological approaches presented here not only lost importance and reach but were actively disqualified. Psychotherapy was at best "adjunct therapy" and the mind, an unnecessary construct.
Psychiatry grew from a small and marginal specialty in medicine to a major one as the public and private spending on mental health, especially psychiatric drugs, grew exponentially.
This new and pharmacologically fortified psychiatry was employed, again, as a political weapon to silence dissent (Perlin 2006) and to disqualify behaviors by devouring everything and regurgitating it as pathologies (Breggin 1983).
The “Pharmacological Revolution”, or “modern psychopharmacology” began in 1950 with the synthesis of chlorpromazine. It is not a coincidence that the first version of the DSM (Diagnostic and Statistical Manual of Mental Disorders) was published in 1952.
Until today, psychiatry is the only medical specialty where nosological entities are vague and ambiguous (Smolik 1999). The violent “medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture” (Kawa & Giordano 2012) created a conflict between a powerful medical practice with less than optimal understanding of causal mechanisms, and all other sciences, not to mention social movements. If there is no consensus as to what is mental illness, there is even less so concerning treatment, where pharmaceutical companies’ aggressive pill-pushing strategy is not veiled. There are many factors holding psychiatry in this “intellectual dark age." Most of them boil down to social control (Conrad 1992) and profit-based institutional control (Frank et al 2005).
What the World Health Organization and local country initiatives are now trying to at least dilute, if not break down, is psychiatry's monopoly over suicide: Its definitions, research, treatment, and prevention. Or, rather, it's an overwhelmingly predominant pharmacological and pathologizing approach. As pointed out by Kawa and Giordano (2012):
Translated into over twenty languages, referred to by clinicians from multiple schools, as well as by researchers, policy-makers, criminal courts, and third-party reimbursement entities, the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) enjoys a nearly hegemonic status as the reference for the assessment and categorization of mental disorders of all types—not only in the United States but increasingly in Europe and more recently Asia.
Up to very recently and still in great part valid to this day, it doesn’t matter how inconsistent and flawed a psychiatric nosological category was: Psychiatry and the DSM are not about accuracy but about power. Things such as the circular understanding of suicide as pertaining to mental illness have been contentious issues for years. If suicide is considered a manifestation of mental illness, then it is tautological to diagnose its cause as mental illness: By definition, the cause of suicide will be mental illness (Baumeister 1990) and by now we know it is much more complex than this.
In studies about the relations between science and its major society, we frequently talk about the "market pull" versus "science/technology push" to explain the dynamics of technological innovation (Godin & Lane 2013, Choi 2018). In the case of psychiatry and pharmacological (technological) innovation, there is a strong interrelated market and policy pull, and a weak science/medicine push, especially because it has nothing to push. The imbalance is so gigantic as to have psychiatry exist for years with the conceptualization of several mental disorders based on possibly spurious drug reactions. Mood disorders are considered serotonin dysfunction disorders when there is not a thread of causal evidence in this direction. Even now, there are attempts to rename mental disorders according to their assumed (but never supported by evidence) molecular mechanism or to "develop of a pharmacologically valid psychiatric nosology” (Ban 2006 and “NBN New Knowledge, New Nomenclature" 2020). The absurdity of supporting the "amine hypothesis of mood disorder" is so abnormal that Healy suggested it played a (Kuhnian) paradigmatic role of psychological nature since it was irrefutable in practice (therefore, weak or unscientific according to the reader's epistemological preference).
The first psychoactive drugs of the pharmacological revolution were discovered by chance while the substance was being investigated for an unrelated condition. For example, Charles Bradley observed an improvement in behavior among ADHD (attention deficit hyperactivity disorder) children while treating some of these patients for severe headaches with Benzedrine (racemic amphetamine). Lithium salts, to this day a standard treatment for bipolar mania or mood swings, were found to sedate guinea pigs in 1949 by John Crade (Robinson 2018).
Figure 13. History of the development of the major classes of drug used in psychiatric disorders
Source: Robinson 2018
Robinson (2018) discerns two periods of drug discovery and psychopharmaceutical innovation: The serendipity and the rational design periods. From the point of view of neurologic and psychiatric research and conceptualization of diseases, we are still in the dark: Because a certain substance altered the behavior of a sample of individuals (clinical trial) more or less significant if compared with controls, the research target became "what does this drug do in the brain?" Drugs do a lot of things everywhere but the first studies pointed to an effect over free amines (serotonin, dopamine, and norepinephrine). The mechanism of mood disorders was announced as a pathologically altered chemical balance of free amines but it was not a true mechanistic scientific discovery: It was at best an association. There is an association with serotonin availability in certain inter-synaptic spaces and an observed change in behavior in a certain percentage of the samples, usually with a significant standard deviation.
Psychopharmacology grew and evolved along this path in which the discovery of all the major classes of psychoactive drugs preceded a detailed knowledge of their biochemical targets or mechanisms of action. The drug determined the concept of the disease mechanism. Drugs shape the cultural understanding of psychiatric disease, mental illness, or, who knows, atypical behavior, cognition, and emotion (Braslow 2019).
The astonishing success and status enjoyed by psychopharmacology do not reflect more effective pharmacological treatment and better drugs. It doesn't reflect a better understanding of disease mechanisms or even nature. The most common word in the new publication titles in any psychiatric newsletter is "association." It is as if the community is overwhelmed with significant and spurious associations and can no longer spare resources and attention to causes and mechanisms. The overwhelming success of psychopharmacology is a result of several factors, at the center of which is pharmaceutical marketing and changes in health policy (Braslow et al 2019).
Several players, private and public, shape the policy response to the market trends and vice-versa (Frank et al 2005).
Figure 14. National expenditures on psychotropic drugs
Source: Frank et al 2005. Original source: Coffey et al. 200, Mark et al 2005
For post-WWII psychiatry equipped with its new pharmacological tools and the dark inheritance of the asylum culture, suicide is the manifestation of individual pathology reflected on social suffering. Patients are still deprived of any right to speech since, by definition, they are "rationally impaired" even if they are not psychotic or dissociative. Individuals experiencing the descent into suicidality and self-destruction are torn between crying for help and defending themselves from psychiatry. Thousands of years of punishment of the suicidal and the "atypical" shape our reaction to "suicide intervention." We carry an immemorial terror of the "stain of madness" not only because of the stigma but because of immediate consequences.
Can we predict and prevent suicide?
The easy answer to both questions is "Yes." However, our ability to predict suicide is not unlike the way we can predict hurricanes or tornadoes: We know it will hit a certain large area and we have probabilities associated with the impact, the location, and even the day and time. We can predict that in a certain community the risk of suicide is high and there is a chance that 5-11 individuals die of suicide in the following 12 months. We still can't predict who, when, and how. We can prevent suicide by bold and aggressive strategies at the community level and we have a high chance of preventing a certain percentage of at-risk people from dying of suicide. We still don't know who and how it will happen.
On its first publication after the adoption of the Mental Health Action Plan (WHO "Mental Health Action Plan" 2013), the WHO affirmed: "Suicide is preventable" (WHO "Preventing Suicide, a Global Imperative" 2017). Yet, actual data on prevention is non-existent. The strategy is unarguably consistent and supported by indirect data but there is not a single implemented program documenting the success of one or another prevention strategy. The WHO cites an American research agenda data as evidence that suicide can be prevented by strategies that involve heavily relying on psychotropics, antipsychotics in particular and post-attempt psychotherapy (National Action Alliance for Suicide prevention "A prioritized research agenda" 2014). The nine percent estimated reduction in five years of intervention in the United States pales in comparison with the national overall increase and the significant increase in certain ethnic groups and cohorts (Canner et al 2018, Shiels et al 2017). Moreover, in a recent study about suicide re-attempt in a cohort of suicide attempters, Irigoyen and colleagues affirmed that there was no evidence that pharmacological treatment prevented suicide (Irigoyen et al 2019).
What we know concerning associations with a decline in suicide is related to societal conditions: War, discrimination, mass migrations, unemployment, bullying, among others. The closest we have to a high-impact preventive measure is minimum wage increase: Kauffman and colleagues (2020) found that a dollar increase in the minimum wage was related to a meaningful 3.4 percent decrease in suicide mortality for those of lower educational attainment. Minimum wage policy protects against suicide in the USA (Ahern 2020).
Figure 15. Effect on suicide rates of the interaction between minimum wage and unemployment
Source: Kaufman et al 2020. Effect on suicide rates of the interaction between minimum wage and unemployment. Minimum wage levels are expressed in US$2015. estimates are for all 50 US states and Washington, DC models include the difference between state and federal minimum wage is US$2015, state and year fixed effects, state unemployment rate, and the interaction between the minimum wage and unemployment. Modeled unemployment rates run from the fifth to 95th percentile for state-months (3.0%–9.4%).
Figure 16. Total predicted suicides among US adults aged 18–64 years with a high school education or less at different minimum wage levels over time and varying unemployment rates.
Source: Kaufman et al 2020. Total predicted suicides among US adults aged 18–64 years with a high school education or less at different minimum wage levels over time and varying unemployment rates. Minimum wage levels are expressed in US$2015. estimates are for all 50 US states and Washington, DC models include the difference between state and federal minimum wage in US$2015, state and year fixed effects, state unemployment rate, and the interaction between the minimum wage and unemployment.
There are global interventions that have not been considered by any suicide prevention program: For example, the effects of climate (Nicole 2020). Burke et al (2017) identified that suicide rates rise 0.7 percent in US counties and 2.1 percent in Mexican municipalities for a 1oC increase in monthly average temperature. The authors project that unmitigated climate change could result in a combined 9-40 thousand additional suicides across the US and Mexico by 2050, representing a change in suicide rates comparable to the estimated impact of economic recessions (Burke et al 2017). Carleton studied the relationship between warming and suicide, controlling for social-demographic variables, and found that a 1oC increase in a single day causes over 70 more suicides. The author estimates that warming over the last 30 years is responsible for 59,300 suicides in India, accounting for 6.8 percent of the total upward trend (Carleton 2017, Stack 2017).
These trends correspond to two preventive measures that can only happen at the highest levels of political decision-making: the minimum wage is determined at the federal level in most countries and initiatives to mitigate climate change are necessarily international.
Establishing a quantitative global goal in suicide prevention as proposed in the WHO Mental Health Action Plan 2013-2020 (WHO "Mental Health Action Plan" 2013), where the WHO Member States have committed to work towards the global target of reducing the suicide rate in their countries by 10 percent by 2020, may or may not be realistic but certainly doesn't reflect any measurable action. As demonstrated by the WHO three years into the plan, the global decrease in suicide in the previous decade was not far from that (WHO, "Preventing Suicide" 2017). In the period between 2000 and 2012, the global population increased and the absolute number of suicides decreased by approximately 9 percent. However, among the 172 Member States with populations of over 300.000, the 2000−2012 change in age-standardized suicide rates ranged from a decline of 69 percent to an increase of 270 percent. The average 9 percent decrease has little meaning if the standard deviation is this large.
Unless great strides are made at the global level towards secularity (controlling the negative religious influence concerning the acceptance of the LGBT community, over deviant behavior and over suicidal behavior itself), low-inequality (controlling the negative impact of poverty, unemployment, food insecurity), adequate income democracies (controlling the negative impact of oppression, discrimination, persecution, and intimidation), the best a global suicide prevention program can aim at is promoting universal consensus over the risk factors for suicide and a global commitment to surveillance.
Without actionable data, there is no action.
Documented advances within the scope of the WHO Mental Health Action Plan (WHO “Mental Health Action Plan” 2013) were on surveillance, according to Ella Arensman, President of the International Association for Suicide Prevention (IASP), Director of Research at National Suicide Research Foundation, Department of Epidemiology and Public Health, University College Cork, Ireland, and WHO Collaborating Centre for Surveillance and Research in Suicide Prevention, Cork, Ireland (Arensman 2017).
Adequate surveillance and, more than that, a social agreement on the necessity to prevent suicide will be the biggest challenges. As pointed out by the WHO (WHO, "Preventing Suicide" 2017), the mere acknowledgment that suicide deaths are preventable is not enough to make it a priority in several countries. It should be no surprise that decision-makers in non-secular, or, worse, fundamentalist countries, not only will not implement the most important actions towards prevention but will continue to work against it. In most countries, suicide is still stigmatized and it will be hard to gain social support for something most individuals came to believe is a "sin" or a "biological inevitability." In non-secular countries, surveillance itself is virtually impossible: The majority of suicides will go unreported and the attempts, unseen. Registering a suicide is a complicated procedure involving several different authorities, often including law enforcement. Most families, if given the alternative, will deny an autopsy and will not accept suicide as a cause of death. The real uphill battle we, as a society, will have to fight to promote prevention and support those in mental suffering is culture.
Until important cultural change doesn’t take place, we’ll follow what scientific interdisciplinary principles we can agree on, in which government and inter-government organizations base their initiatives, and what patients tell us (in a more horizontal and co-produced knowledge approach).
According to Arensman (2017), necessary components of a successful prevention plan are: Surveillance, Restricting Access to Means, Media, Training and Education, Treatment, Awareness and Stigma Reduction, Postvention, Crisis Intervention and Access to Services (Arensman 2017)
According to the WHO (WHO, "Preventing Suicide" 2017), evidence-based interventions for suicide prevention are organized into three types of intervention:
- “Universal” prevention strategies, which are designed to reach an entire population (removing barriers to care and increasing access to help, strengthening protective processes such as social support, and altering the physical environment).
- “Selective” prevention strategies targeting vulnerable groups such as persons who have suffered trauma or abuse, those affected by conflict or disaster, refugees and migrants, and persons bereaved by suicide.
- “Indicated” strategies targeting specific vulnerable individuals with community support, follow-up for those leaving health-care facilities, education and training for health workers, and improved identification and management of mental and substance use disorders.
Figure 17. Evidence-based interventions for suicide prevention
Source: WHO, Suicide Prevention, 2017.
Figure 18. Upstream suicide prevention approaches
Source: WHO, Preventing Suicide 2017.
Why does this matter? The suicide-risk individuals that will either show up at the gym or may be coaxed there by a supportive program are the result of all the negative things that already happened before you met them. There is nothing you can do about their abusive stepfather, about the bullying that victimized them up to high school or about their post-traumatic syndrome secondary to traumatic brain damage due to a grenade in Afghanistan. There is still room for prevention at the community level. The guidelines outlined by the WHO are useful.
Sometimes, community-level and local is as good as it gets and it is very good. We are all impotent concerning the macro-level determinants of suicide. However, they all explode at the community level. Frequently, the at-risk individuals are perceived as such when they are at the last stages of the suicidal progression. That's where personal contact with them can push them one way or the other.
Considering that the WHO Mental Health Action plan (2013) is the best that the very limited interdisciplinary consensus and the political agreement could achieve, it is important to point out that:
At the macro-level, no suicide prevention can be effective without:
- Postvention (continued care after successful prevention of a suicide attempt, given that the single most important determinant of suicide is a previous suicide attempt)
- Legal protection of suicide attempters
- Free and public health care for self-harm and suicide attempt victims
- Aggressively attacking stigma and taboo
- A public conversation about suicide that includes survivors and/or is survivor-centered
- Important measures to combat economic inequality, unemployment, discrimination and free access to public health resources
- Dramatically changing policies concerning vulnerable groups (abused individuals, refugees, and migrants, Indigenous peoples, prisoners, Lesbian, gay, bisexual, transgender and intersex (LGBTI) persons)
- A proper policy concerning chronic pain treatment
The window of opportunity: Social network and the public conversation
Assuming the suicidal person was already victimized by negative social factors, which greatly determine the manifestation of psychopathological negative factors, and considering that there are impulsivity and ambivalence forces at play, how much time do we have to stop an ongoing suicide process? In the majority of suicide attempts, successful or not, the actual suicidal process is too short to interfere with except by chance. What else can this information help us with? The more lethal the means, the lower the chance of successful prevention during the window of opportunity.
Except with rational and psychotic suicides where the typical suicidal ambivalence may either not happen or be managed differently, how long does it take for a victim to mentally engage and perform a suicide attempt? And how long does it take between deciding to go through with suicide and performing the act? The answer is, unfortunately, a very short time.
Most people can recall a movie or even real-life video-taped situation in which a person stands at the edge of a cliff, a bridge or a building roof, hesitant, with an expression of pain and confusion on their face. A short hesitation period and ambivalence are a rule. In some of the positive outcome cases, someone manages to engage the victim and distract them. Is distraction the most effective means of dissuading someone from jumping?
There is no consensus about what kind of approach works at that critical state especially because even the suicidal people that are not mentally ill are in a neurologically different state in which they don’t seek help, tend to reject it, and have unpredictable reactions (Wilson 2017).
Among all the hard things of the psychic world of the "other" to imagine or project into, ambivalence is the easy one. The hard one comes next. Regardless of how rational and altruistic a suicidal act is, it is always a fully experienced transition between existing and not existing. The human mind cannot conceive inexistence. We can imagine several futures including fictional ones but we cannot imagine not existing. Not existing means not imagining anything and not having a mind to feel or think. Death is lonely and weird and mysterious.
The suicidal process is described as consisting of three phases (Deisenhammer et al 2009):
- Consideration: Suicide is considered as a possible solution to current problems and/or suffering.
- Ambivalence: The confrontation between self-destructive and self-preservation forces.
- Decision making: The actual accomplishment of the suicidal act.
Studies carried out in Austria and in India resulted in similar observations (Deisenhammer et al 2009, Kattimani et al 2016). Kattimani and colleagues carried out a three-year study with 347 suicide attempt survivors. As Deisenhammer and colleagues' study before, the analysis was based on the suicide process as reported by survivors:
- First quartile had 96 (30.1 percent) subjects (suicide process time up to five minutes).
- Second quartile had 71 (22.2 percent) subjects (suicide process time six minutes to 30 minutes).
- Third quartile had 77 (24.1 percent) subjects (suicide process time 31 minutes to 120 minutes)
- Fourth quartile had 75 (23.5 percent) subjects (suicide process time of >120 minutes or two hours).
Figure 19. Time between first occurrence of a thought of suicide and suicide attempt
Source: Deisenhammer et al 2009
Figure 20. Time between decision to commit suicidal act and attempt
Source: Deisenhammer et al 2009
Figure 21. Impulsiveness and suicide intent scores related to the length of the suicidal process
Suicide prevention focuses on the longer duration suicidal processes. Realistically, if the red flags were not identified until the decision-making moment, and if the person is alone, as is statistically the most likely scenario, there is nothing to do.
The FBI developed a methodology for more effective interventions in the suicidal crisis of another individual to be implemented in police suicide prevention (Quinnett 1998, 2013). Quinnett believes that suicidal communications are a window of opportunity for trained gatekeepers to intervene. QPR stands for “questioning,” “persuade,” and “refer.” This is as close as it gets to the decision-making moment.
Even though all or most suicidal individuals display red flags and direct or indirect cries for help, there is a point in which they withdraw and engage in the suicidal process. All suicide theories, as different as they may be, suggest the same thing. According to Quinnett, any person can be trained to develop awareness about suicide, enhance surveillance of others in possible distress and this leads to the potential detection of observable suicide warning signs. Once detected and recognized as symptoms of distress, the gatekeeper can then apply the three-step intervention.
The gatekeeper doesn't need to be a psychologist. Quinnett lists at least 25 classes of people who may be strategically positioned to identify distress in the community and could be trained as QPR gatekeepers: family members, friends, neighbors, co-workers, colleagues, teammates, office supervisors, squad leaders, foremen, academic and resident advisors, caseworkers, pharmacists, veterinarians and many others (Quinnett 2013).
The first case described by Quinnett (1998) was an intervention by the shift supervisor on a police officer's suicidal crisis. The supervisor identified the crisis on something the victim said and probably his demeanor. He then asked the officer if they could talk somewhere else and manifested both awareness and concern. The language was important: Being non-judgmental, non-invasive and non-demanding allowed the supervisor to question the action without trying to force the officer into doing anything. He was able to persuade the officer to see a psychologist and to promise to not do anything until they did it. The officer was defensive about not giving up his badge and gun, not being seen as "crazy" or incapable. All these things were dealt with.
Why does this matter? First, because Quinnett’s methodology doesn’t depend on what theory of suicide is more accurate. It addresses detection and intervention regardless of causes or the potential victim’s mental health. Second, because it includes all of us in suicide prevention and provides us with tools. The key here is to show how we are all part of the suicidal context and we can all be part of the solution.
The moral of the story here is that once the suicidal process is initiated, there is a limited chance of preventing the act. However, even among those in the suicidal process, an intervention can be initiated by watchful individuals.
The revolt of the madmen
Among the victims of all the major causes of death and disability, psychiatric patients are the most deprived of rights and benefits. Punishment and deprivation of rights are two of the worst enemies of suicide prevention.
The long history of rejection and punishment of the “deviant” and “atypical” is a dark and dirty one. The unspoken social hatred against non-conformity, especially from the powers that be, was bestowed upon these people systematically, according to different sets of beliefs and theories, and also different forms of constraint and torture. For centuries, they could not collectively speak, let alone react. The medicalization of everything promoted by psychiatry, and its service to institutions seeking to get rid of the unwanted deviant, created the conditions for this forgotten oppressed group to organize for the first time.
They created a Union and a movement.
There are thousands of national and international patient advocacy organizations. Most started as an initiative of patients who sought each other to solve practical problems and empower themselves in the disadvantageous relation with the health care system (providers, insurance companies, hospitals, drug companies, and research organizations). Several of them grew powerful enough to be coveted and finally coopted by the drug industry (McCoy et al 2017).
In most of these cases, patients or patients' families were victimized by a certain disease and received an inadequate response from the health care system. Maybe they found themselves with a rare disease diagnostic and reached out to other patients' or their families. Their affinity is based on their relationship with the disease. The disease affected their bodies and in a certain way provided the common interest between patients and their families, researchers, physicians, and policymakers: They can all agree, even with mutual distrust, on most other aspects of the relation: That they want to treat breast cancer, or prevent diabetes, or understand muscular dystrophies.
Psychiatry, psychiatric illnesses, and psychiatric patients are different. There used to be little or no common ground—for conversation, for seeking treatment and prevention, or for working on research—between mental health patients and psychiatry. Patients were not offered the opportunity to provide input in their diagnosis. Psychiatric diagnostics are based on an analysis of behavioral symptomatology—not on blood tests or clinical images. There is a large room for subjectivity and arbitrary judgment if compared with other diseases and specialties.
Patients were rarely offered any option concerning their treatment. They were frequently violently constrained (involuntary hospitalization). Until today, this type of treatment strategy may happen as a result of an agreement between the family and “authorities,” and may be indefinitely maintained. In the end, the power of life versus one’s minimal citizen right to autonomy lies in the subjective hands of the mental institution’s high-ranking professionals, all of which must be psychiatrists.
These same authorities, in agreement with families or not, could suppress a patient’s “undesirable” behavior through lobotomy or electroshock therapy until the 1970s (Stickings 2019, Moore 2019).
Understandably, mental health patients have built their organizations and movement because they were victimized by the health care system itself through mainstream psychiatry. While other activists call themselves "breast cancer survivors," "HIV survivors" or "myeloma survivor," the forcibly treated "deviant" or "atypical" patients created the "psychiatric survivors movement." It was not a movement for the patients surviving a disease but for the patients who survived the trauma of psychiatric treatment.
Due to the violence and suffering imposed on “atypical” individuals or those undergoing mental suffering, frequently with involuntary hospitalization, psychiatric patient advocacy is unlike any other patient advocacy movement and organization. Instead of organizing just to better treat their disease, like other patient organizations, psychiatric patients organized to defend themselves from psychiatry itself: It is an anti-iatrogenic damage movement.
The origin of the psychiatric patients' movement in the 1970s is contextualized in the momentum created by the civil rights movement, in the rise of new forms of psychiatric abuse during the 1950s and 1960s, with involuntary psychiatric treatment including lobotomy and electroshock therapy, which were brought to light by former or "escaped" patients, by the press and by the movie industry ("Mental Health and Survivors Movements" 1973).
More or less parallel to the pharmacological revolution, psychiatry adopted other forms of radical intervention on behavior: Lobotomy, for example, was introduced after Egaz Moniz won the Nobel Prize of Physiology for the therapy in 1949. By 1950, the surgery was performed in 286 hospitals in the United States and, by 1951, an estimated 18,000 patients had undergone the operation (Braslow 1999). In his case study of a California state hospital, Braslow framed the introduction of lobotomy in the hospital in a particularly unfavorable relation between physicians, staff, and patients. There were 11 physicians for 4000 patients in this hospital (Stockton) and at this point, the focus was order and control rather than treatment. Not unlike its asylum precursors, physicians applied a variety of technologies to maintain order: Electroconvulsive therapy, hydrotherapy, mechanical restraints, and chemical restraints (such as barbiturates and hyoscine). Electroconvulsive therapy (ECT) was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna and it took long for modifications in the protocol to be introduced, making the treatment less painful and less damaging to the patient's cognitive functioning (Write & Bruce 1990, Hirshbein 2012). Until then, ECT was extremely painful and caused permanent brain damage in many cases. Lobotomy was seen as an alternative to ECT. According to Braslow, between March 1947 and June 1954, physicians performed 245 lobotomies on 232 patients in Stockton. They abruptly terminated their lobotomy program with the introduction of the antipsychotic drugs reserpine and chlorpromazine in 1954. Chlorpromazine is the famous Thorazine featured in most movies staged in psychiatric wards in the 1950s and 1960s. The scenes where patients on the run are finally subdued by two strong nurses and given a shot that makes them go limp show the control efficiency of the new drug. Mental hospital scenes of patients in a quasi-vegetative state realistically show the effect of Thorazine. Below are Thorazine commercials from 1955 showing how the drug industry (Smith Kline & French Laboratories then) appealed to authoritarian attitudes in American society: Docility and obedience from the "different/disturbed," female compliance, and family order. Two other adds portray a young child and a menopausal woman "pacified" by Thorazine:
Figure 22. Original Thorazine add showing the controlling power of Thorazine in the institutional setting
Source: “See How Thorazine” 1955.
Figure 23. Original Thorazine add promoting the drug’s virtue in controlling family-disruptive mental and emotional disturbance
Source: “See How Thorazine” 1955.
The perfect storm in the war for social control through brain intervention happened in the 1950s and 1960s: As loud and messy suppressive technologies such as early ECT and older drugs were abandoned, lobotomy, antipsychotics, antidepressants, and other powerful psychotropics were widely used. Civil rights movements constituted the breeding ground for the "deviant or atypical" people's movement, including those in extreme mental suffering. These movements were taking place everywhere, from the US to several European countries, and they were growing intellectually more robust. The wide use of psychiatric hospitals to lock up political dissidents was increasingly documented and revealed. Psychiatric drugs were tested on Viet-Nam soldiers (Kamienski 2016). It was not hard to connect the dots: The mind is the ultimate bastion of autonomy. Therefore, the most coveted item for social control. At the same time that the controlling side of the equation was playing free and loose with victims' health, Nixon launched the infamous "war on drugs," now known to be expensive, ineffective and a tool to perpetuate systemic racism (Rolles & McClure 2009, Rosino & Hughey 2018).
It is not surprising that as soon as the movement took off, it had strong radical components. Some of the founders believed that psychiatry was one of the means of class social control. Unionizing and fighting psychiatry would be analogous to workers fighting employers through their unions. These activists’ objective was social transformation. Since there wasn’t a consensus about the movement’s ultimate goals, it was agreed that sharing the same views on society would not be a requirement to join the movement. The one basic foundation was to defend the dignity of mental patients (“Today in London’s Radical History” 1973, “Mental Health and Survivors Movements” 2020).
The founding of the Mental Patients Union is today considered a landmark in the movement and it can be connected through a continuity line of actors and institutions to today’s organizations and movements. However, much more was happening during that period. Between 1969–1970, the Insane Liberation Front (ILF) was organized in Portland, Oregon, by a small group of people including Howie The Harp (homeless advocate), Dorothy Weiner (union organizer), and Tom Wittick (political activist/organizer). The short-lived ILF influenced several initiatives in North America, including the founding of the Mental Patients Liberation Project, in 1971 and the Mental Patients Liberation Front, in 1976 ("Mental Patients Liberation Front” 2020).
Some of the first issues they started to work on were legal representation and communication. The Bazelon Center for Mental Health Law was founded in 1972 by a group of lawyers and mental health professionals (“Bazelon Center for Mental Health Law” 2020). The first edition of the Madness Network News was published in 1972 ("Madness network news" 2020, "Cynthia Miller Papers, 1973-1995" 2020). Madness Network News' contributors included patients, ex-patients, and sympathizers, especially mental health workers.
The call to found a movement was shared through what came to be known as “the fish pamphlet” ("The Need for a Mental Patients Union." 2020, Cresswell 2009, Spandler 2006).
Figure 24. The fish pamphlet
Source: Cresswell 2009
The fish-on-the-hook was borrowed from psychiatrist Karl Menninger and represents the individual “hooked” to a difficult situation. The individual’s behavior is a manifestation of their attempt to free themselves from the oppressive, binding situation. The full text by Menninger is this:
‘When a trout rising to a fly gets hooked on a line and finds himself unable to swim about freely, he begins a fight which results in struggles and splashes and sometimes an escape. Often, of course, the situation is too tough for him.
In the same way, the human being struggles with his environment and with the hooks that catch him. Sometimes he masters his difficulties; sometimes they are too much for him. His struggles are all the world sees and it usually misunderstands them. It is hard for a free fish to understand what is happening to a hooked one (reproduced in Cresswell 2009).'
At this time, anti-psychiatry activists (participants on a controversy from within psychiatry) and “psychiatry survivors” (patients and ex-patients) shared not only a goal but were brothers-in-arms.
In 1973, the Mental Patients Union was founded to “oppose psychiatric oppression” (“Today in London’s history” 1973, “The Need for a Mental Patients Union” 2020) with over a hundred people in the founding meeting. It is considered the beginning of the organized psychiatric survivors' movement in Britain and it was preceded by two years by the Scottish Union of Mental Patients, established by mental patients at Hartwood Hospital in July 1971 (Gallagher 2017, “Scotland the Brave” 2020). Gallagher’s careful work with Scottish sources has shed light on the significance of all psychiatric patients’ movements, including anti-psychiatry and deinstitutionalization approaches. He demonstrated how the interplay between top-down social and governmental practices and bottom-up resistance and action by patients resulted in a robust social movement.
The founding meeting was successful in several ways. It was held at the Paddington Day Hospital in West London, known to adopt humane methods including psychotherapy. National Health Service authorities wanted to close it. The patients demand that Paddington Day Hospital stay open was met (“Today in London’s history” 1973). They wrote and voted on a “Declaration of Intent of the Mental Patients Union." It began with: “We proclaim the dignity of society’s so-called mental patients. We challenge repressive psychiatric practice and its ill-defined concepts of ‘mental illness.'”
According to participants, several demands couldn't be agreed on such as the abolition of mental hospitals. Several demands are still, unfortunately, disrespected rights of mental patients to this day such as the right to refuse a certain therapy, the right to privacy, and the right of not being held against their will.
Why does this matter? Patients and ex-patients have dealt with disagreement among them since they decided to take their destinies in their hands with the creation of the Psychiatric Survivors Movement. It is not necessary to agree on everything to take action. It is not even necessary to be in the same organization. Their goal was to defend their autonomy and self-determination rights (dignity). Everybody could agree with that. If we agree that suicide rates have always been too high and that suicidal people deserve a chance of not dying by suicide, it’s enough to start changing for the better. We must agree on our respect for them, though.
It was the American root in the Mental Patient’s Liberation front that evolved to today’s international psychiatric patients’ rights organizations Mind Freedom International and World Network of Users and Survivors of Psychiatry (Minkowitz 2012, "Implementation manual for the United Nations Convention on the Rights of Persons with Disabilities” 2008, McDonnell 2014). Like the WNUSP, Mind Freedom has been recognized by the United Nations Economic and Social Council as a human rights NGO with Consultative Roster Status. Judi Chamberlin, who wrote the foundational book “On Our Own: Patient-controlled Alternatives to the Mental Health System” (1978), introduced her work as a platform, speaking on behalf of psychiatric patients and ex-patients:
This is a book about psychiatry and alternatives to it, written from a patient's point of view. For too long, mental patients have been faceless, voiceless people. We have been thought of, at worst, as subhuman monsters, or, at best, as pathetic cripples, who might be able to hold down menial jobs and eke out meager existences, given constant professional support. Not only have others thought of us in this stereotyped way, we have believed it of ourselves. It is only in this decade, with the emergence and growth of the mental patients' liberation movement, that we ex-patients have begun to shake off this distorted image and to see ourselves for what we are- a diverse group of people, with strengths and weaknesses, abilities and needs, and ideas of our own. Our ideas about our "care" and "treatment" at the hands of psychiatry, about the nature of "mental illness," and about new and better ways to deal with (and truly to help) people undergoing emotional crises differ drastically from those of mental health professionals. (Chamberlin 1978)
Judith Chamberlin became a pioneer on psychiatric survivors' movement not only by sharing her experience as an involuntary mental hospital inmate but by pointing out that certain skills and knowledge items could not be obtained in any other manner except by direct experience. During her years of hospitalization in the late 1960s, she not only witnessed psychiatric abuse but acquired an accurate perception about the dehumanization of the psychiatric patient ("Faceless and voiceless subhuman monsters and pathetic cripples").
As soon as she was discharged, she joined the Mental Patients Liberation Front in 1971 and became associated with the Center for Psychiatric Rehabilitation at Boston University. That affiliation facilitated her role as co-founding member at the Ruby Rogers Advocacy and Drop-in-Centers and also of the National Empowerment Center, of which she became a director. These two centers are support organizations run by ex-patients. It seems to have been clear for her then, and later to others, that allies were welcome but the movement and representations had to be organized and ruled by patients and ex-patients only.
By the late 1980s, there were several psychiatric survivors' grassroots movements. They decided that they needed an independent Coalition. In 1988 the Support Coalition International (SCI) was formed and renamed as Mind Freedom International in 2005 with David W. Oaks as its director. Many of the founding members, like Chamberlin and Oaks, go back to the early days of the Psychiatric Survivors Movement in the early 1970s. In 1991, at the biennial World Federation for Mental Health conference in Mexico, the World Federation of Psychiatric Users was formed. In 1997 it changed its name to World Network of Users and Survivors of Psychiatry (WNUSP).
SCI's first public action was to stage a counter-conference and protest in New York City, in May 1990. The counter-conference was “counter” to the American Psychiatric Association's annual meeting, at the same time and directly outside the APA's venue. The obvious message of demanding that their representatives be not only heard, but negotiated with and prioritized was heard, ignored by many, and accepted by few.
Chamberlin (1978) was not alone. Linda Morrison, with "Talking back to psychiatry: The psychiatric consumer/survivor/ex-patient movement" (2013), Robert Whitaker, with "Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill" (2001) have raised their voices and documented psychiatric abuse and epistemological flaws along with other writers from the movement.
Along this journey, patients and ex-patients parted ways with mental health professionals that had defended the same principles and participated in the organizations. Frustration and a perception of ineffectiveness justified that separation during the 1980s (Chamberlin 1990).
There were two moments in which academics were “insiders” (or quasi-insiders) to psychiatry survivors movements: In the beginning, through their interactions with anti-psychiatry, and in the 2000s, with the emergence of “Mad Studies” in tandem with the Mad Pride movement.
The final note to the survivors’ movements chapter is about the suicide attempt survivors’ movement. In line with all the predecessors of customers/users/survivors’ movements, from the earliest psychiatry survivors movement to now, suicide attempt survivors understood that they had a unique and indispensable perspective on suicide and that they must be heard.
DeQuincy Lezine has described the movement’s visibility as starting in the mid-2000s: The 2005 First National Conference for Survivors of Suicide Attempts, Health Care Professionals, and Clergy and Laity, co-sponsored by the Organization of Attempters and Survivors of Suicide in Interfaith Services (OASSIS) and the Suicide Prevention Action Network (SPAN-USA); the National Suicide Prevention Lifeline’s 2007 Attempt Survivor Advisory Summit Meeting, and SAMHSA’s 2010 Building Bridges: Suicide Prevention Dialogue with Consumers and Survivors (Lezine 2014, Carey 2014, “OASSIS” 2020).
Dese’Rae L. Stage created the project “Live Through This” (2020) and as a result of its impact, she and a group of others launched the Attempt Survivors initiative in 2013. It was meant to be a collection of the information needed by people in the wake of their suicide attempts, created by survivors, for survivors (“Attempt Survivors” 2020).
The Mad Pride movement is an offshoot of the early psychiatry survivors' movement. In a sense, it represents some of the natural developments from it, not that different from other minority movements: To claim the stigma and subvert it. Mad Pride is about confronting mainstream psychiatry and the role it plays in protecting the status quo: In its fervent pathologizing effort so as any and all non-conservative behaviors become the object of persecution, diagnosis, and treatment, it disqualifies the deviant as interlocutors and dehumanizes the patient. Conditions, which are ways of existing, when pathologized by psychiatry, become things that people have and it changes them into less-than-human. Mad activism rejects the concept of conditions as mental illness and as a consequence, it challenges psychiatry's identity as a medical specialty. The movement exposes the normative nature of psychiatric judgments (far more normative than any other scientific or science-based practice), the explanatory limitations of psychiatric theories (low empirical weight), and the classificatory inaccuracies that beset the discipline (logical fallacies and other shortcomings, Rashed 2020).
The Mad Pride movement was formed in 1993 as a response to local discrimination against people with a psychiatric history living in boarding homes in the Parkdale area of Toronto, Ontario, Canada. Much like its predecessors and allied movements, such as Mind Freedom, Mad Pride fought for the rights of customers/users/survivors of psychiatric health care. The difference is that instead of just claiming health care users' rights, they confronted the stigma by embracing the slurs. Like gay-rights activists before, who reclaimed the word queer as a badge of honor rather than a slur, these advocates proudly call themselves mad (Glaser 2008). As mentioned so many times before, words have power (Torrey 2011). By claiming to be rightful members of society, mad people challenged all negative and demeaning preconceptions about a wide and heterogeneous group of people. I've been calling them the deviant or atypical in this book because that is all they have in common: Their behavior can be different enough to be tagged to their identity.
The Mad Pride movement is the prototypical identity politics movement: Atypical and deviant individuals are attributed to a burdensome identity by society since time immemorial (Rashed 2019 (a) and (b), 2020, Farber 2012, Corrigan et al 2011). Like gay people, mad people have two choices: To deny their identity and compromise with mainstream institutions for the “lesser evil,” or to confront all institutions with the power of mobilization to force stigma and prejudice out of dominant discourse. Even better: To force several scientific disciplines and one medical specialty, psychiatry, to recant and de-pathologize their identity. “We are mad” means challenging everything: The notion of mental illness, the prerogative of medical specialties and other social institutions, including families, to overpower them in any social situation, and also to claim specific identity rights.
The movement was launched a few years before the release of the book “Mad Pride: A celebration of mad culture” (Curtis & Dellar 2000). Both Curtis and Dellar were early members of the movement. In an interview, Rob Dellar explained the many items in the Mad Pride platform and their realistic perception of mainstream psychiatry’s shortcomings. One important problem was the way that drug companies were interacting with the mental health sector. "The government was encouraged by the media and one or two maverick charities to put forward legislation that increased coercion of people with mental health issues," he said (Abraham 2016).
Mad Pride, more than its predecessors, was about identity. The original movements were concerned with immediate needs, such as guarantees to the protection of their civil rights. This agenda is still very much present and justified by abuse. However, once some rights were conquered the chief issues became defending them against permanent threats from mainstream institutions, advancing identity recognition, and rights to special requirements.
Considering the tremendous power derived from thousands of years of the most violent attacks against non-conformists, deviant or atypical, of specialized institutions for detaining and separating the non-conformists from major society, of torture methods and murder, Mad Pride can be considered successful in its tactic of forcing the acknowledgment of the "mad amongst us."
It's impossible to predict how far it will go, whether the movement will be successful in forcing society to repress and criminalize attacks on non-conformists (bullying) and guaranteeing their right to live their life without fear. The immense majority of mad people still hide because in all but a few places, being mad is punished, legally or not, or simply quenched by excluding the mad from job applications, from public service, from advanced education, and from family rights. However, an arrow for political action which includes suicide preventive action has been successfully outlined by the movement. The voices of the mad now have to be heard, even if with a limited reach, even if still not with equal legitimacy (Cohen 2020).
The neurodiversity movement
The questions for those that have and those that still haven’t (and hopefully never will) been in the receiving end of a psychiatric diagnostic is: How do they want to be addressed? There is a lot in a name (Reaume 2002, Minkowitz 2012, Torrey 2011). The difference between “lunatic,” “patient,” “psychiatric survivor,” “client,” “customer,” and “partner” is the difference between completely stripping the individual of their humanity (“lunatic”), interacting with the individual as long as they agree to compliance and passivity as opposed to pro-activity(“patient”), an enemy who succeeded in surviving psychiatry’s damaging attack (“psychiatric survivor”), the recipient in a service-providing system controlled by the service provider (“client”), the recipient of service according to an officially regulated contract (“customer”), and a colleague with a skill and knowledge set that are needed for treatment, prevention, research and policy decisions (“partner”).
How the “non-conformist,” “deviant,” or “atypical” people choose to be addressed has an impact on the social representation of their condition with players beyond medicine. “Mad Pride” is an attempt to separate the term “mad” from the notion of pathology. The “neurodiverse movement” made important advances and are campaigning for their right to not be pathologized.
“Neurodiversity” is a term associated with the branch of the civil rights movements derived from the early days of psychiatry survivors’ movements. It represents the “neuro equality” platform of those diagnosed with neurological or neurodevelopmental disorders: First, it is a challenge to the still prevalent tendency to pathologize all phenotypes associated with neurological or neurodevelopmental disorders (e.g. Autism Spectrum Disorder (ASD)). Second, it rejects the ranking of individuals’ interests and needs according to the mainstream understanding of properly functioning cognitive capacities (Fenton & Krahn 2007).
This year, Seven Kapp edited a book about the autistic community’s “stories from the frontline” (Kapp 2020) featuring what the neurodiversity movement is today and what key actions defined the autism rights branch of the neurodiversity movement since it organized into a unique community over 20 years ago. It is the first book about a mental condition fully written by authors with a positive diagnostic for that condition. This is also known as “lived experience” knowledge and is considered indispensable for effective co-production of knowledge that includes all stakeholders on a given subject or problem.
Autistic activists have been at the vanguard of the neurodiversity movement and today, "neurodiverse" means "in the spectrum" for most people. Their motto, however, represents all non-conformists, deviants, and atypical people: "Nothing about us without us." Kapp describes the motto as an expression of standpoint epistemology: A standpoint position "claims that authority over knowledge is created through direct experience of a condition or situation. Standpoint epistemology is related to the idea of lay expertise, which is discussed extensively in the sociological literature” (Russel in Kapp 2020, p. v).
Autism activism is several decades old. Its first organization, Autism Network International (ANI), was founded in 1992. The term neurodiversity was coined in 1998 by Judy Singer on Martijn Dekker’s mailing list InLv. The movement matured towards the cross-disability rights movement and the term incorporated its political dynamic (Kapp 2020, p2).
Although the neurodiversity movement has little institutional and leadership overlap with Mad Pride or psychiatric service customers/users/survivors, both share several important features: 1. The demand for autonomy and inclusion rights; 2. The demand to be co-participants in the production of knowledge and policies about their conditions; 3. The origins of the movement being in great part a response to existing stigma; 3. The shift to identity-politics type movements as a result of concocting their identity by and for themselves. This is relevant in the broad discussion about suicide because society’s resistance in agreeing with these demands has been a cause for poor prevention policy outcomes and disrespect for millions of individuals’ civil rights.
An important (unanswered) question introduced by the neurodiversity movement is the extent to which certain differences inherent to their condition represent actual disadvantage to navigate society's institutional structure, social demands, and securing their livelihood. While the mad person within the Mad Pride or customers/users/survivors' groups is not defined by the movement as including those who will always need specific social assistance, the neurodiversity movement assumes that part of those they represent fit into the general description of a disabled person.
That is an internal contradiction that doesn't have any easy solution: While embracing the "neurodiverse," as opposed to "neurological disorder patient" label is empowering, stresses the demand for autonomy and rejects pathologization, the demand for special rights tells another story. They are not just different: They have a disadvantage or a disability. We can argue that some of these conditions can create a disadvantage or an advantage (or both). Indeed, a significant sub-group or neurodiverse individuals are gifted because and not despite their condition. Companies that value this type of talent are making adjustments to their workplace accommodations to absorb them (Austin & Pisano 2017).
The logical sequence to the question is: What are we going to do concerning the fact that many of these different individuals have no way of living an autonomous life in society as it is, regardless of whether this is a problem that wouldn't exist in a hypothetical different society? They are different and they may be, as many are, significantly gifted compared to a neurotypical person. Still, there are issues in our modern social life that they might not be able to handle, making them deserving recipients of public service to this class of people. Legally, they are disabled.
Disabled means incapacitated. It used to mean “legally disqualified.” Dis is a word-forming particle from Latin which means lacking or opposite of. Able is also a word of Latin origin which means "apt."
Therefore, being neurologically “different” in a neurotypical dominated society can be harmful not only because of stigma but due to lack of special care.
The public acknowledgment of the international burden of neurological disabilities is recent ("World report on disability 2011" 2011, "Neurological disorders: Public health challenges" 2006). It is estimated that about one billion people worldwide suffer from neurological disorders and that 6.8 million people die annually from these disorders. The numbers are staggering: About 13 percent of the world population lives with a neurological disability. From the history of the neurodiversity and consumers/users/survivors' movements, besides an important volume of academic publication, we know that the needs of this population were not only neglected, but they were stigmatized and often punished.
Legal rights for neurodiverse people have been conquered recently and in a few countries. There is a long way to go (Math et al 2016).
Possibly the greater contribution of the neurodiverse movement to suicide risk people is the energetic demand of diversity acceptance. Being perceived as different (non-conformist, deviant, or atypical) frequently makes the individual vulnerable to bullying and other forms of social violence. Shame and confusion for being different as well as accumulated failures according to social standards are highly associated with suicide. The neurodiversity movement forces acceptance, an acceptance that society never willingly gives.
In the basement of the Bureau International des Poids et Mesures (BIPM) headquarters in Sevres, France, a suburb of Paris, there lies a piece of metal that has been secured since 1889 in an environmentally controlled chamber under three bell jars. It represents the world standard for the kilogram, and all other kilo measurements around the world must be compared and calibrated to this one prototype. There is no such standard for the human brain. Search as you might, there is no brain that has been pickled in a jar in the basement of the Smithsonian Museum or the National Institute of Health or elsewhere in the world that represents the standard to which all other human brains must be compared. Given that this is the case, how do we decide whether any individual human brain or mind is abnormal or normal? To be sure, psychiatrists have their diagnostic manuals. But when it comes to mental disorders, including autism, dyslexia, attention deficit hyperactivity disorder, intellectual disabilities, and even emotional and behavioral disorders, there appears to be substantial uncertainty concerning when a neurologically based human behavior crosses the critical threshold from normal human variation to pathology (Armstrong 2015).
“Hear them out”—the problem of inclusive prevention and treatment: Co-production of knowledge
From the early Psychiatric survivors' movements to today's neurodiversity movement, psychiatric patients have been fighting to be included in the dialogue about "deviant", "atypical" or "diverse" behavior, cognition, and emotion as capable and equal interlocutors. They want to participate in the definition of what is a mental or neurologic illness and how to deal with their behaviors, including suicide.
The first time they screamed their platform was in the early 1970s in England ("Mental Patients Liberation Front” 2020). This is what they demanded then, in a clear list of 24 items:
Mental Patients Union Demands taken from the Declaration of Intent of April 1973
- The abolition of compulsory treatment i.e. we demand the effective right of patients to refuse any specific treatment.
- The abolition of the right of any authorities to treat patients in the face of opposition of relatives or closest friends unless it is clearly shown that the patient of his own volition desires the treatment.
- The abolition of irreversible psychiatric treatments (ECT, brain surgery, specific drugs).
- Higher standards in the testing of treatments before use on us.
- That patients be told what treatments they are receiving are experimental and should have the effective right to refuse to be experimented on.
- That patients be told what treatments they are receiving and what the long-term effects are.
- Also the abolition of isolation treatment (seclusion in locked side rooms, padded cells, etc.).
- The right of any patient to inspect his case notes and the right to take legal action relating to the contents and consequences of them.
- That the authorities should not discharge any patient against his will because they refuse treatment or any other reason.
- That all patients should have the right to have any treatment which we believe will help them.
- That local authorities should provide housing for patients wishing to leave the hospital and that adequate security benefits should be provided. We will support any mental patients or ex-patients in their struggle to get these facilities and any person who is at risk of becoming a mental patient because of inadequate accommodation, financial support, social pressures, etc.
- We call for the abolition of compulsory hospitalization.
- An end to the indiscriminate use of the term ‘mental subnormality.’ We intend to fight the condemnation of people as ‘mentally subnormal’ in the absence of any real practical work to tackle the problem with active social understanding and help.
- The abolition of the concept of ‘psychopath’ as a legal or medical category.
- The right of patients to retain their personal clothing in hospitals and to secure their personal possessions without interference by hospital staff.
- The abolition of compulsory work in hospitals and outside and the abolition of the right of the hospital to withhold and control patients’ money.
- The right of patients to join and participate fully in the trade union of their choice.
- That trade union rates are paid to patients for any work done where such rates do not exist.
- That patients should have recourse to a room where they can enjoy their own privacy or have privacy with others, of either sex, of their own choosing.
- The abolition of censorship by hospital authorities of patients’ communications with society outside the hospital and in particular the abolition of telephone and letter censorship.
- We demand the abolition of any power to restrict patients’ visiting rights by the hospital authorities.
- The right of Mental Patients Union representatives to inspect all areas of hospitals or equivalent institutions.
- We deny that there is any such thing as ‘incurable’ mental illness and demand the right to investigate the circumstances of any mental hospital patient who believes he or she is being treated as incurable.
- We demand that every mental patient or ex-patient should have the right to a free second opinion by a psychiatrist of the patient’s or Mental Patients Union representatives’ choice if he or she disagrees with the diagnosis and that every patient or ex-patient should have the right to an effective appeal machinery.
The first publications by the Psychiatric Patients Moment was not a cry for help anymore but a loud demand to be heard. For too many centuries, perhaps millennia, the “madmen” were silenced and censored. From now on, a central battle would be to make sure everybody in society heard them.
In the beginning, they were heard, and, more than heard, interpreted and spoken for by the antipsychiatry and other early critical psychiatry movements. Their legacy today is small and marginal to the project of incorporating consumers/users/survivors in knowledge production. The most open approaches in psychiatry that can still be considered mainstream are far from incorporating patients in knowledge generation (Smith et al 2020, Baklien & Bongaardt 2014, Mezzich 2007).
Mental health consumers/users/survivors' movements are not much closer to being an equal (or at least empowered) player in mental health policy than at the beginning of the movement. The difference, however, is that now they can't be ignored.
Studies about the interface of science, technology, medicine, and society have documented a relatively recent trend of change in the way scientific knowledge is produced. Shutting sciences into the Ivory Tower, letting it cook for some years, and then collecting the applied results in the form of technology and medicine doesn't correspond to the reality of science production today, if it ever did. We have figured that out a couple of decades ago. Science is much more "porous" than previously believed and we think it has always been so. Since around the 1970s, the "pores" were big enough and scientific production pulverized through different institutional settings that the non-scientific actors in science production became the focus of research. Science was responding to problem-solving situations in a less disciplinary and more inter (or trans) disciplinary manner in these alternative institutional settings (Gibbons et al 1994, Latour 1987). The first studied cases of specially created structures to mediate the negotiation of interests and transference of knowledge, still unidirectional, were technology transfer agencies in research institutions. These agencies facilitated and managed the transformation of a piece of empirical research into proprietary knowledge that could be legally protected, licensed, and commercialized (Comacchio & Pizzi 2012, Kidwell 2013). This is also where the figure of the “knowledge broker” was first identified (Berbegal-Mirabent et al 2012, Hargodon 1998). That's the agent responsible for making sure knowledge crossed the scientific disciplinary barrier. This barrier exists to keep everything that is legitimate science (production, reproduction, and sanction) inside and everything else outside but now we know that this barrier is porous. The knowledge broker was then, at first, the class of agents (or organizations) that makes sure scientific knowledge follows an efficient path through the barrier, into "society at large."
It became clear that this was not a one-way street and other things besides demands and market needs leaked from the outside into the protected scientific environment. There was a lot of resistance and there still is. However, as much as the figure of the “interdisciplinarian” is needed to facilitate productive inter, trans and cross-disciplinary work, knowledge brokers are needed to facilitate the inflow of “items” from stakeholders to science.
At this point, the main focus concerning science's permeability was promoting the most effective negotiation between industry, policy-makers, academic and other research organizations, and other power-invested stakeholders. Knowledge brokering was first and foremost the translation of science into formats that could be used by these external agents into the market.
It worked well on technology producing fields and the agents responsible for developing and commercializing these products. It also worked well with government decision-making bodies.
Still, each participant had the same role as before and scientific knowledge production continued to be as esoteric and field-contained as before.
The environment and health presented new problems. Both are unsolved equations. Although traditional knowledge about bioactive compounds has fed mainstream medicine from its origins, the discovery of traditional medicine and its use of bioactive compounds unknown to science created another type of knowledge flow: Biopiracy (Shiva 2016). Biopiracy, or the forcible appropriation of indigenous knowledge and the native organisms used to produce the coveted products, is a non-collaborative co-production of knowledge in which only one party benefits from the interaction.
Medicine, an assumed science-based social practice, has been impermeable to patients until they figured how to exert pressure enough to force their concerns to be taken into consideration. Medicine came into the spotlight for all its flaws and was attacked by science, a conflict that generated the "seal of quality" known as "evidence-based medicine," by policy-makers, legislators and regulatory organisms, whose political gains and interests require medicine to comply with their demands and by strong patient advocacy organizations (Eddy 2011, "Evidence-Based Medicine Working Group" 1992). Even though in time, the most robust patient advocacy organizations were flipped by strong economic powers in the health industry, at first they showed physicians that patients had the power to influence medical practice by their organizational power over politicians and legislators and also by directly forcing physicians to respect them.
Mainstream psychiatry, however, is immune to most of this. Its promiscuous relation with the drug industry is beyond brokering: There is no line separating the two. Even with empowered critics from the inside, mainstream psychiatry is structured in a way that makes interdisciplinary dialogue and practice difficult and frequently impossible. Several definitions for the same phenomenon are not only different between the sciences and psychiatry: They are incompatible. This is the branch of psychiatry that won’t negotiate with patients.
The modern dissenters in psychiatry have a different relationship with consumers/users/survivors’ movements from that of early critical psychiatry. They have still not gone far beyond expressing allegiance and separating themselves from their mainstream colleagues, a disagreement that has more academic than policy consequences. They haven’t yet managed to be effective knowledge co-producers with consumers/users/survivors.
From the patient movements presented in the previous chapter, organized to defend themselves against psychiatry, promoting a public representation of psychiatry as motivated by oppression and power, anti-scientific or just plain evil, we are now observing the rise of new strains of survivors organizations with a much deeper understanding of co-production of knowledge.
All health prevention initiatives depend on adherence by those victimized by whatever needs to be prevented. The only way to implement suicide prevention initiatives is to hear what suicide-risk and suicide survivors have to say. To prevent suicide, society must grant individuals’ right and autonomy to take their lives. Prevention becomes, then, the mitigation of suicide social determinants and the institutionalized offer of alternative options to death.
To “hear them out,” it is frequently necessary to kick their relatives and relations out of the room and away from the at-risk individual, and to exclude organized religion from the conversation about suicide.
An international team of users and survivors of psychiatry, led by Tina Minkowitz, participated actively in the negotiations at the United Nations (UN) in New York from the first session of the Ad Hoc Committee in August 2002 through the adoption of the completed text on December 13, 2006. The Ad Hoc Committee was a unique process for all of us. We seized a historic opportunity and accomplished something basic and fundamental that has changed the human rights landscape for us and for all people with disabilities. (“Implementation manual for the United Nations Convention on the Rights of Persons with Disabilities." 2008)
Realistically, the co-production of knowledge in psychiatry is not in the foreseeable future. Some significant steps forward have been celebrated, such as the recognition of consumers/users/survivors' movements in a consultative capacity. This is by no means a linear path.
The NSUN letter was signed by more than 100 individuals, as well as organizations from more than 20 countries, including Argentina, Peru, India, Chile, Columbia, Japan, Kenya, Estonia, and Hungary (nsun.org.uk, 2018a). It said there was little or no involvement of user-led organizations in planning the event, in a blatant breach of the UN Convention on the Rights of Persons with Disabilities (UN, 2006). (Beresford 2018)
Meanwhile, other collaborative initiatives involving several marginal segments—marginal to academia, marginal to the major society, those deprived of basic human rights—emerge. Side by side with indigenous psychologies and other post-colonial co-constructed bodies of knowledge, knowledge about mental health is slowly crawling into forbidden spaces. It has already grown roots into Academia and, in a few countries, even “infiltrated” health care organizations.
This article argues that civil mental health laws operate to constrict how people think, understand, and speak about psychosocial disability, madness, and mental distress. It does so regarding views and experiences of mental health service users and psychiatric survivors (users and survivors) and their/our accounts of disability, madness, and distress, such as those articulated by the emerging field of Mad studies (Beaupert 2018).
Anti-psychiatry, Post-psychiatry and Mad Studies
Evidence strongly suggests that the manner with which mainstream psychiatry has dealt with suicidal people is counter-productive. Its refusal to engage the victims of mental suffering in the decision-making process has just aggravated the stigma and victims' social isolation. Since the 1960s, alternative approaches have emerged from within psychiatry with the potential to act in a suicide protective manner. It is important to know their main ideas and consider them a resource available to all those involved in suicide prevention.
No other medical specialty or even scientific discipline has such a disturbed, extreme and at the same time intimate relationship with their patients or research subjects. It has been the inflictor of pain, the torturer of non-conformists, the dehumanizer of the undesirable, and the instrument to quench dissent. It has done all that against its victims will, in support of itself and the political status quo. It has denied a voice to the deviant and atypical by pathologizing their minds, their behavior, and their speech.
The primordial reason for that is the nature of scientific and technical knowledge in modern society, painfully carved as the rightful and monopolistic holders of legitimate truth. That is the power with which science as a social institution has become indispensable. Despite resistance, rejection, and even destructive attempts from society, today dangerously visible in science denialists movements and governments, grudgingly or not, the world will turn to science for verdicts and solutions: What is causing the new disease? Will the meteor crash into Earth? How can the most destructive bomb be made? How do children learn? Science still holds the power of the answer, albeit temporary in its truthfulness. Medicine as a technical practice that relies on science's sanction has the ultimate power to declare what is normal and what is pathological.
When that power is combined with political will, the consequences can and often are deadly.
It is no wonder that psychiatry has been the most hated of all medical specialties and also possibly the most powerful, despite having the least empirical value amongst them. Fear and hate often function in a feedback loop. The more one fears to be officially labeled as "mad," the more they will hate those empowered to provide the label.
As much as mainstream psychiatry has been efficient in dehumanizing and disqualifying the thoughts and words of their voluntary and involuntary patients, it understood that they couldn’t go on ignoring the survivors’ movements especially after the World Health Organization gave them consultative status. The coercive authority of psychiatry has been exposed and the genie cannot be put back into the bottle.
We have seen how psychiatry has been challenged since its early days and a movement of patients and ex-patients, self-identified as survivors of psychiatric torture, has gained structure, a platform, and momentum in the wake of the American civil rights movement.
When consumers/users/survivors’ movements were validated and joined by critical psychiatrists themselves, in an intellectual movement that was known as antipsychiatry, mainstream psychiatry could no longer ignore its contenders. They had to respond and defend themselves.
The anomalous status of psychiatry among not only the sciences but among medical specialties is acknowledged both by critics and “critics of the critics” (Nasrallah 2011, Desai 2005). One could argue that they should be addressed as “psychiatry’s defenders” but that’s hardly the case. They are involved in defending themselves against the several robust waves of intellectuals, mostly from inside psychiatry, that have brought to light not only its intellectual shortcomings but also its political and economic agenda and its lack of ethics.
The "critics' critics" arguments are typical of a political campaign: First, they lump together all their challengers, highlight the ones that lack any legitimacy, such as Scientology or right-wing movements, and attempt to discredit "criticism" as a homogeneous and unsupported trend. That tactic didn't hold water: There is no interaction or continuity between whatever came before the 1960s and what happened then.
Psychiatry’s shortcomings were irreversibly exposed. Antipsychiatry morphed into other intellectual schools. Psychiatry survived.
The story I am telling about how society has handled mental suffering, non-conformism, deviation, and atypical individuals, which includes suicidal individuals, is a long sequence of different forms of abuse, torture, and coercion. It is, up to very recently, this history of society's institutions created to get rid of the unwanted and unbelonging. Political science, as the discipline concerned with power relations in society, provides as much of the explanatory framework to understand the history of psychiatry as the several science meta-sciences (history, philosophy, and social studies of science and medicine). From its origin up to the late 1940s and early 1950s, psychiatry was the marginal field of medicine devoid of scientific status while tropical medicine, infectious disease medicine, cardiology, endocrinology, and immunology collected all the accolades. Psychiatry was medicine's poor cousin, and psychiatrists, not much more than prison wardens and torturers, with the role of being a cog on the wheel of the war against dissent.
The advent of psychoanalysis and its adoption by a non-negligible number of psychiatrists, shook the specialty’s status quo in the 1930s and 1940s, driving the first wedge into psychiatry and attracting brighter and more compassionate minds to it.
The real fracture, though, started with anti-psychiatry. The movement that came to be known as anti-psychiatry was developing since the early 1950s but the term “anti-psychiatry” was coined by David Cooper in 1967. Cooper was a South African-born psychiatrist and theorist who fled his home country for being an anti-apartheid activist. Once established in London he became involved with alternative institutional and treatment strategies for schizophrenia and other mental afflictions.
He was not alone—not inside psychiatry, not among social movements and not as an intellectual. The voices of challenge and change in psychiatry had to come from the inside and they did (Crossley 1998). It was inevitable. At this point, there was already enough of a critical mass of reformist psychiatrists to constitute an intellectual movement: Thomas Szasz, Giorgio Antonucci, R. D. Laing, Franco Basaglia, Theodore Lidz, Joseph Berke, Morton Schatzman, Leon Redler, and Silvano Arieti networked intensely for decades, frequently until their deaths.
Like all other schools of thought that challenged mainstream psychiatry (generically known as “critical psychiatry”), its diagnosis frailty and lack of scientific foundation, its equally unsupported nosology, its harmful treatments, the dehumanization of patients and its social and political use to silence dissent, anti-psychiatry is depicted by detractors as an unreasonable opposition to science and progress. Another important tactic adopted by detractors of psychiatry's reformist movements is to divulge alternative (false) histories in which critical psychiatrists were featured as part of anti-science and far-right extremist trends when they were actually at the opposite end of the ideological spectrum.
Unlike other critics of psychiatry from before or after, anti-psychiatrists questioned the foundations of psychiatry itself: Its purpose, its nosology, the concept of mental illness, and the very distinction between madness and sanity (Crossley 1998, Ralley & Dumolo 2012).
Anti-psychiatry’s intellectual supporters outside medicine were some of the brightest minds of the time, such as L. Ron Hubbard, Michel Foucault, Gilles Deleuze, Félix Guattari, and Erving Goffman.
The most important support it had, though, came from the psychiatry survivors' movement. It was one of the first occasions in which scientists and physicians looked outside their field and up to the end-user of their expertise for intellectual collaboration. It was the first manifestation of co-production of knowledge where science/medicine outsiders were—at least in theory—equals in the collaborative effort.
This wasn't easy and arrangements changed in time. At some point, the movements closed their doors to non-patients and established boundaries. It was still fine to cross the boundaries and cooperate but survivors/patients decided that their voice needed to come from independent organizations where all shared similar lived experiences. That was and still is their most precious asset since the realization that nothing can substitute personal lived experience was growing in different corners of social life.
That beginning of the movement, though, explains the perception of radicalism and lack of practical application. Frequently, important steps in the history of ideas are marked by violent ruptures with the previous paradigm and its sociocultural context. Sometimes, the radical strikes from that beginning stain the perception of the movement for a long time. Cooper critically deconstructed the nuclear family model, central to all conservative thinking, on several occasions including his foundational book Psychiatry and Anti-Psychiatry (Cooper 1967) and later on The death of the family (Cooper 1974). He advocated an alternative social organization, the commune, free from the rigid roles of father and mother, of monogamy, of contractual marriage, of the traditional binaries (passive-active, homosexual-heterosexual), where true therapy could take place. Therapy was seen as the process of ridding oneself of internalized family ghosts. Madness was seen as both a resistance and a sign of the repressive nature of the traditional family (Chapman 2016).
That was too counter-cultural for the delicate tastes of the medical establishment and the major society. Cooper's contribution towards a subject-centered approach to mental suffering, his criticism of mental institutions, and his pivotal role in the dialogue with survivors' movements ended up underrepresented in the histories of this period.
As is often the case, the founder of a movement is devoured by its own and relegated to the role of an anomaly in the larger movement of critical psychiatry. R.D. Laing’s son and biographer, Adrian, argues that there was only ever one anti-psychiatrist: Cooper (Chapman 2016).
The second icon of anti-psychiatry, or maybe not, according to his son, is Ronald David Laing (Crossley 1998). R. D. Laing was a Scottish psychiatrist known for opposing treatment (or, rather, control) methods adopted in mental institutions during the early 1960s. Two important points made by Laing align him with other critical psychiatrists: First, his belief that psychiatric nosology was inadequate. Second, the belief in a subject-centered approach to mental suffering. Laing did not yet reclaim the early works in sociology, such as Durkheim, that proposed a model of social pathology that manifested as individual psychopathology. However, he and other critics of mainstream psychiatry favored a much heavier role for the social environment in mental suffering.
Whether Laing himself claimed to be part of the anti-psychiatry movement or not doesn’t change the fact that he was the architect of its core ideas.
Laing was a prolific writer and his books exerted significant influence over the younger generation of psychiatrists as well as intellectuals from other fields and patients. Mainstream psychiatry's reaction to his popularity was negative:
Bright young schizophrenics, like bright young people generally, are interested in reading about their condition. From the vast and varied selection of literature available to them, they appear to show a marked preference for R. D. Laing's The Politics of Experience (1967). The present authors, like other members of the "square'' older generation, are of the opinion that they know what is best, and that this book is not good for these patients (from Siegler et al., 1969, p. 947, in Crossley 1998).
Crossley (1998) believes that three overlapping elements characterize Laing's impact: A proto-scientific revolution (which, according to the author, failed), a shift within left-wing politics, and the emergence of the 1960s counter-culture. Laing invested much effort in changing clinical practice and theoretical constructs within psychiatry. Unlike other critical psychiatrists, he insisted on reform rather than a substitution of psychiatry. For example, Laing suggested that schizophrenia is a label and that the patients' particular behavior reflected a family phenomenon. Laing's criticism of mainstream psychiatry evolved into a more political approach, clearly pointing out the nature of the mental institution as one responsible for dehumanizing and invalidating the patient as a human being. That didn't help him gain popularity in mainstream psychiatric institutions or journal outlets, pushing him away from the field itself and more into the counter-cultural social movement. The convergence with other movements into an anti-family, pro-commune perspective, and his experimentation with LSD, obstructed his potential impact on psychiatry at that point.
The third prominent name in anti-psychiatry (who, like Laing, denied belonging to the movement) is Thomas Stephen Szasz, a Hungarian-American academic, psychiatrist, and psychoanalyst. Unlike other critical psychiatrists—both those identified with anti-psychiatry and those who chose other labels—Szasz was not a radical political reformer. He is known for challenging the notion of mental illness itself and psychiatric diagnosis. Much like modern critical psychiatrists, he pointed out that there were neither serological, genetic markers nor image evidence to corroborate the diagnostic of mental illness. Szasz was a firm opponent of involuntary psychiatric treatment and institutional commitment.
His critical approach to mental illness was one of the first systematically elaborated and published (Szasz 1961). Szasz maintained his critical approach to psychiatry all his life, having participated, in 2001, in the Russell Tribunal on Human rights in Psychiatry held in Berlin. The majority verdict claimed that there was "serious abuse of human rights in psychiatry."
These three figures recognized today as foundational to the anti-psychiatry movement networked intensely with each other and several other psychiatrists, intellectuals, and movement leaders but as they disagreed more and more, they grew apart (Roberts & Itten 2006).
Is anti-psychiatry dead? Evidence shows that it gained prominence at the same time as some of its protagonists were pursuing different projects and identifying with other labels. Detractors seem eager to proclaim the death of critical veins inside psychiatry and declare them anti-scientific, or ideological sparks from the past. Some authors consider that the movement never died, it just stopped being anything related to psychiatry or psychiatrists. Instead, it would be now an outsider movement with no allies inside psychiatry (Nasser 1995, Whitley 2012). Anti-psychiatry’s legacy is claimed by the new social movements and preserved in initiatives such as the Anti-psychiatry Coalition (“The Antipsychiatry Coalition” 2020). At the same time, it is vehemently rejected in mainstream environments. According to Rashed (2019), accusations of “anti-psychiatry” are used to silence legitimate criticism of psychiatry as well as to disqualify mental health activism.
As anti-psychiatry lost some of its impact on psychiatry and medicine in general, and as customers/users/survivors’ movements were recognized by the WHO in an official consultative capacity, critical perspectives continued to evolve. The best structured of them is known as “post-psychiatry."
The term 'post psychiatry' was coined by Campbell in 1996 in an anthology of first-hand experience essays about mental distress (Campbell 1996). The term was derived from the shared idea that a new psychiatry was needed for a postmodern world. Patrick Bracken and Philip Thomas have first outlined the project, later shared by other scholars and practitioners.
Bracken and Thomas (2001) outlined post-psychiatry in their article "Postpsychiatry: A new direction for mental health." The authors mention the government’s change of direction concerning mental health policies in Britain. A new ethos informed it, one that commanded attention to the links between poverty, unemployment, and mental illness. Policy guidelines focused on disadvantage and social exclusion. To satisfy the new approach, a new kind of psychiatry and a new deal between health professional and service users (the "consumers" and "psychiatry survivors" of the early days) had to emerge.
Bracken and Thomas published their foundational article in 2001, the year of UK’s general election, following a period of Labor Party control. The election was the last to date in which any government has held an overall majority. Possibly, it was also the last time innovative social policies such as the outlined mental health guidelines could be implemented. It was the beginning of the future, a future in which the relations between science and society would take the expected step forward into problem-focused, interdisciplinary and co-produced knowledge. Sadly, it was not but they didn’t know it then.
John Armstrong Muir Gray, then director of the National Knowledge Service and Chief Knowledge Officer to the National Health Service, among other policy positions, said:
"Postmodern health will not only have to retain, and improve, the achievements of the modern era but also respond to the priorities of postmodern society, namely: Concern about values as well as evidence; preoccupation with risk rather than benefits; the rise of the well-informed patient" (Bracken & Thomas 2001).
Bracken & Thomas were faced with a larger problem when it came to psychiatry: Although the specialty survived anti-psychiatry and other powerful intellectual and political challenges, the improvements called for by the UK government would be much more extensive. The challenge now would be to uncouple psychiatry from all the shortcomings extensively analyzed and revealed by former and present social movements.
The goals of post-psychiatry would be to advance psychiatry into a context-driven approach, an ethical, rather than technological orientation, where service users could be involved in shaping the culture and values of the working teams, as well as reframing the relation between medicine and madness, rethinking and repurposing the politics of coercion. If and when society was faced with the need to remove an individual’s freedom due to their mental disorder, this decision should no longer be the monopoly of psychiatry.
Backlash and antagonism were expected. In a critical article against post-psychiatry, Kecmanovic (2009) adopted the old tactic of misrepresenting the contender's claims to confront and disqualify them. Kecmanovic didn't seem to settle for one or another interpretation of postpsychiatry's perspective on diagnostic to disagree with. First, he claimed post-psychiatry rejected any diagnostic procedure. For Kecmanovic, its proponents would then be campaigning for deprofessionalization, depsychiatrization, and de medicalization of psychiatry. He moved on to claim that post-psychiatry promoted collaborative diagnosis involving the care provider and the user (patient). The fact that the two claims are not logically compatible didn't stop him from continuing his deconstructionist quest. He portrayed post-psychiatry as relying exclusively on an analysis of the social context in which the user/patient manifested symptoms. Kecmanovic couldn't make up his mind as to whether he accused post psychiatry of ignoring symptoms or of negotiating the nature of the symptoms with the user/patient. The same logical inconsistencies characterize the rest of his criticism of post-psychiatry. His arguments may have some value but unless they are cleaned of their many logical flaws, from the most red herring fallacies to other informal and formal ones, there is no possible debate. This type of response, when internal to a scientific field, can only be properly comprehended if contextualized. In this case, the fallacious criticism of post-psychiatry is a defensive strategy from mainstream psychiatry. The argument's structure is composed of an introduction where the contender is described as having some merit and then a long diatribe about how it is illegitimate because the "good premises" were pushed too far.
Contrary to Kecmanovic's claims that post-psychiatry failed to address mainstream psychiatry's most relevant challenges, authors from different countries believe that post-psychiatry has been able to provide positive and practical answers to them as well as a much needed theoretical and philosophical ground. Harangozó (2019), from Hungary, Stupak, and Dyga (2018), from Poland and Korolenko and Shpiks (2016), from Russia, pointed out how postpsychiatry's approach resolves the problem of misdiagnosis and produces better treatment results.
Democratic psychiatry and political psychiatry
Besides post-psychiatry and anti-psychiatry, other critical branches of psychiatry include alternative or democratic psychiatry, founded by Italian psychiatrist Franco Basaglia, political psychiatry, founded by French West Indian psychiatrist Ibrahim Frantz Fanon, and radical psychiatry, founded by French-born American psychotherapist and writer Claude Michel Steiner.
Democratic psychiatry, introduced by Franco Basaglia in Italy (Foot 2014), is at the foundation of the "Trieste model" of public psychiatry, considered by the WHO one of the most progressive and efficient in the world. Like anti-psychiatry, its origin goes back to the radical challenge of mainstream psychiatry from the 1960s. In 1974, Basaglia implemented an alternative approach to psychiatric care based on the centrality of the suffering person as opposed to a diagnosed disorder. Trieste has been a collaborating center of the WHO for four decades to disseminate its model and practical guidelines across the world.
Portacolone et al (2015) described the attempt to translate the Triste model to San Francisco through a collaboration between the Department of Mental Health in Trieste and the department of Psychiatry at the San Francisco General Hospital, an institution affiliated with the University of California in San Francisco (UCSF). The agreement was signed in 2006 by Dell'Acqua and Okin, then chief of psychiatry of the San Francisco General Hospital. The authors concluded that obstacles outside the scope and power of the implementing team made the translation impossible.
The obstacles stem from both the demographic characteristics of San Francisco and the American Health Care system. Unlike Trieste, San Francisco is a city marked by extreme economic inequality, a thin and insufficient social safety net, homelessness, and widespread drug abuse. More than that, the American private-centered health care system made it impossible to adopt more inclusive and efficient mental health programs. The sociopolitical and demographic context in the USA was much less hospitable to reform and the intellectual environment equally unfavorable: psychiatric institutional values were much less challenged, anti-stigma efforts on which social inclusion depends were less extensive, and all in all, the experience showed the world that psychiatric reform towards overall better service to those in mental suffering depends on a combination of favorable factors that goes way up to the societal and government levels.
Political psychiatry was founded by Frantz Fanon, a French West Indian psychiatrist and anti-colonial political activist from the French colony of Martinique. Fanon was strongly critical of psychiatry as it was practiced in the colonies, inseparable from the oppressive empire-colony relations. He exerted influence on Franco Basaglia’s work in Italy and remains, to this day, a reference for mental health service for ethnic minorities in central countries as well as in peripheral countries.
As those he inspired and critics before him, Fanon emphasized the flaws of mainstream psychiatry concerning its neglect of the social context in which mental suffering is manifested. Also like other critical psychiatrists, Fanon suggested that patients benefit from a community-based approach instead of institutionalized care.
Fanon’s main contribution to psychiatry is his confrontation of a model based on the exclusion of the patient, in which their identity is defined by their otherness and the assumption that their discourse is incomprehensible in essence (Menozzi 2015).
Allies to mad people – the non-conformists, the atypical, the neurodiverse, the deviant, the unwanted – also come from the social sciences and the humanities. Mad studies is a field of scientific inquiry that integrates users/consumers from its inception. It is a close cousin, for example, of indigenous psychology, a movement in psychology that advocates not only a subject-centered approach to mental suffering but the co-production of psychological knowledge with traditional cultures.
Mad Studies is a field of inquiry but not just that: it is a field of praxis. It is a field of knowledge defined by co-production between users, scholars, and activists (not necessarily exclusive categories). Menzies et al (2013) define it as an interdisciplinary and problem-focused field.
Mad studies represent an attempt to maintain and promote the growth of the alliances created in the wake of the psychiatry survivors' movement. The items of the early agenda are present but some have become increasingly problematic, such as the fast psychiatric pathologization of behaviors: with each new patented substance, a new disorder is inserted in the DSM or expanded to include children, for example.
In this sense, "Mad" as a noun refers to all the categories of non-conformists, deviant and atypical individuals whose behavior, thoughts, and emotions disturb the conveniently medicalized definition of sanity. Mad doesn't mean "they who have a disorder" but rather "they who have been rejected by major society through mainstream psychiatry through nosologic labels conveniently organized to satisfy the status quo and the pharmaceutical industry."
Castrodale (2015) defined "Mad Studies (as) a growing, evolving, multi-voiced and interdisciplinary field of activism, theory, praxis, and scholarship."
Richard A. Ingram coined the term “Mad Studies” at the First Regional Graduate/Undergraduate Student Disability Studies Conference at Syracuse University on May 3, 2008. He had been a senior research fellow in the School of Disability Studies at Ryerson University. Ingram presented the paper which named the new discipline/field two months before being subjected to psychiatric confinement (Ingram 2016).
As Ingram described the coming together of Mad Studies, he pointed out that there was method in their madness. However, there must also be Mad in their method. Ingram believed that this was a new form of producing knowledge and if it is incorporated in academia, it should shake it up as academia reinvents itself:
"The ultimate horizon that I would hope for would, therefore, be that if Mad Studies does enter academia that it unsettles all academic disciplines: That is what it should do because universities are the place of reason. If Mad Studies achieves its objectives, it needs to have as part of its end goal the shaking up, the disturbing, of all forms of academic knowledge" (Ingram 2016).
Ingram predicted Mad studies’ impact in academia as one that would constructively force open seals that obstruct the cross-talk with multiple stakeholders and also the incorporation of “outsiders”’ knowledge contribution. He also predicted an almost complete impermeability of psychiatry to Mad studies (Ingram 2016).
While I don't think he is wrong in predicting impermeability, Mad studies are growing roots in traditional academia, and as it grows, so does the (expected) criticism against it. The deliberate choice of terms, beginning with Mad and madness, was an attempt to challenge and out psychiatry and its stigmatizing lexicon “rather than devalue those of us who have been subordinated by the two” says Beresford (2019).
Mad studies is a field or discipline for “engaged academics”, as outlined by Cresswell and Spandler (2013), which entails its own contradictions. Especially in this field of “psychopolitics”, a term coined by Sedgwick (1982) and elaborated on by Cresswell and Spandler, where participants’ identities are permanently questioned, given their deep engagement. Many such academics share the identities of institutional scholars, activists, and also consumers/users of mental health systems.
How academia will interact with this new interdisciplinary discipline or field is unpredictable although I suspect the fate of this interaction is highly dependent on what happens at the political level in each society. In other words, if the executive, judiciary and legislative powers are less hostile to inclusive practices, Mad studies might flourish.
Stigma and the law
Words carry cultural baggage. We call it "theory-ladenness." The idea that an observational term may be "loaded with theory" comes from epistemology and the philosophy of science. When Thomas Kuhn argued that two paradigms were "incommensurable" he was referring to the fact that observational terms were theory-laden by different sets of assumptions, becoming non-translatable (Kuhn 1962). The "paradigms" that Kuhn proposed as integrated systems of conceptual models and practices for the functioning of science constitute complete world views.
In the 1950s and 1960s, Thomas Kuhn, Norwood Hanson, Paul Feyerabend, and others questioned the objectivity of observation since, according to them, one cannot use observational evidence, expressed by a term, without committing to the theory where that term acquires its semanticity. The more controversial the theory and the higher the number of competing models, the lesser the epistemic value of the observation and the term (Bogen 2009).
That is true for all observational terms: they are all dependent on an integrated system of semanticity like a language or a culture. Certain terms will be used less controversially both among scientists and between scientists and whoever they are in dialogue with, outside of science. Examples:
Table 6. Observational expressions and their contexts
"Mental illness" or "disorder" is now not only controversial but ideologically and politically laden (Torrey 2011). The mere fact that suicide prevention is coordinated as a part of a "mental health" initiative is controversial. Several parties with a vested interest in suicide prevention programs would rather see it as a stand-alone social program. "Mental illness" became a problematic term and it will remain so as long as the evident epistemological flaws on psychiatric nosology remain. It is theory-laden by more than one theory.
I will adopt the nomenclature that most accurately respects the reality of the phenomena and interdisciplinary nature of related knowledge. I will refer to the condition in which suicidal people are as "mental suffering"—not illness, not a disease. By the same token, the condition in which individuals find themselves with a low probability of dying of suicide as "mental wellbeing."
The suicidal state of an individual is a mental health problem. And a social network and community resources problem. And a support network and welfare problem. And a macroeconomic problem. And an educational problem. And a political problem. And a legal problem. Finally, certainly, a legislative problem because if the laws aren't changed, all suicide prevention program investments are significantly wasted.
For the moment, let’s just hold this thought: The United States is the only country that doesn’t have a national public health system, where there is private monopoly in the health industry and health care, and that this is the reason why it is from hard to impossible to enforce laws or create laws that are consistent with science rather than the company’s profit. The fact that things that must be necessarily free of cost and readily available are not so in the US may be associated with suicide spikes in certain regions or social groups.
As the literature reviewed here demonstrates, the one greatest predictor of successful suicide is a previous suicide attempt. If suicide attempt victims are not immediately offered free multi-disciplinary health care, the health care system becomes a suicide-conducive force.
Suicide attempts belong in the same category as snake bites, reproductive health, and non-transmissible disease screening: Either it is free-of-cost, efficient and government-controlled, or society, through its institutions and corporations are one of the factors in the increase in morbidity and mortality from these conditions.
There are a few pieces of legislation that could protect the suicide attempt victim: Under federal rules from the Health Insurance Portability and Accountability Act—HIPAA—employment-based health plans (now extended to individual insurance plans) can't discriminate against a particular person by denying eligibility for benefits or charging more because they have a specific medical condition (Andrews 2014). These are all private health insurance plans and they have an exorbitant power to shape the laws to their needs. For example, they are entitled to specify what kinds of injuries they want to cover and which ones they don't. These are the so-called source-of-injury exclusions. That's where they can specify that if the injury is self-inflicted, the victim is not eligible for coverage from the health plan that ultimately they pay for (employment benefits are not gifts). Health insurance companies do not have to justify the denial of service. Finally, both insurers, health providers and employers hiring an employer-based health care program for their company are protected by federal law on denying service based on their religious beliefs or their conscience ("Conscience Protections for Health Care Providers" 2018, "Department of Health and Human Services" 2018). In other words, there is very little legal regulation over health care providers or insurers in the US: Health insurers will cover what they want and health providers will provide whatever they want (Koons & Tozzi 2019).
There are two publicly funded programs in the US: Medicare ("What's Medicare" 2020) and Medicaid ("Medicaid" 2020). Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and People with End-Stage Renal Disease. It is still health insurance, it is not public health, it may involve a premium and out-of-pocket expenses. About 43 percent of Medicare patients had out-of-pocket expenses exceeding their assets (Renter 2014). Medicaid is a health plan for low-income people who qualify, depending on the percentage of the State's poverty income that the person can document, besides other issues. Medicaid covers suicide attempts and self-inflicted injuries (Coursolle 2020). Medicare doesn't (Renter 2014).
There are around nine percent of uninsured Americans as of 2018, far better than the 18 percent before the implementation of the Affordable Care Act in 2014. However, suicide attempts, the most important event in a suicide prevention program remains an unsolved problem since most people will avoid medical attention and insurers will fight not to pay the related health claim (Gallup 2019).
Finally, if the victim does receive medical treatment for a self-inflicted injury, they may expect that their privacy will be violated since the health care provider is legally entitled to contact several individuals related to the victim, including those that may have played an important role in the negative factors leading to the suicidal state ("US Department of Health and Human Services” 2014). What happens after that, depending on whether there was police involvement or not, varies.
The United States is not the only country where suicide prevention faces a legal brick wall: Among WHO member states are 25 countries where suicide is currently still criminalized and an additional 20 countries where, according to Sharia law, suicide attempters may be punished with jail sentences (Arensman 2017). In nine African countries, suicide is criminalized and suicide attempts are prosecuted and penalized. At this point of international suicide prevention efforts and the first global program reaching its end, an internal conversation is called for in every country. The argument in favor of keeping suicide criminalized is usually the expected anti-scientific and theocratic discourse: "Suicide is inherently evil, immoral, or sinful; therefore, continued legal prohibition and judicial sanctions are defensible" (Adinkrah 2016). There is no reliable data on suicide or suicide attempts from these countries.
The Catalonia Suicide Risk Code Epidemiology (CSRC-Epi) study represents one approach to suicide prevention through surveillance, evaluation, and care offered to suicide attempters or victims of self-inflicted injury. The study takes into account that there is an unknown proportion of suicide attempters who do not contact healthcare services, and emphasizes that the study is limited by that (Mortier et al 2020).
Countries with no well-structured national public health system and private monopoly in health care and the health industry, such as the US, have a structural economic and policy obstacle to implement a successful suicide prevention program. Theocratic countries where suicide and suicide attempt are criminalized are at an even more unfavorable position to make any progress in this direction (Mishara & Weisstub 2015). However, even secular democracies with national public health systems such as Greece, Ireland, Italy, and Portugal face important obstacles for a suicide surveillance and prevention program: Their strong religious traditions (Orthodox and Catholic). Suicides are usually registered as “undetermined” or “accidental” deaths. Pritchard and colleagues conducted population-based studies and compared them to test whether there was any significant difference in patterns of suicides, undetermined deaths, and accidental deaths between these four Western countries and 21 predominately Islamic countries. They found that for the Western comparator countries, the average suicide rate was 66 per million population, the average undetermined death rate 56 per million, and the average accidental death rate 58 per million, yielding a suicide: UnD + AccD odds ratio (OR) of 1.73. The average values for the other three groups were as follows: Less-traditional Islamic countries: Suicide rate, 31 per million; UnD+AccD rate, 101 per million; suicide: UnD+AccD OR = 3.3. Former USSR countries: Suicide rate, 61 per million; UnD+AccD rate, 221 per million; suicide: UnD+AccD OR = 3.6. Gulf Arab states: Suicide rate, 10 per million; UnD+AccD rate, 76 per million; suicide: UnD+AccD OR = 8.6. Middle Eastern and North African countries: suicide rate, 6 per million; UnD+AccD rate, 151 per million; suicide: UnD+AccD OR = 25.2. The patterns of these mortalities in the Islamic countries were significantly different from Western comparator countries.
What we learn from this is that legal impediments to suicide prevention, such as the US virtual impunity of monopolistic private health corporations, determined not to cover suicide attempts and self-inflicted injury, or the Muslim countries' criminalization of these acts, is just part of the problem. Of course, access to free, public, and efficient health care is associated with lower suicide rates (Holliday 2018). However, deeply ingrained stigma, usually coming from religious traditions, can make it hard to seek help after a failed suicide attempt and also hard to register suicide deaths.
Stigma goes much deeper and wider than anachronic or flawed legal situations. Fighting the stigma associated with madness was a platform item of all the psychiatry survivor movements up to now. Mental health laws are instruments to perpetuate stigma by removing power and agency from the service users. The stigma associated with the cognitive, behavioral, or emotional deviants or atypical (mad people) is much more destructive than the stigma associated with most other conditions within major societies. Mad people in the health care system are discriminated against and treated with cruelty by health care providers themselves to this day (Bates & Stickley 2013).
An example of how stigma and legal problems can hinder surveillance and prevention problem is Pao and colleagues' (2020) proposal that a universal suicide screening is implemented at all hospitals. Their reasoning is solid: The majority of people who died by suicide visited a health care professional months before their death. According to the authors, the medical providers who assisted these patients are in a privileged position to detect suicide risk. They cite the successful initiative at the Parkland Health and Hospital System (PHHS). The authors seem aware of how patients might react to the several questionnaires imposed on them: They introduce a “less threatening step” to lower the defenses of patients who might feel they are being treated in a punishing way.
They would be treated in a punishing way: Several people with power in that specific medical structure would decide to screen them for something that can brand them with stigma and several potential catastrophic outcomes. Clearly, Pao and colleagues didn't take the time to talk to psychiatry survivors' movement representatives or they would know that.
Their initiative flowchart shows an agile decision-making system:
Figure 25. Suicide adult screening pathway
Source: Pao et al 2020.
Unless the legal issues involved in the suicidal process and the stigma are addressed, the chances of this program to work are small.
These are typical (personal communication, anonymous) dialogues with suicidal patients in hospital settings (HP=hospital personnel; P=patient):
HP (turning the patient’s wrists and observing slash scars): We should get you some help with this…
P: That’s unnecessary. It’s healed.
HP: I mean mental health help. You seem to have hurt yourself.
P: No, you’re wrong. These were accidents.
HP: Seems like you are very much accident-prone.
P: Whatever. Accidents. Nothing else.
HP: I have to report this injury and you can only leave the hospital with a family member.
P: You are not. This was an accident.
HP: This was not an accident and you know it.
P: Fine. Call the police. I see five irregularities here. I will report you.
HP: It’s probably not an infection. Your bloodwork shows elevated liver enzymes. This one here… it suggests you might be drinking more than you should. Or maybe also taking something to calm you down?
P: No, don’t worry. You collected the blood the morning after a party at my mate’s house. That’s all.
HP: Are you sure you don’t want to talk to one of our mental health people?
P: No, I’m feeling great. Just tired.
This is practicing sly normality (Mills 2014) or camouflage (Schneid & Raz 2020). It's a skill that most people can develop when they are overpowered by social actors capable of punishing or destroying who they represent: an ethnic minority, a political clandestine opposition, or the non-conformist, deviant or atypical. In societies that punish the Mad and persecute those with overt self-destructive behavior, many learn to "pass" as "normal", even if "normal" exists as much or as little as madness. It doesn't matter because sly normality or camouflage is not about understanding the oppressive "other": it's about surviving by looking like them.
Even patients who are not used to lying will lie to any authority that broaches this sensitive topic. In places where they may be criminalized or involuntarily hospitalized, they will do whatever it takes to hide the evidence of suicidal behavior. In the US, they will lie to avoid a hospital bill and also because they don’t know where the information will end.
The reason why there is a five-decade-old psychiatry survivors' movement is that there are actual reasons to fear psychiatric probing and treatment. Unless the mental health and psychiatric establishment give up their overbearing and inflexible denial to work with "the other side", represented by survivors organizations, this line of screening and prevention has a small chance of making a dent on suicide surveillance and prevention.
Why does this matter: 1. Because without a legal reform that makes it mandatory for health providers and insurance companies to provide care to suicide survivors and victims of self-inflicted wounds, any suicide prevention attempt is strongly incomplete; 2. Because health care professionals must be trained and/or selected based on their emotional health and immunity to suicide stigma; 3. Because those responsible for suicidal people who act on their prejudice and discriminate the victims should be held accountable and punished. Only then we can hope to reach the first steps on true suicide prevention.
“There was nothing you could do” X “I should have…” (Suicide prevention/predictability)
As agreed by suicide prevention task forces, scholars, and some customers/patients, suicide is preventable. No matter how ideal a society is in implementing a comprehensive suicide prevention program, some suicides will still happen. The reason that suicide is not altogether preventable like measles is that it is a stochastic event: someplace, sometime, given certain uncontrolled circumstances, there will be a known probability that someone will die from suicide even in the ideal optimal scenario. And being crystal clear on this, the ideal scenario, if it ever is to exist, is so far into the future that none of us will see it in our lifetimes.
We are stuck with high suicide rates that we can and should try to decrease according to contextual strategies designed by teams of stakeholders. We agreed suicide is preventable but what proportion of suicides we will be able to prevent is not possible to estimate.
The tragedy of uncertainty and unpredictability strikes at the individual level. No matter how many gatekeepers we have and how well we manage to instill awareness in society at large, Chuck, Pablo, and Annika will still die of suicide. Chuck was your student, Pablo was your friend and Annika was your sister.
It gets worse: even the suicidal person, aware that after two attempts they are much more at risk to die at the third, aware that the states of mind conducive to their suicide is impulsive and short-lived, aware that they generally choose to live despite their deep mental pain, even this person may not be able to prevent their own suicide. Most of us tried the check-ins with chosen supervising friends, we tried self-support groups, we tried mood-checking-systems but the truth is that when suicidal people engage in the suicidal process, there are neurological alterations that make all these measures unlikely (Wilson 2017). The more the suicidal person avoids seeking support, the more likely the suicide (Benatov et al 2020).
What happens to the teacher, the friends, the health care providers, the co-workers, the gatekeeper, and the positive family elements? They become vulnerable members of the community (Pitman et al 2017), they must be watched, supported, and followed in their efforts to make sense of their loss for as long as necessary. This process, or "suicide bereavement", is different from "natural bereavement" (coping with the loss of someone to natural causes). Individuals immediately affected by someone's death by suicide, who we will call "suicide secondary victims", are estimated to be 6 to 28 per successful suicide. The total number of secondary victims just in the US is around 3-5 million (Cvinar 2005). Siblings, parents, and peers are at a much higher risk of developing major depression and PTSD (Brent et al 1995, Brent et al 1993a). After all we've discussed about the controversial nature of psychiatric diagnostics, whether it is a "real" major depressive state or just "looks a lot like major depression" (Brent et al 1993b) doesn't matter: the self-destructive risk is the same. As Andriessen and colleagues (2017) suggested, suicide exposure goes far beyond the family context and research and support must cover all the affected. Suicide affects the professionals involved with the victim. It is estimated that 22–39% of psychologists and 51–82% of psychiatrists experience at least one patient suicide in the course of their career although these numbers are uncertain. That's not a small rate. In the aftermath of a death, many of these professionals are taken by a sense of guilt and failure. Some of them question their professional and personal adequacy. As Kelleher and colleagues (2014) pointed out, these people, too, need special attention and given space and opportunity to elaborate their loss, a loss that happens at many levels.
Cvinar (2005) explained that suicide bereavement is "different" but also warned against the paucity of studies and proper methodology in the matter. One of the aspects in which suicide bereavement may be different is that family secondary victims may be subject to stigma and discrimination. Stigma is correlated with shame. The feeling of shame affects the secondary victims' ability to interact with society or, as so frequently recommended, to "move on." It also affects the relationships within the family unit and the result may be complete isolation of the bereaved during the post-suicide period. With shame comes blame – self-blame and finger-pointing as well, which may lead to a vicious cycle of accusations, remorse, and anger. How much of this cycle of isolation and family tragedy is a consequence of the family members' perception of society's reproach and how much is actual discrimination is unknown.
Some things are quite specific to suicide secondary victims: stigma, blame, search for meaning, and being misunderstood. Even if the primary victim left a suicide note, coming to terms with that person's suicide may take years or it may never happen. A certain level of search for meaning in death happens in every death. Natural deaths might be easier to come to terms with. Violent deaths create permanent cycles of hypothetical questions. If the victim was killed in a car crash, some family members will spiral down in "what if" scenarios even when reassured everything was completely random. Family members of murder victims rarely overcome the trauma. Sometimes it seems better to embrace the tragedy, create an organization and devote all one's energy to preventing other crimes than "moving on."
This is all different with suicide. The medicalized version of suicide is more benign to family members because it's easier to dismiss it as losing the genetic lottery. The primary victim was just born "wrong." It's sad but it's nobody's fault. That's false for the majority of suicides and we know it: neglect, sexual abuse, bullying, social isolation due to war or migration, oppressive treatment are all highly associated with suicide, which, we now know, may have multiple causes.
Most families will deny as much as possible that the death was a suicide and when they can’t, they will hold on to the mental illness explanation as a drowning man to whatever floats. Deep inside, many feel it can’t be that simple.
With a multi-factorial approach to the primary victim’s suicide, it is everybody’s responsibility. Dealing with the loss in this realistic way may exorcise the ghost of doubt but it requires a lot of work. It involves transforming the inevitable guilt into a sense of social responsibility, accepting it as a result of ignorance and social circumstance. This is not easy and frequently it is not even possible.
Another difference between suicide bereavement and natural death bereavement is that the suicide might be replicated in what is commonly called “suicide contagion” (Poland et al 2019, Pitman et al 2017). Contagion is not well or consensually understood. Epidemiological data simply shows that those directly related to a suicide victim have a higher suicide attempt and completion probability right after the first suicide. Because of an alarming increase in suicide rates among Army personnel but not Air Force or Navy between 2005 and 2009, a well-funded study project was launched. The results from this initiative have been harshly criticized for methodological reasons and because they failed to generate actionable data. The studies, however, strongly suggested clustering and contagion: suicide attempts from 2004 to 2009 tended to cluster in Army units in which prior suicide attempts had occurred (Hoge et al 2017). The problem, like with so many other issues in suicide studies, is that the concept of contagion is not clearly defined or consensual. Other studies seem to corroborate the contagion hypothesis (Hom et al 2017).
In all suicide clusters that deserved a follow-up study, it was unsurprisingly found that the victims had a previous mental illness, diagnosed or not. However, as Baumeister (1990) pointed out long ago, this is a tautological statement: since suicide is assumed to be a manifestation of mental illness by mainstream psychiatry, mental illness will be found and diagnosed. This is scientifically discommendable.
The truth is that we don't know what this phenomenon represents. We don't know whether the secondary victims are overwhelmed with sadness and identify with the primary victim, thus replicating their behavior. We don't know whether it is overwhelming guilt and if it is, we don't know why. We don't know if it's guilt out of failure (to save the primary victim or in any way prevented the suicide) or guilt out of potential fault (of having been mean or in any way negatively acted against the primary victim.
Survivor’s guilt is another ill-defined term in psychiatry that refers to the guilt of having survived a fatal situation where others died. It was first described in psychoanalytic publications about Holocaust and Hiroshima survivors. On a study among PTSD patients at a UK traumatic stress clinic, Murray (2018) reported that 90% of the patients who had survived where others had died had feelings of survivor guilt. Surviving a fatal traumatic event was associated with higher levels of suicidality. Awareness of survivor guilt was associated with more severe PTSD.
The peers of a suicide victim can feel that they were spared that death and they may devolve into sharing it.
Why that matters: first because you will probably find yourself in the group of those impacted by suicide at some time in your life. The closer you are to the suicidal person, the stronger the impact. The more ambivalent the relationship, the more dangerous. Suicide bereavement is different from natural death bereavement. You shouldn't underestimate that impact and it's a good idea to seek help while you can still consider it. Second, because you might find yourself in the position of observing a social group experiencing the impact of suicide and you can promptly act to assist the group.
The "what if" thoughts are torturing and endless. The cycle of regret and powerlessness results in exhaustion and depression. Hopefully, there will be some closure later.
In cases of excessive mental suffering, as the first account from Kay Jamison on “Night falls fast” (1999) or other refractory cases of bipolar disorder or depression, the patient’s death by suicide may be a relief on their loved ones. If they fought together with and for the victim with all the tools available to them and nothing gave the victim any relief from that suffering, their death may be less ambivalent although not less sad.
What suicide is not
These are all claims that have been more or less elaborated on “lay theories” of suicide. “Lay theories," in this context, are prejudicial assumptions made by anyone with no lived experience or technical knowledge. They are not just false but damaging. Also, they tell a lot about who is voicing them. Finally, they strongly adhere to the perspective of suicide as an individual problem, unrelated to social context. If they stray away from the purely individual account of a suicide it will be to blame the victim’s family or social circle.
- An act of selfishness: It is common to hear lay individuals accuse the suicide victim of being selfish and not thinking about "anybody else." What they mean is that the primary victim was unable to project their continued existence into a future in which the unbearable mental suffering and even the external problems maintaining it would have a more positive outcome. Sometimes, what makes a suicidal individual postpone the suicide are the people who would become secondary victims to their death. When all hope is gone and the pain—whether physical or mental—is intense enough to quench other thoughts. Finally, one of the common aspects of suicidal thinking is the victim's belief that they are worthless, a burden to everyone who loves them, and that everyone will be better off when they are gone. In that sense, appealing to a suicidal person's "sense of responsibility to their family," or to "think about your children" can push them faster into the suicidal process since it intensifies the feeling of guilt and inadequacy.
- A sin: The idea that having sex before marriage, marrying a person of the same sex, abusing drugs, or killing oneself are sins are religious beliefs, not truths. Religion has a dark history with victims of mental suffering. Organized religions were chief perpetrators of torture on deviant, atypical, or suffering individuals. Religious ideas have no place in any conversation about suicide. If the suicidal person is obsessed with the idea of sin, someone familiar with this issue should be engaged. Several religious leaders or priests have a much more benign understanding of suicide and could be of help. Anything that either intensifies religious guilt or drastically confronts the victim's beliefs is dangerous. The victim is in a fragile condition, their self is shattered and they don’t need an atheist to deprive them of a few beliefs they are still trying to juggle.
- A weakness: The value-laden "weakness versus strength" value is related to all the bad things in social life. It is unsupported by evidence of any type. However, it is foundational to any form of oppression: The oppressor is justified because, by definition, they are stronger. Being seen as physically weak by children from our industrial societies is reason enough to be bullied; being seen as mentally or cognitively weak (and it doesn't matter if other terms are institutionally used, such as cognitive disability or impairment) is a reason for pity or contempt; any behavior that deviates from a given moral norm is considered a weakness or a character flaw. Poverty or life difficulties, in general, are systematically judged a weakness since the dominant view is that it is always the result of poor life choices. A suicide victim is frequently said to be someone who wasn’t strong enough to face life challenges. There is not a shred of validity in any of these claims. They are just false beliefs based on the moral of oppression.
- Unmanly: We frequently hear that someone was not “man enough” to handle problems and if the suicide victim is male, that is probably a frequent response. Again, this is just an expression of a false set of beliefs derived from an oppressive (and bigoted) moral system.
- A character or personality flaw: A favorite one is "mental toughness" in the prejudiced menu. Suicide victims would be not mentally tough enough. Mental toughness is the object of empirical research and theorizing. Unfortunately, the concept is not consensual and measuring tools still not sufficiently adequate. A study about the relationship between mental toughness and suicidal ideation among military police was carried out by Smith and colleagues (2016). The psychometric properties of the Mental Toughness Psychological Skills Profile (MTPSP, a scoring questionnaire), and its association with suicide ideation, were evaluated in a sample of active-duty U.S. Air Force Security Forces personnel, a subpopulation especially vulnerable to suicide risk. The MTPSP is comprised of factors which were independently correlated with general distress, somatic anxiety, positive affect, presence of meaning in life, search for meaning in life, positive self-bias, social support sources, and suicide ideation. The Confidence factor was the only one that had a significant association with suicide ideation when all five factors were considered simultaneously but were fully mediated by social support. Self-confidence may be associated with reduced suicide risk because those individuals tend to report higher social support.
- A crime: It is a crime only where the law is based on religious principles and not on a system of rules to best regulate the actions and interactions of the members of society. That would be a theocratic legal system and there is nothing rational about it. It exists to ensure the dominant religion remains dominant. Suicide cannot be typified as a crime in a properly secular society.
- Cowardice: This claim is based on the assumption that, first, any adversity must be faced (and not avoided or eliminated) and any suffering must be endured. If one chooses not to, it represents a lack of courage in this perspective. For the cowardice claim to be true, we must also assume those two assumptions to be true (any adversity must be faced and all suffering must be endured). We know they are false. This lay theory may lead to the assumption, too, that the suicide victim is scared or intimidated by something and that they are escaping from it through death. That is not consistent with any study about the suicidal mindset. The dominant feelings do not include fear. The suicide victim’s state of mind is dominated by hopelessness which actually provides the necessary courage to ignore the pain and the disturbing inability to conceive inexistence.
- Laziness: The laziness claim is comparable to the weakness or sin claims. It refers to the need to push all the determinant factors on anyone's suicide back to the victim. The laziness claim is also a child of the naïve individualist lay theory, where the belief that success or failure is a matter of good choices and determination. There is abundant evidence that this not the case, ever, not even within a specific cultural and income group. This claim also assumes that the suicide victim offends society in several ways: First, they are losers in the competition of life. Second, they don’t embrace their failure to work harder: They drop out of the game because they are too lazy to play it. Suicide victims are frequently exhausted and may be withdrawn due to depression. They are not lazy.
- Cheating: The cheating claim is directly related to the laziness one. Life is a game and it has rules. Winners win because they are just naturally better, make better moves (choices), and are determined. Losers lose because they make bad choices. That is a reflex of that society's moral system: A hierarchical and oppressive one where winners dominate losers. Losers are the object of contempt but suicide victims are far worse: They cheated by dropping out of the game. This game has a rule against not playing it, which is illogical but a large part of every society shares it.
- The apple that doesn’t fall far from the tree: That's the only claim that involves anybody else except the individual. All the claims in lay theories carefully protect society from any responsibility for the suicide death. This one shifts the responsibility for the suicide to the victim's family, which is then stigmatized and ostracized it the community shares this belief strongly enough. According to this belief, the victim’s sinful, weak, or criminal behavior is consistent with their family's nature. The family is not blamed for inducing the victim to suicide but rather for existing and producing an offender such as the victim.
Hopelessness is considered the state of mind most correlated with suicidal intent, even more so than depression. Hope is the state in which the individual can conceive of a future in which a positive outcome to their problems can happen. By directing attention to the future, hope delays self-destructive action. Hopelessness obliterates the expectation of a future. Goal and purpose are related concepts but they are not equal to hope.
Hopelessness and despair
“Deaths of despair” are on the news on an almost daily basis. Among the dictionary definitions of “despair” are “the complete loss or absence of hope” and “the feeling that there is no hope and that you can do nothing to improve a difficult or worrying situation." The etymological roots of the word "despair" are the combination of Latin particle "de" (down from) and the word "sperare” (to hope). The dictionary definitions of hopelessness include “a feeling or state of despair; lack of hope," "the feeling or state of being without hope."
These deaths of despair, that include suicides (by all methods), substance overdose not-ruled-as-deliberate, and liver failure, are deaths of "loss of hope." According to psychoanalysis, they are all suicides (Menninger 1938). They are undeniably deaths resulting from self-destructive behavior.
If you live in the USA, you are bombarded with the notion of deaths of despair on an almost daily basis.
Table 7. List of the first 10 news items with the expression "deaths of despair" in the title, collected on July 30, 2020
There is still little consensus about whether despair and hopelessness are synonymous or if they are being used with the same meaning in research. More objective definitions and cross-talk would be beneficial since there is a body of published research that only employs the term “hope” and “hopelessness” and another that uses “despair." I will assume here that they are synonymous and, therefore, “deaths of despair” are “deaths of hopelessness."
What is hope
Hope is diversely defined as a mental state, an emotion, a feeling, an attitude, or a cognitive response to reality that projects a positive solution to present distress in the future. The importance of hope in suicide is that when it exists, the individual can cope with the stressors. In the absence of hope, it becomes harder and harder to handle problems without a perspective of improvement. Eventually, the person may no longer be able to cope and engages in self-destructive behaviors to escape the pain.
Hope is broadly defined as the ability to envision/feel that there is a solution in the future to current problems or psychic pain. Hope has many implications for the individual. To start with, there is a future to expect. For this reason, hope supports social connection and belongingness, both considered essential for social integration since Durkheim (1897). As a corollary, hope also implies the belief in the possibility of being rescued as opposed to being abandoned (Goldblatt 2017). Indirectly, hope also favors trust, a pre-requisite for accepting help.
What exactly is hope remains elusive or not consensual. Whether it is a cognitive appraisal of reality (therefore, a thought), an emotion, a feeling, or a propositional attitude, is unclear (Crane 2009, Halevy 2017, Milona 2020). Goldblatt (2017) defines hope as a mental state (Putnam 1992). In this mental state, a desire is directed toward the future: The desire for a positive outcome. As such, it supports a positive resolution to psychic pain. The reason why hope is so significant in suicide prevention is that by connecting the victim to the future positive resolution of pain, it postpones self-destructive action. In other words, hope is what halts suicide but also what buys time for more substantial hope.
We could say that, at the individual level, prevention starts with “a little hope."
“Hope theory” is part of the line of psychology called “positive psychology." In cognitive terms, hopeful thought is the belief that there are pathways to desired goals combined with the ability to become motivated to seek them. As a cognitive component, hopeful thought would be then able to drive the emotions and well-being of people (Snyder et al 2002).
Whether hope is the emotional antecedent of cognitive response, vice-versa or the response itself will remain a topic of controversy in and between the sciences. However, the controversy is immaterial to the role of hope and its absence in suicidal behavior. Everyone agrees that it is intimately connected with suicide, with few exceptions (like Mendonca & Holden 1996).
Hope is not faith, hope is not wishful thinking and hope is not denial. Hope is not goal, purpose, or motivation either. Hope is the ability to believe and focus on a positive outcome in the future. Not just believe but believe enough to be mobilized. Sometimes, just mobilized enough to not move in the direction of the suicidal act.
It’s not hard to connect the dots and figure out that if hopelessness is a more powerful correlate of suicide than depression, suicide intent itself, or any other indicator, measuring hopelessness could be the most valuable tool to identify suicide risk. It also doesn’t involve asking the patient: "Have you had thoughts of suicide in the past two weeks," to which most suicidal people would quickly reply: "Absolutely not." If a health care provider talks about suicide with a potential victim who is a stranger to them, the chances of identifying suicide risk are small. If a gatekeeper or someone in the community engages the potential victim in a conversation that involves the future, there’s a chance: The future is absent from their language.
The future tense is less used in the speech of hopeless people:
- Where are you going to be at Christmas?
- Christmas is always at Molly’s parents' house.
- I don’t really care about New Year’s celebrations.
- Will you go to Greg’s retirement party?
- I don’t know.
- What are your career plans now?
- Next week is my dissertation defense.
- I heard it’s all set for you to be in Yale in August
- I guess so.
- I love you very much and I have always been proud of you.
- What do you mean? I didn’t even finish school! Shit’s gonna get real in two years!
- And you’re going to be there with me.
- I am always on your side. No matter what, you will make it.
Suicide feels like a solution to chronic problems:
- How’s the job search? Pete wanted to share some suggestions with you.
- It’s all figured out, don’t worry.
- We need to talk: Your ex-wife’s lawyer has contacted me and she did not agree. She has other demands as well.
- This is not going to be a problem.
- How so?
- Trust me: It won’t.
It is also evident that hope is a protective factor concerning suicidal desire. One of the reasons why hope is possibly the most important protective factor is another dominant feature in suicidal behavior: Ambivalence. Ambivalence is present on suicidal behavior right to its final outcome. It is the alternation of the desire to die and to live. The one factor that can tilt the scale in favor of life is hope (Goldblatt 2017).
With so many approaches to hope and suicide, it’s a good idea to reach back to the pioneers. Edwin S. Shneidman is considered one of the fathers of contemporary suicidology. Shneidman considered that suicide was caused by “psychache," or psychological pain (Leenaars 2010), which I have been calling mental suffering. It takes place when the pain becomes unbearable, beyond a subjective threshold for enduring such pain.
Shneidman’s listed ten commonalities in his definition of suicide in the article “A Conspectus for Conceptualizing the Suicidal Scenario," in 1992.
I. The common purpose of suicide is to seek a solution.
II. The common goal of suicide is cessation of consciousness.
III. The common stimulus in suicide is intolerable psychological pain.
IV. The common stressor in suicide is frustrated psychological needs.
V. The common emotion in suicide is hopelessness-helplessness.
VI. The common cognitive state in suicide is ambivalence.
VII. The common perceptual state in suicide is constriction.
VIII. The common action in suicide is egression.
IX. The common interpersonal act in suicide is communication of intention.
X. The common consistency in suicide is with lifelong coping patterns (Leenaars 2010).
For Shneidman, hope was the common emotion underlying the suicidal act, contrary to the cognitive approach of hope theory. It makes sense that an unbearable state of psychache calls for a solution. The solution is the cessation of consciousness while for the escape theory of suicide the solution is escaping, suicide being the last stage of escaping.
Regardless of which conceptual approach we choose, there is always a threshold after which all other coping mechanisms are insufficient and suicide is the only visible solution. It seems appropriate to assume that whatever else defines this threshold, the loss of hope is the strongest component.
Shneidman also proposes ten commonalities of suicide prevention:
- A program of support of suicide-prevention activities in many communities throughout the Nation.
- A special program for the “gatekeepers” of suicide prevention.
- A carefully prepared program in massive public education.
- A special program for followup of suicide attempts.
- An active NIMH program of research and training grants.
- A redefinition and refinement of statistics on suicide.
- The development of a cadre of trained, dedicated professionals.
- Governmentwide liaison and national use of a broad spectrum of professional personnel.
- A special followup for the survivor-victims of individuals who have committed suicide
- A rigorous program for the evaluation of the effectiveness of suicide-prevention activities (Leenaars 2010).
Although there is little consensus about what hope is, there is some agreement that it is associated with the ability to set goals and engage in goal-oriented action. Long term goals, on the one hand, and purpose (an all-time type of goal) are associated with better coping mechanisms, the existence of a social network, and stronger social ties and resilience. Purpose is what gets people to hang on even when external conditions are unfavorable. How long can any individual hang on to their purpose or if everybody has a breaking point (the threshold) is unclear.
The body of research on suicide and how it is associated with environmental stressors suggests that at extremely uncertain and unfavorable conditions where the individual is socially isolated and detached, or where their original culture is disrupted to a point of leaving the individuals without a value system or even an identity, the threshold will be achieved by many people because of said social conditions.
Apparently, a reason to live (involving intrinsic and extrinsic motivation and goals) is much more significant than a reason not to die.
Shanahan and colleagues (2019) propose that developing tools to identify detrimental conditions through multidimensional conceptual mapping is critical in suicide studies. They suggest that such studies should provide the tools to identify the pathways to despair and from that to premature death. They should also help to identify the sub-groups more vulnerable to the negative impacts of economic, cultural, and social disruption. According to the authors, and I agree, only then can we envision preventions and interventions that might be effective. Whether they will be or not depends on the larger political and cultural conditions.
Where does hope come from?
If hopelessness is such a strong correlate to suicidal behavior, understanding how to restore lost hope becomes imperative at all levels. If you are a gatekeeper, it is important to identify hopelessness and also to have some tools to help the vulnerable person restore lost hope or start their journey of hope reconstruction.
Studies about hope, the psychology, and the philosophy of hope, ironically take hope for granted. It was only when the absence of hope was associated with self-destructive behaviors that the ontological issue became a question. From most of the literature on hope, one concludes it is just there as a default setting, just as most human behavior is goal-oriented.
The question is how to restore hope when it is lost.
Goldblatt (2017) suggests three pathways towards hopeful engagement with the suicidal patient. These are (1) relational coping, (2) symptom management, and (3) link to a core identity. Goldblatt concluded that hope was strongly correlated to the formation of a caring interpersonal relationship. The more “empathic time” the caretaker spent with the suicidal person, the more favorable was the reconstruction of their hope. That required a proactive role from the caregiver on engaging and forming a relationship with the otherwise withdrawn patient. Hope is related to the construction of a meaningful connection and conveying acceptance, which can trigger a trust response from the patient. Hope may return when there is a process of reparation to previous attacks that led to injuries to the ego. Goldblatt proposes that symptom management is indispensable for the victim to tolerate the ongoing suffering when psychic pain is decreased. The final step to the recovery of hope is re-integrating the shattered self and a new connection to the victim’s core identity.
Hope recovery (and loss) are culturally contextualized. Holt and Reeves (2001) described how they developed a definition of hope for the Dominican Republic rural village where they conducted their study. That was done through an ethnographic analysis (in ethnonursing practice). It resulted in a concept of hope as "an essential but dynamic life force that grows out of faith in God, is supported by relationships, resources, and work, and results in the energy necessary to work for a desired future. Hope gives meaning and happiness" (Holt & Reeves 2001).
Gibson (2019) adopted the term “respair” to describe the rise of hope in social theory and its implications for anthropological thought and practice. Respair refers to the return of hope after a period of despair at a societal level. It highlights the relation between hope and its "others:" despair, disappointment, and waiting. These others concerning which hope is an alternative are not the only concepts associated with hope from an anthropological perspective. These associated concepts include anticipation, desire, disappointment, doubt, faith, fear, optimism, among others. Gibson and the authors she reviewed were mostly concerned with shared hope, how it can be construed as a social good (whether an asset, capital, or currency).
The approach is relevant for suicide prevention programs considering that the most effective interventions are at the community level where grassroots movements grow. Questions such as what is collectively muting hope and what can foster it are relevant in this level of intervention.
That brings us to the question of where is the locus-of-hope and how we can manage that in ways that suicide variables are affected. Wagshul (2019) observed that of the three suicide pre-conditional factors according to the interpersonal theory of suicide, two are reduced by increased hope (thwarted belongingness and perceived burdensomeness). The third one, acquired capability for suicide, seems to be increased by hope, which makes little sense. We have a hint that hope is not one but several related phenomena from the anthropology contributions. Wagshul (2019) then suggests looking at Bernardo’s (2010) locus-of-hope construct. Bernardo (2010) developed his model within Snyder’s (Snyder et al 2002) cognitive approach to hope as an individual difference variable, a trait-like disposition for two types of hope cognitions, agency and pathways. He proposed an extension of this approach by conceptualizing locus-of-hope. Research on hope theory offered the empirical foundation for this thesis: Individual-focused agency and pathways have been shown to be associated with positive goal-directed cognition and actions. However, studies on conjoint agency, endogenous social agency, proxy, and collective/shared agency suggest that goal-directed cognitions may involve goals and actions of other people. In this sense, hope may lie not only in one's own plans and capabilities (internal locus-of-hope) but in those of others (external locus-of-hope). According to Bernardo (2010), individual differences in the four locus-of-hope dimensions are correlated with individual differences in individualism and collectivism. Individualism and collectivism, according to this school of thought, are cultural attributes: Cultures can be more individualistic, placing goal setting and seeking at the individual level, or more collectivistic in their pursuit of goals and happiness. Different social theories place a heavier emphasis on one or the other according to their models. In today's globalized world, although pure types may be found, the rule is that different societies will tend more to one or another end in the individualism-collectivism gradient. Bernardo used the Auckland Individualism and Collectivism Scale to correlate to his locus-of-hope dimension measures.
To test his locus-of-hope hypothesis, Bernardo modified the original Dispositional Hope Scale developed by Snyder and colleagues (1996) adding eight new items constructed for each of the three external locus-of-hope subscales: external-family, external-peers, and external-spiritual. Consistent with the original scales, four items referred to agency and four to pathways. Bernardo hypothesized that individualism (but not collectivism) would predict internal locus-of-hope while collectivism (but not individualism) would predict both external-family and external-peer locus-of-hope. He also predicted a relation between collectivism and external-spiritual locus-of-hope. The test studies included 268 students (127 females, 141 males) from three sectarian universities (2 Catholic and 1 Protestant) ranging from 16 to 21 years.
Based on Bernardo’s (2010) categories, Wagshul (2019) designed a study to understand the discrepant results about suicide factors and hope. Data from a sample recruited online (N = 193; 88.6% aged 21–49; 59.1% men; 80.3% white) were analyzed to isolate the effects of external locus-of-hope on acquired capability for suicide, controlling for depression, demographic variables, and internal locus-of-hope. The results confirmed that internal locus-of-hope positively predicts acquired capability for suicide and demonstrated that external locus-of-hope has the opposite effect.
Wagshul (2019) concluded that interventions designed to raise one’s level of externally located hope have the potential to deter suicidal individuals from actualizing their plans. That is not as simple as it sounds. First, what the study shows is not that external locus-of-hope directly lowers acquired capability for suicide. It just shows that, statistically, the likelihood of possessing acquired capability for suicide is lower in a person who has external locus-of-hope than in a person without that quality.
The studies highlighting locus-of-hope are an important tool in considering suicide surveillance and suicide prevention. That doesn’t mean they are easy to incorporate in a surveillance or prevention design. Understanding that hope is culturally contextualized and construed complicates rather than simplifies the task. Or, rather, pushes prevention farther away from mainstream psychiatry and suggests that anthropology, social work, other community programs, and customers/users/survivors groups may be an indispensable tool.
Whether the locus-of-hope is predominantly internal or external for a given at-risk community, restoring hope must happen at the intersection of the individual and the community levels.
When approaching a disturbed and potentially suicidal person, acquiring some information about their cultural origin, types of culturally established expectations, and shared values are important. That doesn’t mean conducting an ethnographic interview: It means attempting to understand where that person places their hope. That can be critical to take protective steps and know how and who to refer the person.
Lifting, mental well-being, and mental suffering
We reach the final and directly applied part of this book: Can lifting help a suicidal person out of suicide risk? If so, what are the conditions to make this possible? Can it be harmful to the suicidal person?
The short answer is yes to both. Since my goal is to prevent unnecessary suicides and help suicidal people and suicide survivors recover, it is important to examine both the conditions that can make lifting a suicide-protective activity and those that can make it a suicide-conducive one.
The reason for this book is that unlike other physical activities and sports, lifting (and strength sports in general) has been shown to be associated with higher than average suicide rates, as compared to the studies' demographic. There is a small number of studies about suicide and lifting (and strength sports in general) and the data suggest a negative effect. While studies are abundant about the suicide-protective effect of sports in general, there are no more studies about suicide and lifting.
Based on by-proxy and anecdotal data, I believe lifting can be one of the most powerfully protective activities concerning suicide. However, we have to make sense of data on the contrary and which factors may contribute to negative or suicide-conducive effects. Also based on anecdotal data and anonymous communication, these factors are unfortunately present in many lifting environments.
It is our moral obligation as a society to combat any socially derived suicide-conducive factor. While the choice to live or deliberately stop living must be respected, conditions in which this is less of a choice and more a result of extreme mental suffering due to a negative environment or history have to be confronted and changed.
If I am right and lifting can be so powerfully protective, then the imperative to identify and eliminate suicide conducive factors is even more important.
For this reason, I will divide this item into three parts: First, I'll list the effects that make lifting a suicide protective activity. Second and based on the previous list, I'll examine the necessary conditions to favor those effects, therefore promoting a suicide protective activity and environment. Third, I'll examine how lifting can be harmful and suicide-conducive.
Can lifting help a suicidal person out of suicide risk?
Lifting can help a suicidal person for five reasons:
- There is abundant evidence that solitary physical practices involving partial sensory tunneling and conducive to flow can promote altered states of consciousness that ultimately lead to mental well-being.
- Mind-body integration/anti-fragmentation force
- Excellent promotion of inter-organ cross-talk and recovery of physiological homeostasis and well-being
- Simple, uncomplicated and problem-oriented social interaction
- A concrete way to exercise regulatory behavior in an otherwise chaotic life, slowly recovering self-sufficiency and autonomy. Moreover, hope, the one factor most highly associated with suicide prevention, can only be cultivated in a goal-oriented life.
Probably yes for five reasons:
1. There is abundant evidence that solitary physical practices involving partial sensory tunneling and conducive to flow can promote altered states of consciousness that ultimately lead to mental well-being.
In simple terms, flow is a state of complete absorption in a task, resulting in several sensory, cognitive, and emotional temporary alterations. This concept is particularly useful when considering the potential beneficial effects of lifting for the vulnerable person. There is a broad literature about the advantages of mindfulness and meditation practices for mental wellbeing. These practices share a common mental attitude and neural correlates with any skillful and autotelic (rewarding in and of itself; auto= self, telos=goal) task done in a dedicated manner: Focus. A certain type and level of focus can produce an altered state of consciousness and specific neural responses. It is no wonder that the creator of the term and first conceptualization of flow, Mihaly Csikszentmihalyi (1975) studied several sports activities for his pioneering work.
Flow research as it has been outlined by its pioneers is part of Positive Psychology’s agenda (Nakamura & Csikszentmihalyi 2002). Positive Psychology is a domain of psychology founded and named by Martin Seligman. It refers to the scientific study of the "good life," or “eudaimonia:" the positive human experiences that result in happiness and welfare, or a meaningful life. That is where my claims about not only flow but self-regulated behavior's positive role for vulnerable individuals come from. They come from an approach dedicated to studying and provision of guidelines to obtain all the things that the suicidal victim has lost: A meaningful life, hope, and happiness.
Nakamura and Csikszentmihalyi (2002) start their chapter asking what constitutes a good life and they answer:
Viewed through the experiential lens of flow, a good life is one that is characterized by complete absorption in what one does. (Nakamura & Csikszentmihalyi 2002, p. 108)
If intrinsic motivation or involvement in autotelic activity explains several aspects of a good life, it makes sense that one of the most important symptoms of depression is the loss of interest in everything and the inability to be interested and obtain pleasure from anything.
The conditions for the flow experience include:
- Perceived challenges, or opportunities for action, that stretch (neither overmatching nor underutilizing) existing skills; a sense that one is engaging challenges at a level appropriate to one’s capacities.
- Clear proximal goals and immediate feedback about the progress that is being made (Nakamura & Csikszentmihalyi 2002, p. 109).
Given these conditions, individuals may enter a state with the following characteristics:
- Intense and focused concentration on what one is doing in the present moment.
- Merging of action and awareness.
- Loss of reflective self-consciousness (i.e., loss of awareness of oneself as a social actor).
- A sense that one can control one’s actions; that is, a sense that one can in principle deal with the situation because one knows how to respond to whatever happens next.
- Distortion of temporal experience (typically, a sense that time has passed faster than normal).
- Experience of the activity as intrinsically rewarding, such that often the end goal is just an excuse for the process (Nakamura & Csikszentmihalyi 2002, p. 109).
The flow state is sensitive to any change in the balance of the conditions it requires or the dynamic system constituted by the person and the environment. The concept of emergent motivation, as one that emerges as a response to proximal goals produced by the interactional dynamic system, is important. Given enough time to experience flow, emergent long-term goals can take shape (Nakamura & Csikszentmihalyi 2002, p. 110).
While the vulnerable individual is engaging in the task of reassembling their shattered self, of establishing a relationship with society in which they may start to build a meaningful life, lifting provides the goal and feedback structures that may elicit the flow experience.
From each autotelic lifting experience, however imperfect it may be, the individual comes out with a more structured self. The self becomes organized around goals (Locke 2002) and this is what lifting is providing: Goals tailored to the skills, attention, and energy.
Flow is also determined by how much attention can be devoted to the task. The vulnerable person usually has little control over the wave of negative intruding thoughts that demand and monopolize their attention. However, it is not possible to share the attention on not falling during a squat with anything else. And then comes another squat, and then another.
Little by little, squats reclaim back the individual’s attention control.
With more attention control, the more chances the person has of experiencing flow. The more experienced they get, the more the person will engage in the activity. From each experience, they emerge with an increased ability to enjoy goal-oriented activities and to focus on goals. Since the flow state is intrinsically rewarding, it stimulates the individual to replicate them and to expand that state to other fields of life.
The appreciation for goal-setting and goal-oriented action is an acquired attitude. Squat by squat, the individual re-acquires the ability to live a meaningful life.
Studies suggest that the ability to experience flow is nearly universal. It may not be easy and the frequency in which individuals experience flow varies significantly. It is easier for those with an autotelic personality, defined by a general attitude of life enjoyment and tendency to engage in things for their own sake (Nakamura & Csikszentmihalyi 2002, p. 112). That is the exact opposite of our vulnerable individual. However, if they are at the gym with the intention of lifting something, the hardest and most taxing task was performed successfully: to be there to do something for the fun of it.
Flow theory has informed psychotherapy for over two decades in the most diverse cultural settings, with positive results (Nakamura & Csikszentmihalyi 2002, p. 112).
On a cautionary note, the concept of flow is immersed in scientific uncertainty: there are no causal explanations for the state. There is still a limited understanding of what factors are associated with flow and how they influence the state (Swann 2016, Swann et al 2018, Weber et al 2016).
The type and number of brain network phenomena taking place during the flow state, or during the transition between flow states and other states is unknown. They may be relevant to explain the results observed (Huskey 2016, Huskey et al 2018).
I suggest that the simplicity of movement, the subjectively perceived levels of complexity (the more proficient the lifter, the more technical complexity they perceive), the nested goals based on the most simple of all (moving from point A to B and back to A), and the simple feedback inherent to lifting may increase the chances of a vulnerable individual with a shattered self to reclaim their ability to control attention, to enjoy setting goals and to engage in a goal-oriented autotelic activity. Flow and psychoanalytic theories support the hypothesis. There is a small set of published studies showing that strength training can have "mindfulness" effects (Vernon 2018) and others suggesting that it can alleviate PTSD symptoms (Whitworth et al 2019).
In other words, it makes sense and many of us can tell stories that fit my narrative but we will only know for sure after this hypothesis is systematically tested with adequate interdisciplinary scientific methodology. Since the exact nature of flow is uncertain, this probably will not happen soon.
2. Mind-body integration / anti-fragmentation force
Sadly, mind-body integration has become a catch expression for new age scammers. That is unfortunate considering that the state of fragmentation of a suicidal shattered ego includes perceptive and cognitive distortions that affect the individual’s self-representation. That involves the perception and representation of their own bodies. That’s one extreme aspect of body alienation, as if the body was external to the self, “someone else’s body."
Restoration of balance in self-perception and self-representation involves reclaiming that body as their own. The body should become something that "I am" and not something that "I have" (and may have lost).
Lifting is particularly suited for this endeavor since the motor tasks involved require heightened levels of self-perception. As one learns, automates and improves their lifting skills, proprioception, and kinesthetic awareness increase. Proprioception is the biological phenomenon of being aware of one's body position and movement. This information is generated by mechanosensory neurons called proprioceptors (Tuthill & Azim 2018). Kinesthetic awareness involves proprioception and refers to the individual's awareness and control of their body in the environment relative to that environment (Ramstrand et al 2019).
The idea that emotions are reflected in unconscious or involuntary motor patters is not new (Shatan 1963). The more immersed in psychic pain, the less the mind responds to feedback information from the rest of the body. The mind can develop stunted or inadequate responses and it may feel like the body belongs to someone or something else.
Lifting is a safe and efficient way of providing the mind with simple and discreet proprioceptive information and generates kinesthetic awareness. Many other forms of physical activity or body practice can promote the same result, and maybe, for some people, they will be preferable to lifting. However, for an individual depleted of energy, mental organization, and executive functions, the task of skillfully moving a steel rod from point A to B and then back to A may be an optimal way to stimulate all aspects of conscious motor task execution.
Collective sports certainly promote higher levels of kinesthetic awareness since the player must integrate a great deal of information from the environment with proprioceptive information. If the suicidal individual is trained in collective sports and if they are willing to engage in it, it will promote “mind-body integration” too. However, for many individuals consumed by mental suffering to the point of having a shattered ego, simple tasks that can be pleasurably executed with more and more skill may be what does the job.
3. Excellent promotion of inter-organ cross-talk and recovery of physiological homeostasis and well-being
Until a few years back our understanding of the endocrine “organ cross-talk” was limited to three “axes:" The hypothalamic-pituitary-gonadal axis (HPG axis, involving the hypothalamus, the pituitary gland, and the gonadal glands), the hypothalamic-pituitary-adrenal axis (HPA axis or HTPA axis, involving the hypothalamus, the pituitary gland, and the adrenal) and the hypothalamic-pituitary-thyroid axis (HPT axis, involving the hypothalamus, the pituitary gland, and the thyroid). They are still important (Hoermann et al 2015, Duntas 2016, "Hypothalamic-Pituitary-Gonadal Axis" 2020, Klein 2003, Smith & Vale 2006, Plotsky et al 1998). However, our current understanding of endocrine, paracrine, and autocrine regulation is incredibly more complex.
Endocrine regulation involves hormones produced in endocrine glands that act at tissues remote from the glands; paracrine regulation involves many peptides released by nonendocrine cells that act on nearby cells, and autocrine regulation involves substances that act on the cells producing them (Welle 1999).
The new players in endocrine, paracrine, and autocrine regulation involve the exercising muscle, the adipose tissue, the gut, the gut microbiota, and other combinations. The resulting image is of a network of interconnected organs and functions involving the whole body.
Of all the new axes, the one that matters the most for us here is the skeletal muscle-brain axis (or skeletal muscle-brain-liver-adipose tissue axis) which provided a new understanding about exercise-induced adaptation. The first revolutionary idea was that not only the adipose tissue but also the muscle manifest endocrine activity. (Delezie & Handschin 2018).
The contracting muscle secretes myokines, protein hormones which can exert autocrine, paracrine, and long-distance endocrine effects (Severinsen et al 2020). The muscle tissue is an important node in the body network cross-talk. However, it must contract to play its beneficial moderating function. The inactive muscle behaves differently (Delezie & Handschin 2018, Pedersen 2019).
All these advances have brought us to a much more integrated understanding of organic functions. The several brain networks have shown to be all connected in what is known as connectome ("Human Connectome Project" 2020, Sporns et al 2005, Witvliet et al 2020). The set of secreted proteins and peptides into the extracellular space or retained intra-cellularly is now known as secretome and includes cytokines, myokines, growth factors, insulin and so many other signaling molecules (Uhlén 2019). Biological networks are networks of networks: Genetic, metabolic, signaling, and neural networks are interconnected.
It all starts by promoting regular contraction of the large muscles of the body in an integrated manner. Nothing accomplishes this role better than power and strength compound movements. Lifting is one of the activities that promote just that.
4. Simple, uncomplicated and problem-oriented social interaction
A vulnerable or at-risk individual's social interaction carries damaging patterns for years. They are either socially isolated and disconnected, exhausted and withdrawn from oppressive relations, or severely hurt and traumatized by social relations from their past. This individual tends to update the damage in any subsequent damaging social interaction to the point that they can't handle it anymore. The mental organization of social interaction is too draining and confusing. Although it is important for their safety that they maintain and increase the number of meaningful and more profound social interactions, it is also important to have an opportunity to explore them with the least pressure. The simple exchange they might engage at the beginning of their lifting journey, concerning what bars to use, who's the best person to give some input on their bench press or their clean, and an offer to spot them while squatting can be quite enough for the week. They can explore being appreciated and useful by helping someone with a hand-off or joining a group that needs loaders. The problems to be solved are simple, codified and so are the tools to participate. They don't involve all the things that got distorted during years of living under mental suffering.
This may be their first positive tour out of complete social isolation or perverse social interactions.
5. A concrete way to exercise regulatory behavior in an otherwise chaotic life, slowly recovering self-sufficiency and autonomy. Moreover, hope, the one factor most highly associated with suicide prevention, can only be cultivated in a goal-oriented life.
Humans can display different types of behaviors. Some behaviors are automatic, requiring little conscious control. Others are self-regulated by executive functions. Executive functions are a set of neurologically orchestrated cognitive processes through which the individual may exert control over their own behavior. Self-regulated behavior is critical to achieving a goal. It is also important in avoiding potentially harmful situations. Self-regulation includes selecting, monitoring, and facilitating some behaviors while inhibiting others. Repressing an impulse, for example, is an inhibitory control over behavior (Coolidge and Wynn 2001).
The automatic or prepotent response is pre-codified and is triggered by a stimulus (Diamond 2013, Hofmann et al 2009, Plutchik 2001). The executive system overrides the prepotent response. The prepotent response may be an impulse or a conditioned response.
Unsurprisingly, both integrated neural functioning and endocrine function are compromised in suicidal individuals. Impaired executive function is a characteristic of suicidal individuals and the suicidal act (Bredemeier & Miller 2015, McGirr et al 2010).
The suicidal individual–whether at risk and/or having survived an attempt–has either given up trying to set goals, an increasingly harder and meaningless task for them, or they are barely recovering this ability. Also, despite ambivalence, suicide happens and more often than not, it is the result of impulsive behavior.
All the tasks ahead of a suicidal individual are inter-related: They must recover hope and hope is intimately related to goals. Hope can be cultivated in goal-oriented lifestyles. Self-sufficiency and autonomy depend on goal-oriented behavior.
Even though the neurological propensity for several behaviors, including self-regulated ones, is genetically determined, it is also developed like a skill.
Lifting involves, at the same time, very simple and codified tasks with standardized objects, and extremely complex skill improvement. From a simple act of pressing a bar to the acquisition of skills and improvement of the snatch movement, lifting covers the whole spectrum of simplicity to complexity of goal-oriented, self-regulated behavior (Stone et al 2013).
Self-regulated behavior is present from the moment a novice touches the bar with the intention of learning or executing a simple barbell movement to the training program of an Olympic Weightlifting Olympian.
Being able to decide, plan, and execute a lift is a big step on a long road of autonomy construction or recovery.
All the five factors described here can make lifting an optimal strategy for preventing suicide or recovering suicidal people. The indirect evidence I used here suggests so. A few published studies suggest that strength training has positive emotional, cognitive, and behavioral benefits for both healthy subjects and those suffering from depression or another diagnosed disorder (O'Connor et al 2010, Gordon et al 2017). As much as my arguments concerning lifting here may sound compelling, they are hypothetical, based on by-proxy or anecdotal evidence. It is important to emphasize that they have not been tested with actual suicidal individuals in a lifting environment.
Conditions to make lifting a suicide prevention or recovery strategy:
1. A relaxed, tolerant, and unintimidating environment.
That is not as hard to achieve as it may seem and it doesn’t require “counter-intimidation." Even among adolescents, where counter-intimidation and repression measures are necessary, the greatest predictor of bullying behavior is the perception of approval by the most influential individuals (Steinfeldt et al 2012). Many of the most influential leaders in the strength sports are the right people to do that. Caring and mature gym owners can provide a safe environment for vulnerable people. They will probably be able to come up with their own strategies to help vulnerable people. How much the vulnerable person will be willing to share is unpredictable, not to mention hypothetical. However, a suicide-risk person or someone surviving a suicide attempt could be offered to share their “special needs." They probably don’t know what these needs are nor do they see themselves as deserving any care. The work at the gym begins by making it possible for the person to accept that they deserve care and respect. The rest is a long, often endless path towards self-integration.
2. A training environment that protects the personal and intimate space.
A person at risk of suicide or recovering from a suicidal period has shattered boundaries (Maltsberger 2008). Without boundaries, none of the nurturing items above can take place. Space is both tangible and intangible, both cultural and physical. Around the person, there are concentric spheres from the most internal (the intimate space) to the most external (the social space). The respective distances vary according to context, including culture. This is a representation based on Hall's (1966) model:
Figure 26. Diagram representation of personal space limits
Source: Diagram representation of personal space limits, according to Edward T. Hall's interpersonal distances of man, showing radius in feet and meters. Inspired by Reaction-bubble.png by Libb Thims (“File: Personal Space” 2020)
The vulnerable person has problems with one or more spheres of space. The multi-layered, non-verbal form of interaction that shapes relationships with spaces and people (Hall 1966, Holmes and Spence 2004) has been disruptive for the vulnerable person.
The chance that this person has experienced violent interactions resulting in an invasion of their intimate space is higher than that of the general population, or the other people at the gym. Trauma survivors frequently develop an alarm reaction to being too close to strangers (or even acquaintances) and a dislike of being touched.
There might be issues with the built environment which is the separation from a more protected to the least protected environment: The public space (Reynald & Elffers 2009).
The ideal situation is a somewhat protected area, like a rack, for example, that forms an imaginary and symbolic temporary home. Given the dynamic of most gyms, it is not difficult to accommodate a vulnerable person’s need for a protected intimate and personal space with the exception, possibly, of peak hours. Peak time at a gym is not the best time for the vulnerable person to be there. It can take a while to rebuild a system of possible interactions with others.
3. The protected personal and intimate space must allow the survivor to explore the deep focusing lifting motor/body practices that are conducive to the silent periods of relief and reorganization.
Experiencing flow states, as discussed above, is a highly desirable outcome of lifting for the vulnerable person. When or whether at all this person will be able to experience it doesn’t depend on the external conditions alone or even chiefly. However, external conditions can impair or promote the flow experience. The requirements for a flow-conducive environment are simple: A protected area, if possible the same one at every training session, the negotiated physical distance from others, and silence.
Whatever sound the survivor needs must be chosen by them and must not be disturbed by the outside environment. Providing this “sensory bubble” is not rocket science: A power cage and no loud ambient music provide just that. Suicide survivors are usually quiet people that don’t demand anything although they should be supervised.
The controversial training sounds that some gyms prohibit are not the problem here. The constant bang sound of someone deadlifting at the gym, the clanging noise of everything else can be an issue for someone not familiar with them. Experience shows that from toddlers to training-naive older people, once they are told what to expect, display no fear or annoyance. Someone talking loudly is much more of a stress trigger than a lifting grunt.
Silence refers to two things: The first is the absence of unwanted loud ambient music. Unwanted loud music is a physiological stressor. The second is that trauma victims may have a strong reaction to it. The third is that loud ambient music is a form of interpersonal violence, a non-declared intention to force others to submit by making them listen to the music chosen by whoever wants to exert power. That can have damaging effects on the vulnerable person. If it just dissuades them from ever coming back, it's one lost opportunity to help this person. If they lack even that much ability to react and reject what feels uncomfortable to them, it's worse: They may return to an environment where they are being violated and spiral down into their habitual self-destructive pattern that should be prevented.
5. A balance between self-organization freedom and a gradual and gentle coaxing back into discipline.
If the survivor achieves a few moments of peace by repeatedly doing sets of three drop snatches, it is best to leave them alone. A lifting-knowledgeable friend or coach should be aware of the possible detrimental effects of too much repetition of a single compound movement and carefully suggest introducing other items to their repertoire.
6. A balance between welcoming the survivor with a caring and attentive approach and overwhelming them with excessive worries. Over-anxious family members or friends may not be the best choice for lifting partner to a survivor.
The survivor or at-risk individual must perceive a caring attitude in others. Too much attention, especially anxious attention, however, may be counter-productive. It is impossible to know what each vulnerable individual needs in terms of attention and care. Showing that they are welcome and they belong in that environment is the first step to learning as they go.
7. A balance between letting the survivor choose their way at the gym and integrating them in social activities.
The at-risk individual arriving at a gym comes with baggage and the gym is not the place for a psychotherapeutic reconstruction of this past. They may be averse to socializing (at first or always) or they may crave interaction. Whatever it is, they are on a journey to recover (or build from scratch) their autonomy and self-sufficiency. Integrating them is something that must be considered according to this. The friendly social group is not there to substitute the vulnerable individual's decisions but rather to engage them in decision-making.
8. A positive perspective on strength, on the lifts, and on the competition. That means not pulling the survivor into a power hierarchy.
Examples are phrases that put abilities and anatomical features in perspective ("Bodybuilding Motivational Quotes For Weightlifting" 2019) such as:
"Biceps are like ornaments on a Christmas tree." - Ed Coan
It is a funny phrase and it also makes a point: for that athlete, biceps volume is not relevant. It is not a competitive advantage and the person doesn’t really care about biceps aesthetics.
"Just remember, somewhere, a little Chinese girl is warming up with your max." - Jim Conroy
This phrase is useful in many ways and not only to the vulnerable person. First, it expresses, in the form of a joke, a fact that most people who study sports talent screening know: Nothing beats China in terms of the volume of the talent pool. Therefore, there is a probability larger than zero that somewhere a little Chinese girl is warming up with your max. What does that mean? First, it means that no matter how good anybody is today, chances are that, in time, there will be someone better. It doesn’t make any accomplishment better or worse. It just puts “accomplishment” and “success” in perspective. That perspective is favorable to suicide-prevention because it gently opens the argument to the importance of intrinsic motivation. We want our vulnerable person to enjoy their lifting experience regardless of Jeff’s numbers or the qualifying total table. Why? First, because lifting should be fun by and for itself. Second, because somewhere, a little Chinese girl is warming up with your max.
"My old routine was McDonald's on the way to the gym, coffee during my workout, Burger King, and Copenhagen post-workout." - Dave Tate
We can probably agree that this is not the best nutrition advice. Some folks can strongly react to it and present a long list of nutritional capital sins such as trans fats, the percentage of high glycemic index carbohydrates and they may not be wrong. However, if the priority is to produce a positive, tolerant, and relaxed environment, there's nothing like showing that the leaders in this activity are human. They like junk food.
"Fortunately, there is a solution, and it’s not performing multiple sets of whatever cable Kegel exercise is being pushed as “The Answer.” Just a little hard, smart, basic work." - Jim Wendler
This is not only true but compassionate. There is a dialogical context in this phrase. Wendler is responding to something said, done, or a cultural habit in the training world. What he is saying without resorting to the authority argument is that there is no need for difficult and extremely strenuous work. Just a little hard, smart, basic work. Not a lot–a little. And a little is as much as our vulnerable person can do if they are engaged and enjoying their lifting.
The authors of these phrases are leaders in the strength sports. Whether the environment will be positive and protective to the vulnerable individual is highly dependent on the leaders’ attitudes. A study conducted at the Georgian Weightlifting Federation in Tbilisi, Georgia, showed that: “Although Olympic weightlifting remains stereotypically hypermasculine, coaches compliment female weightlifters’ technique as superior to men's and train their athletes to integrate masculine “nature” and feminine “culture” in the expression of physical strength. In doing so, coaches do not instill fully formed subjectivities but manage embodied forms, using exclamatory cues to disaggregate the athlete into action, affect, and anatomy” (Sherouse 2016).
Can lifting be harmful to the suicidal person or conducive to suicide?
1. Whereas participation in collegiate sports is associated with lower than average incidence of suicide, participation in strength sports is associated with a higher than average incidence. This is an associative evidence. We have no idea about the causation.
A Swedish study with a political/moral agenda and hypothesis concerning the causational relation between testosterone analog use as PED (performance-enhancing drug) and suicide produced an unsuspected result. Lindqvist and colleagues (2014) revealed a previously undetected association: among those active in wrestling, powerlifting, Olympic lifting, and the throwing events in track and field when the suspicion of AAS (androgenic anabolic steroids) use was high, between 1960-1979, in the cohorts between 20-50 years, there was an excess mortality of around 45 percent if compared with the general population. The overall mortality rate wasn't increased comparing these athletes and the general population. The data analysis suggested that a higher mortality in some cohorts and from some causes compensated for a lower mortality in others. Elite athletes live longer and this is not news (Lemez & Baker 2015, Garatachea et al 2014). These elite athletes had lower mortality rates for cardiovascular disease and cancer, as identified in other studies (Garatachea et al 2014, Lindqvist et al 2014). What the Swedish study revealed was that, among these athletes, the suicide rate was two to four times higher when comparing former athletes in the cohorts between ages 30-50 with the general population.
The authors' conclusion is fallacious: According to them, strength and power athletes between 1960-1979, when anti-doping testing was not enforced, would have died of suicide as a consequence of their AAS abuse, as opposed to athletes from other sports who, as a corollary to the authors' hypothesis, didn't abuse AAS. First, there is no evidence that strength and power sports have or had higher AAS use than any other sport (Baron et al 2007, Sullivan 2013). Informally, "it is known" that the power and strength sports are not the highest ranking when it comes to the use of testosterone analogs. It should be obvious that it is impossible to obtain a reliable estimate on AAS illegal use among any social group, whether Olympic athletes, non-Olympic athletes, or just random people. The more money and power are involved, the more sophisticated and widespread will be the means of obtaining a negative test result (Alquraini & Auchus 2018), including bribery (Maennig 2002, Dimant & Deutscher 2015). Second, despite an abundance of published peer-reviewed articles of varied methodological strictness (Thiblin et al 1999, Trenton & Currier 2005 as examples of very poor methodology), there is no evidence of an association between AAS use and suicide.
Despite no evidence in favor of the AAS-suicide link hypothesis, it seems to have been important enough to deserve other studies in Scandinavia, preceding Lindqvist groups. Pärssinen and colleagues investigated premature mortality among Finnish powerlifters suspected of having used AAS (2000). Finnish male powerlifters who competed at top levels during 1977–1982 were selected as the study group. The mortality during the 12-year follow-up was 12.9 percent among the powerlifter group versus a 3.1 percent mortality in the control group. Needless to say, quantitative analysis with these numbers and “samples” is not scientifically adequate. However, the fact that three out of the eight powerlifter deaths were of suicide while at the control group, four out of 34 deaths were suicides is a legitimate observation.
This is an example of interesting facts with a flawed hypothesis (good data and bad science): There is an increased suicide rate among power and strength athletes in Scandinavia according to these two controversial studies. The conclusion that “it is probably attributable to AAS abuse” is not only empirically flawed but also logically wrong. There are many more variables that could be associated with suicide and were not measured. Sports are tiny cultures and that’s where we have to look.
The suicide rate among "other sports" (those that are not power or strength sports) is significantly lower than the general population controlling by cohort and cultural environment. Sports participation appears to be a protective factor against suicide among collegiate athletes. Within this population, males have higher suicide rates than females and African-Americans have a higher suicide rate than Caucasians. The highest suicide rates were among male football players (Rao et al 2015). Sports participation seems to be protective against suicide in most contexts and social groups (Rao & Hong 2016, Colin 2012).
There are other exceptions to the protective role of sports besides strength and power sports. Minority high school females seem to be more at risk if they participate in sports than other groups, controlling for age and sex. There is no explanation but it is hypothesized that they are more frequently victims of bullying (Lester 2010, 2017).
Suicide rates among strength and power sports out of the collegiate environment were never studied again after the Scandinavian studies. We have no idea if the higher suicide rates observed in those countries' strength athletes is similar to other countries. What I know is that the suicides that I have encountered, like that of Egbert, which I described before, are not identified or entered in the public record as suicides. In his case, there was a careful agreement to call it an "accidental overdose" in public or in written communication. All the people who were close to him had witnessed the result of his previous suicide attempts including bleeding on a competitive platform from profound unhealed wrist cuts. There is no excuse for anybody to deny that suicide. Yet, that's what was done. His body was not autopsied and now he is another number in the statistics of "accidental drug overdoses."
Whether the Scandinavian studies represent a universal trend or not will probably never be tested. These data, anecdotal information, and my own observation suggest there is a chance of negative, suicide-conducive conditions manifesting in the strength sports. They can be identified at the "strength gyms," in social media communication and post-competition comments.
2. In a large number of strength gyms, intimidation, strictly hierarchical, aggressive inter-personal relations are tolerated. Bullying is not only tolerated but frequently stimulated. Bullying is strongly associated with a higher incidence of suicide among vulnerable populations.
Bullying and intimidation are forms of inter-personal violence (Coutinho 2018).
Bullying includes all forms of non-lethal violence perpetrated over victims to establish and maintain a power structure (hierarchy). In our complex society, there are several small sub-cultures where behavior is uncodified, unruled, and where bullying is practiced.
Legally, equal members are “peers." High school classmates, gym members, or same rank co-workers, for example. Bullying is therefore also referred to as “peer abuse” (Bennet 2006).
Intimidation is any behavior that conveys to the intimidated party that they must comply. In the gym context, it means that there is an unspoken and unwritten code that establishes a hierarchy, a set of values, and accepted behaviors. This unspoken code is enforced through intimidation.
The association between bullying and suicide has been documented (Kim & Leventhal 2008, Hertz et al 2013). Most studies are concerned with the suicide risk associated with childhood and adolescent school bullying, whether immediate death risk or long-term deteriorating mental health ending in suicide. Bullying among adults is harder to study but workplace bullying is a reason for concern and a demand for more research (Lutgen 2018, Conway et al 2017).
One never knows how vulnerable to suicide a person is because vulnerability is a result of their life history, always opaque to strangers. Bullying is, then, stochastic suicide inducement: The bully doesn’t know when, where or who will commit suicide as a causal result of their actions but there is a certain probability that it will happen.
Bullying at gyms is part of what is known as the "gym culture." A closer look shows that there isn't "a" gym culture but rather several such cultures. The gym culture of a fitness/bodybuilding-oriented gym is different from that of some CrossFit boxes, which are different from our "strength gyms" (the "underground," "old school" strength training gym). Commercial gyms take measures to avoid bullying and the formation of actively dominant clicks by establishing contractual clauses against aggressive and intimidatory behavior. These rules also can make competitive strength training harder since competitive preparation requires a long time using a single rack or bench. Lifters training at commercial gyms cannot force their way to a rack or to their favorite barbell. In some commercial gyms, lifters manage to beat the rules (or settle an agreement with the owner) by training together and monopolizing equipment for longer than it would be acceptable. Sometimes there is no agreement. Tension builds up and eventually either the lifting crowd dominates, bullying other members out of the equipment they want (or just bullying them to enforce compliance) or they get kicked out of that gym.
Subtle acts of bullying may not be verbal but not less eloquent for that reason: Eye-rolling, shaking one's head with a smirk after a contemptuous stare at the victim, strategically making the victim's way through the gym hard or physically blocking their access to some equipment. In actual strength gyms, there can be a hierarchy in the access to equipment. A low ranking or unwanted gym member may have difficult access to some of the racks or some of the bars. If they are not soon adopted by a higher-ranking member or behave subserviently for some time, they might never get accepted, their time at the weight room will be marked by anxiety, hyper-vigilance, and finally disgust. That's how intimidation serves two purposes: Getting rid of those who won't abide by the non-written rules and clearly signaling to those who want to be accepted that it is a hierarchical structure and they are expected to behave accordingly.
At this point, we have no way of conducting a study about intimidation at strength gyms. Unlike commercial gyms, where we can always find disgruntled customers willing to speak, especially if given the benefit of anonymity, this does not happen at strength gyms. Individuals who left strength gyms in an atmosphere of either animosity or disaster will not speak out.
Whether or not a negative atmosphere will emerge and dominate a strength gym is hard to predict since it depends less on the strength athletes present than on leaders and followers that constitute the community. Studies conducted about the athletes show that negative personality traits may be prevalent, such as intolerance, authoritarianism, narcissism, bigotry, and homophobia (Darden 1972, Rubinstein 2003). That doesn’t mean that they set the unspoken code of conduct or value system. They are a part of it.
We have a few by-proxy sources of evidence: Two documentaries, intimidatory expressions extracted from forums or reported by readers, resentful expressions about situations where the strength gym culture doesn't prevail, and "motivational quotes" taken from the internet.
There were few documentary movies about the strength training or strength gym environment ("Power Unlimited" (2007) and "Westside vs. the World" (2019) being the most realistic). Most of the content is highly positive, supporting a nostalgic narrative about the "good old days," true for most interviewed people. Both documentaries provide a glimpse or some indirect evidence about a darker side of the strength culture. In the movie "Westside vs. the World," one of the first members of the gym, who is portrayed as a social outcast, enjoys a period of belonging and acceptance in that tiny lifting universe. However, he can keep up neither his performance nor his dominance and dies of an overdose. The spectator is left with the suspicion that it may have been a suicide and with no doubt about the victim's self-destructive behavior. Some beatings described in interviews sound like hazing. There are stories about people making huge sacrifices to be accepted by the "inner sanctum." Some claim, decades later, that it was all worth it. Others don't share this view. Intolerant behavior coming from beloved members of a community can sound perfectly innocent and even entertaining.
The movies help us understand how bullying acts in the strength gym culture could be harmless, including for those who were bullied. Unlike a high school, where the victims cannot run away from their tormentors, a gym member can just leave. In these high-performance strength training gyms, most of those who did not agree with the unwritten and unspoken rules and hierarchy did not stay, which explains why the ones interviewed decades later remember those days as the best of their lives.
We have no idea how many people trained in less positive environments ended up with the deadly end of the intimidation rope. As I have discussed above, we will never know. We are left with the disturbing Scandinavian numbers and anecdotal accounts about negative bullying experiences.
Table 8. Intimidatory phrases taken from forums or contributions from people who will remain anonymous
The bold and italic marked words and expressions from the extracted messages above show that the “gym culture” and the “strength gym culture” specifically may be potentially dangerous for vulnerable individuals. These phrases were taken mostly from American gyms but also from other countries, which shows a certain universality about the “strength gym culture." Some were witnessed interactions sent to me in an anonymity agreement. The target of the verbal abuse felt intimidated and complied at that moment. I don’t know if they remained at the gym or left but I have no reason to think these interactions did not happen.
We could summarize all the messages in one statement: There are “us” and there are the worthless “others." If you are worthless you will take abuse. You will comply with our rules and change yourself to conform to our standards if you want to stay and be accepted.
Table 9. Examples of strength gym culture members complaining about how they are treated outside strength environments (expressions taken from internet strength forums)
Some famous motivational phrases (either attributed to celebrities or anonymous) express the same values. They are all factually (and sometimes logically) false.
Table 10. Motivational phrases from the internet
Source: "20 Fitness Motivation Quotes" 2017, "Bodybuilding Motivational Quotes For Weightlifting” 2019
The final consequence of a hierarchical and bullying environment is segregation and cult mentality. For our vulnerable individual, segregation, and, ultimately, exclusion, if taking place at the beginning of the gym experience, is still the safest option. Remaining in the group, playing the "carrot and the stick" game for acceptance in a cult-like social structure is by far the worst outcome in the interaction with the "strength gym."
3. The cult environment: whereas in the beginning, the survivor with a shattered self may feel that the "us against the world" mentality, the entitlement, the inflated collective positive self-representation and the collectivism of a cult environment are comforting, on the long run they will deepen internal fractures, social difficulties, and in the end, hopelessness.
This item is about the damaging effect of a cult environment. While the cult-like strength gyms exist, there is an increasing number of strength gyms founded on opposite assumptions, embracing tolerance and a role in the major society.
Cult is one term used for "sect." Sects or cults are self-segregated social groups within the major society. They are usually the result of frustration concerning the difficult access to power in the major society. Religious, political, ideological, or philosophical cults/sects are defined by their perception of complete separation from the major society. How this perception is achieved among a large number of people is an object of controversy. Mind control, brainwashing, coercive persuasion are concepts that refer to an observed phenomenon: Cult members who still have family and other relationships become withdrawn and unwilling to interact with them; their worldviews are tautological and increasingly discrepant with reality; if confronted, the confrontation is seen as proof of the cult's conspiration theories. There are several theories about how such profound transformations in a subject's belief system and behavior can be produced. They all involve extreme forms of manipulation. There is no doubt that they are negative for the subject but they do not necessarily involve overt violence. Well known writings about them include "Captive minds, captive hearts," by Tobias and Lalich (1994), and Hassan's "Freedom of Mind" (2018).
Some examples of leaders and their cults are Jim Jones (Jonestown Guyana), David Koresh (Branch Davidians), Stewart Traill (The Church of Bible Understanding), Charles Manson, Shoko Asahara (Aum Shinrikyo), Joseph Di Mambro (The Order of the Solar Temple a.k.a. Ordre du Temple Solaire), Marshall Heff Applewhit (Heaven’s Gate) and Bhagwan Rajneesh (Rajneesh Movement).
According to Navarro (2012), who studied psychopathic cult leaders with the FBI, their beliefs are not different from any other sect, expressed as the leader’s “ideas”: Everyone else outside the cult is “the enemy," “wrong” or “lost” and the cult worldview is illuminating. There is an irresistible allure to the cult, gang, or sect. Usually, it is the promise of an identity and a purposeful life. In the strength gym environment, the identity part is not hard. There are two problems: First, the allure of embracing a purposeful life is an illusion. There is no visible purpose outside the group's immediate existence. There is no grand, top-level goal located in the future. Second, the new identity is strongly shifted towards collective approval and goals and leaves no space for inter-individual diversity. The vulnerable person is frequently "different."
Susceptibility to being recruited by a cult or gang has a high overlap with those of the suicidal state: A history of abuse, a shattered self, intolerable mental suffering, social isolation, lack of belongingness, and socioeconomic hardship (Curtis & Curtis 1993). This person is easily vulnerable to accepting a new culture and playing a submissive role in it.
The cult provides this new identity, this new way of thinking about themselves and others, including in-group identification and out-group rejection (Ward et al 2001). Demeaning others increases the group’s self-esteem (Branscombe & Wann 1994). Inter-group threats and the correspondent out-group responses increase group cohesion and conflict (Riek et al 2006). In the case of strength gyms, the threats are usually amplified. The types of inter-group threats identified in the literature include: Realistic threat, symbolic threat, intergroup anxiety, negative stereotypes, group esteem threat, and distinctiveness threat.
The two important aspects of the strength gym culture are reacting to negative stereotypes, and to group esteem threats, and defending their distinctiveness marks. Strength gym culture members' video-taped and broadly divulged attempts at getting kicked out of commercial gyms are a clear manifestation of the group's need to reinforce their self-esteem while acknowledging (and mocking) their negative stereotype ("Powerlifting Motivation" 2016, Bonvechio 2013).
Certain strength gyms, which can also self-identify as underground gyms, dungeon gyms, warehouse gyms, or old school gyms may constitute actual cult headquarters. Members are usually proud that their gym has no non-cultists ("pussies", "the mediocre", "normal people", "weak", "soft") and they may be proud of the intimidation tactics used to make outsiders feel unwelcome and leave.
Very few of them are strength/lifting clubs, a place where a couple of friends get together to lift with the equipment they crowdfunded to purchase and legally closed to non-members. Most strength gyms are small business opened to the public (but not really). They are not "strength sports training centers:" They are a gym or health club in the fitness industry.
It's a tense relationship. Strength gym talk (including the omnipresence of "motivational" memes, phrases and even people) is a permanent attempt to reinforce the belief that they are not an "ordinary gym," that they have nothing to do with the fitness industry, that they don't share the same values, aesthetics, equipment or environment maintenance. Several such gyms used to take pride in being unclean, in not having heating and air conditioning, and ignoring any regulation concerning indoor sound loudness.
Their message is that they may look like a gym but they are far from what an outsider to the “world of strength” would expect from a gym.
Group cohesion is based on certain core beliefs:
- We are qualitatively different than “other people," we are physically and overall stronger than they are, we are mentally tougher, grittier, and more resilient.
- Unlike “the others," we are capable of completing a routine regardless of how we feel.
- Others can’t understand our values. Our values are morally superior to the “others”’ values.
- Others can’t understand us and all communication attempts are futile.
- We are brave while the “others” are cowards.
- We don’t think others look good and they don’t think we look good: We can only appreciate each other.
Below is a list of phrases collected from five different newsletters subject lines along the past five months. They were shuffled and classified according to six content items.
Table 11. Verbatim sentences obtained from strength sports newsletters and social media
Table 12. Social Media statements from some strength training leaders
More than intimidation and bullying, which, depending on the survivor’s recovery stage, may just drive them away, the cultist atmosphere is conducive to suicide. Cults are the opposite of social integration.
4. The distortion of identity construction and the dangerous pursuit of a purposeful life.
Why would an individual end up in such an environment? Some can end up innocently there: A friend invited, there were beer and girls and they kept coming. That's not unlike the way religious or ideological cults grow. A friend invites someone to play basketball. Once there, the kid realizes that it's a community center and there is a powerful adult who is emulated by all youngsters. He has some funny ideas. If the kid has a healthy family environment, is engaged and committed in their academic life, and has a functional social network, he probably won't return. The kids that keep going back are the ones that don't have a protective social environment and may be deep into social isolation and meaninglessness.
How far down the rabbit hole do you want to go?
Whether you are a scholar, a community reference, a social movement leader, or a family member, there is a lot at stake concerning how far down the rabbit hole of suicide understanding and prevention you are willing to go. There is no easy choice. There is a reason why major players in our societies invested so much in silencing the "mad." Siding with them and confronting everything else is a tough choice.
If I achieved any goal with this book you are probably feeling frustrated with the extent of our ignorance about suicide and our impotence in relieving mental suffering, demonstrated again and again by the prevalence of suicide. That’s part of my goal: To advance in the understanding of a problem and advance solutions to it, it is necessary to confront ignorance and ineffectiveness. You may also feel uncomfortable about the uncertainties involving suicide prevention and management of at-risk situations. Not only uncertainties but complex ethical questions.
The deeper we go into this rabbit hole, the more uncomfortable it gets. Discomfort comes from the nature of the subject itself, from impotence but also because most of the time we reach uncertainty or controversy, and from there, multifurcations. Which path is the most productive one? Decision quality depends on many factors in a fine balance. Having several options or alternative approaches can be a positive factor in decision-making. However, there is an optimal number of alternatives after which decision-quality decreases because processing power is insufficient. Unfortunately, suicide studies and practice usually present us with a higher-than-optimal number of alternatives. That requires more tools to evaluate the alternatives from the decision-maker standpoint. Some alternatives are easy to dismiss but most of them are not: No matter how inadequate they are, they may offer relevant contributions. Optimal decision-making is also associated with optimal information quantity and quality. That's where the concept and agenda of evidence-based practice (medicine, nutrition, social work, among many others) come from. Too little information is a bad scenario that requires the decision-maker to resort to by-proxy data. The smaller the quantity and the lesser the quality of the information, the harder it is to find adequate by-proxy data. This whole book involved an effort to find as much by-proxy data as possible and throw the widest-reaching net to collect different and complementary conceptual approaches because the core data about suicide rates in the strength sports and gyms is frustratingly limited. To make it worse, there is no hope for more data in the foreseeable future.
Insular disciplinary cultures in a time and context when interdisciplinarity has hardly been so critical to make any progress in the understanding and prevention of suicide is unnerving. Integrating social sciences, psychology, psychiatry, neurology, epidemiology, public health, public policy, and other disciplines is no longer an option: It is an obligation since there is no progress on the matter without it. Yet, there are still fields, mainstream psychiatry being the paradigmatic example, that are almost impermeable to negotiate interdisciplinary work and knowledge production.
If the cross-talk between scientific disciplines is full of obstacles, the cross-talk with consumers/users/survivors, the only groups that can provide the essential lived experience knowledge, is practically non-existent. It doesn't help that this is the one road for co-production of knowledge that remains disqualified by the sciences, involved institutions, other stakeholders, and society at large. In short, nobody wants mad people participating in this discussion with any decision power.
This is one of the most uncomfortable academic rabbit-holes I have crawled into.
Once into this rabbit hole, one cannot avoid political decisions. Can we agree about the rights of the deviant and atypical populations as well as the rights of those in extreme mental suffering? Some rights, such as proper care for self-harm patients, so that they feel comfortable enough to share what is happening with no fear of punishment, are hardly controversial in intellectual terms. However, secularism and theocracy are not mutually exclusive in practice: Several legal restrictions on health care coverage to self-inflicted injury victims are originally religious. There is some gaslighting with the pre-condition issue (the insurance company won't cover self-inflicted injuries because they are a psychiatric pre-condition). That is also fallacious: It's an injury, whether it's caused by a vertigo-caused domestic accident, incompetent use of a knife, or slashing one's wrists. The problem with slashing one's wrists it that there's an unspoken and unwritten agreement that it's immoral and "wrong."
But how do we deal with other demanded rights, such as euthanasia? After years of activism, some countries and some states in the US approved euthanasia with hard requirements for application. Still, perfectly rational individuals with no hope concerning their psychic and physical pain will be institutionalized if caught in the act of attempting suicide.
We have no answer to that. No matter how deep we dig into the literature, it will come down to an ethical decision that each one of us needs to make as a professional.
Suicides are rational decisions more frequently than they are officially registered as. It is also true that no matter how rational the person is, they will be in an altered neurological state during the suicidal process. I defend the legalization of euthanasia and simplification of procedures so that anyone who needs assistance to die can obtain it. But who is “anyone?"
In epistemology, after rejecting an approach through systematic critique, it is always wise to check where the paths that leave that crossroad lead us. Epistemological recklessness is destructive because the problem is not to go deep but to go deep in the wrong hole and not find your way back (Collins 1992, Dascal 1991).
Consistent scholars will usually adopt positions that are throughout coherent. The defense of autonomy and self-determination is a principle to several movements and schools of thought. I don’t recommend a blanket application of this principle, however, because I am not confident about how much of an individual’s decision was made by them or for them. An individual trapped in an oppressive situation in your society (whoever you are), within anybody’s reach and ability to confront the oppressors, deserves suicide prevention. When suicide prevention is a signal to the hopeless and helpless individual that there is proactive willingness to interfere with the external cause of their mental suffering, I believe it is legitimate and it should be done. It is showing hope to the hopeless and offering help to the helpless.
Training people in communities to be gatekeepers, people who will watch for signs of distress, hopelessness, and helplessness, is important. A significant part of egotistical suicides happens because the victim has become disconnected. They become part of the invisible crowd and their death will be just another entry on public health data. Maybe not even as suicide. This is a fact. Our reaction is our choice: These suicides are happening to people who became invisible. Nobody talks to them and nobody pays attention to them. The gatekeeper can pay attention to those that are becoming invisible. Adopting a systematic program to reach out to the invisible people is a political decision and we are all part of it.
In the list of people whose suicides I described in chapter 2, I would volunteer to babysit the Chemistry graduate student during the Christmas Holiday until we could set therapy for him, for example. The department could have been mobilized and a cascade of resources made available. Who knows? We could have been looking at a future Nobel Laureate or the father of three little kids sailing their life over the Ocean. Nobody had the babysitting choice because there was no surveillance in place. The faculty member who lost her faith could have been helped. Arriving in Latin America at that time, in Academia, was tough. There were all sorts of obstacles to productive research and teaching–from laboratory supply import to library quality. Landing in a mediocre department that selected the pettiest and most frustrated scholars during decades of complicity is a disaster waiting to happen. These colleagues were passive-aggressive bullies. Someone could have seen that. I could. A gatekeeper could. She just needed to be geared back to the path of hope, a hope she had already elaborated and committed to.
Would my cousin have found a way to live with the “psychache” caused by his severe form of what seems to have been bipolar disorder? Would the intervention of secular gatekeepers have helped then, when there was nothing except lithium to offer to these patients? I don’t know. Could my classmate have used a little more empathy from us and a proactive intervention from a university gatekeeper? I don’t know that either but it would have given him a chance of a better choice. And what is a better choice? Given my principles, it is a more autonomous and conscious choice. Several schizophrenic patients lead reasonably happy lives with supportive families and communities.
There is no prevention to those people living with extreme pain or disability who needed some assistance to leave life with dignity. The other side of suicide prevention is legalized and quality euthanasia.
My greatest pains on that list are Aaron Swartz and Egbert. The first one is Aaron. Aaron had to be a martyr to turn an important wheel of the civil rights movement. I don't see any way in which anyone could have fought the forces that drove him to that decision. The federal government, acting on behalf of corporate publishers, had not only destroyed Aaron's life but was moving forward to destroy his mission and his family. It is painful to realize how pathetically small we are in the face of the destructive social forces capable of creating a suicidal trap.
The second pain is Egbert. If I was the gatekeeper, when and where would I intervene? I don't know. I had direct contact with that boy and had no idea of what kind of mental suffering he was going through. When I still coached him, I showed him how to improve his lifts. That was easy because he was a natural talent. After I left the gym and he opened up to me about medication issues, an obvious sign that things were beyond bad, I didn't know what he needed to hear. A gatekeeper needs to have a specific type of contact with the victim. While avoiding pressure and judgment, the gatekeeper must have synchronous interaction (on ground or video-conferencing) to detect the level of urgency or the nature of the issue.
There certainly was something there that I missed and that’s when we crawl into the “what if” rabbit hole. Egbert is a case in which I can see many opportunities for prevention. A local gatekeeper could have figured how to help young Egbert out of his early life traumas; a school gatekeeper could interpret his negative social interactions and helped him out of them; a community worker could work with that boy to build a hopeful mindset and accept help where he needed.
We failed Egbert as a society by not identifying red flags way back into his childhood.
The questions we all eventually ask ourselves, whether we are scholars, teachers, family members, or coaches are: how deep am I willing to go? Into which holes? What position should I take concerning extreme forms of mental suffering where no treatment seems to help? Should I refrain from interfering in the decision to die made by a friend who genuinely tried all possible approaches to their "psychache" with no success? There are only bad alternatives: lifelong mental hospital confinement or more aggressive therapeutic approaches. Our ethics can tell us not to interfere. Our emotions may try to take over. What about emotionally close people? An elderly parent dealing with excruciating chronic pain? What if they ask for our help to die with dignity? Suppose their arthritic hands can’t do it. Do we understand death enough to know what to do?
These are exercises that each professional involved in suicide (prevention or research) or person willing to be a gatekeeper has to engage with more than once.
Are we, as scholars, willing to point out the epistemological flaws in mainstream psychiatry that led to tautological clinical statements and unsupported policies? Are we willing to confront medicine, force them into interdisciplinarity and, even harder, to force them into accepting to produce knowledge as equals with their patients? The skeptical question being: Can we or will we ever be able to do it, considering their century-old carved space in society as a medical specialty and, most of all, the enormous multinational pharmacological investment on "treating the mad?"
Are we, as citizens of a Civilized world, willing to name and demand change at each oppressive or abandonment situation we see as “suicides in the making?" Because that is what they are, that is why suicide is one of the major causes of death but is hardly handled as something important. Suicidal people are seen as people who don’t matter so much.
How much are we willing to invest to provide visibility and humanity to the invisible people who slip through the cracks of our networks? How much are we willing to provide help to the helpless and hope to the hopeless? How much are we willing to be defeated more than to be successful?
There is a lot of soul searching to do as we stare into the rabbit hole or the abyss.
False beliefs (lay theories) about suicide and the right answer
Shneidman’s fables and facts (Leenaars & Shneidman 2010):
FABLE: People who talk about suicide don’t commit suicide.
FACT: Of any ten persons who kill themselves, eight have given definite warnings of their suicidal intentions.
FABLE: Suicide happens without warning.
FACT: Studies reveal that the suicidal person gives many clues and warning regarding his suicidal intentions.
FABLE: Suicidal people are fully intent on dying.
FACT: Most suicidal people are undecided about living or dying, and they “gamble with death,” leaving it to others to save them. Almost no one commits suicide without letting others know how he is feeling.
FABLE: Once a person is suicidal, he is suicidal forever.
FACT: Individuals who wish to kill themselves are “suicidal” only for a limited period of time.
FABLE: Improvement following a suicidal crisis means that the suicidal risk is over.
FACT: Most suicides occur within about three months following the beginning of “improvement,” when the individual has the energy to put his morbid thoughts and feelings into effect.
FABLE: Suicide strikes much more often among the rich–or, conversely, it occurs almost exclusively among the poor.
FACT: Suicide is neither the rich man’s disease nor the poor man’s curse. Suicide is very “democratic” and is represented proportionately among all levels of society.
FABLE: Suicide is inherited or “runs in the family.”
FACT: Suicide does not run in families. It is an individual pattern.
FABLE: All suicidal individuals are mentally ill, and suicide always is the act of a psychotic person.
FACT: Studies of hundreds of genuine suicide notes indicate that although the suicidal person is extremely unhappy, he is not necessarily mentally ill.
I hope the main takeaway you get from this journey across different scientific disciplines and traditions is that if we strip ourselves from the thousands of years of fear, turned hatred, turned intolerance against those who hurt themselves, we may get closer to empathizing with them. And if we go a little deeper and appreciate the weight of the social environment on that person’s suffering, on the role of social pathology–a disease of society–on suicide, we may understand that it could happen to any of us. Given the right circumstances and the right push, anyone can die of suicide. That’s a terrifying thought but it is required to make us take action. Suicide is preventable but can only be prevented if we understand that we are part of the equation. Ignoring the problem is action. Bullying or condoning bullying is a huge action. Standing up against bullying and against intolerance is also action. We can choose to go on being part of the problem or to be part of the solution.
- Suicide is a consequence of many possible things and mental illness is just one of them. All of them can be minimized.
- Strength training is conducive to mental well-being.
- Cultist environments and bullying are highly associated with suicide and mental suffering in general.
- Environments that accept and encourage bullying are actively promoting mental suffering and perhaps suicide.
- Be responsible, whether you are a gym owner, a coach, an athlete, a gym member, or the elusive "influencer:"You can either be the problem or the solution. There is nothing in between.
- Above all, educate yourself about the nature of suicide. If you recognize individual or social red flags, act: Either contact someone or, if you are prepared, intervene.
- "20 Fitness Motivation Quotes." Life Fitness. Last modified December 18, 2017. https://www.lifefitness.com.au/20-fitness-motivation-quotes/. Accessed on 7/25/2020.
- "A Social Networking Site is Not an Open Access Repository." Office of Scholarly Communication. Last modified September 28, 2018. https://osc.universityofcalifornia.edu/2015/12/a-social-networking-site-is-not-an-open-access-repository/. Accessed 8/11/2020.
- "Attempt Survivors." Attempt Survivors. https://attemptsurvivors.com/legacy/. Accessed 7/30/2020.
- "Bill Gates, Benchmark And More Pour $35M Into ResearchGate, The Social Network For Scientists – TechCrunch." TechCrunch. Last modified June 4, 2013. https://techcrunch.com/2013/06/04/bill-gates-benchmark-and-more-pour-35m-into-researchgate-the-professional-network-for-scientists/ . Accessed 8/11/2020.
- "Bodybuilding Motivational Quotes For Weightlifting." Motivation Ping. Last modified June 10, 2019. https://motivationping.com/quotes-weightlifting-bodybuilding/. Accessed on 7/25/2020.
- "Bodybuilding Motivational Quotes For Weightlifting." Motivation Ping. Last modified June 10, 2019. https://motivationping.com/quotes-weightlifting-bodybuilding/ .Accessed in 7/25/2020.
- "Conscience Protections for Health Care Providers." HHS.gov. Last modified March 22, 2018. https://www.hhs.gov/conscience/conscience-protections/index.html. Accessed in 7/29/2020.
- "Cynthia Miller Papers, 1973-1995" University of Massachusetts Amherst Libraries Special Collections and University Archives. Digital Commonwealth. Accessed July 20, 2020. https://www.digitalcommonwealth.org/collections/commonwealth-oai:np197v43j.
- "Despite Law, Health Plans Refuse Medical Claims Related To Suicide." NPR.org. Last modified February 18, 2014. https://www.npr.org/sections/health-shots/2014/02/18/279014945/despite-law-health-plans-refuse-medical-claims-related-to-suicide . Accessed 8/11/2020.
- "Fentanyl Has Taken over America's Drug Market. Where is It Coming From?" San Diego Union-Tribune. Last modified June 17, 2018. https://www.sandiegouniontribune.com/news/public-safety/sd-me-fentanyl-pipeline-20180617-story.html .
- "File: Personal Space.svg." Wikimedia Commons. Accessed July 26, 2020. https://commons.wikimedia.org/wiki/File:Personal_Space.svg.
- "Hypothalamic-Pituitary-Gonadal Axis." ScienceDirect.com | Science, Health and Medical Journals, Full Text Articles and Books. Accessed July 22, 2020. https://www.sciencedirect.com/topics/neuroscience/hypothalamic-pituitary-gonadal-axis.
- "JSTOR Swartz Evidence All Docs." Internet Archive: Digital Library of Free & Borrowable Books, Movies, Music & Wayback Machine. 2010. https://archive.org/stream/JSTORSwartzEvidenceAllDocs/JSTOR-Swartz-Evidence-All-Docs#page/n3/mode/2up . Accessed 8/11/2020.
- "Madness network news" Google Books. Accessed July 20, 2020. https://books.google.com/books/about/Madness_Network_News_Volume_1.html.
- "Medicaid." Medicaid.gov: the Official U.S. Government Site for Medicare | Medicaid. Accessed July 29, 2020. https://www.medicaid.gov/medicaid/index.html.
- "Mental Health and Survivors Movements." Andrew Roberts' Web Site. Accessed July 18, 2020. https://studymore.org.uk/MPU.HTM#1973 .
- "Mental Patients Liberation Front Inc - GuideStar Profile." GuideStar Nonprofit Reports and Forms 990 for Donors, Grantmakers, and Businesses. Accessed July 19, 2020. https://www.guidestar.org/profile/51-0187483 .
- "Mental Patients Liberation Front." Homepage. Last modified November 23, 2011. https://pbha.org/stories/mental-patients-liberation-front/ . Accessed in 7/19/2020 .
- "Movement History of the Consumer/Client/Survivor/Ex-patient/Ex-Inmate/User Community (Timeline)" Waiting for the Redirectiron... Consumer Family Network of North Dakota. Accessed July 19, 2020. https://www.ndcfn.org/movement-history-of-the-consumer-client-survivor-ex-patient-ex-inmate-user-community-timeline.html .
- "NIMH » Suicide." NIMH » Home. https://www.nimh.nih.gov/health/statistics/suicide.shtml . Accessed 8/11/2020.
- "OASSIS." Suicide Prevention. https://www.ktullis.com/OASSIS/OASSIS.htm . Accessed 7/30/2020.
- "Scientific Reports Overtakes PLOS ONE As Largest Megajournal." The Scholarly Kitchen. Last modified April 7, 2017. https://scholarlykitchen.sspnet.org/2017/04/06/scientific-reports-overtakes-plos-one-as-largest-megajournal/ . Accessed 8/11/2020
- "Scotland the Brave - User Movement Roots - by Andrew Roberts." Andrew Roberts' Web Site. Accessed July 18, 2020. https://studymore.org.uk/mhtscot.htm.
- "See How Thorazine, One of the First Antipsychotics, Was a Hot New Drug in the '50s." Click Americana. By Albert W Bloom, Text from the Pittsburgh Post Gazette (Pennsylvania) April 22, 1955. Accessed July 19, 2020. https://clickamericana.com/topics/health-medicine/doctors-warn-false-hopes-pills-mental-ills-1955 .
- "Suicide Rate in 1990 Vs. 2017." Our World in Data. Accessed August 11, 2020. https://ourworldindata.org/grapher/suicide-rate-1990-2017 . Accessed 8/11/2020
- "Suicide" Our World in Data. https://ourworldindata.org/suicide . Accessed 8/11/2020.
- "The Need for a Mental Patients Union." Wayback Machine. Accessed July 18, 2020. https://web.archive.org/web/20160315043243/www.ctono.freeserve.co.uk/id90.htm.
- "The Opioid Crisis: The United States and Canada’s Fentanyl Epidemic." Wilson Center. Accessed July 15, 2020. https://www.wilsoncenter.org/article/the-opioid-crisis-the-united-states-and-canadas-fentanyl-epidemic .
- "Today in London’s Radical History: Mental Patients Union Founded to Oppose Psychiatric Oppression, 1973." Past Tense. Last modified October 1, 2018. https://pasttenseblog.wordpress.com/2016/03/21/today-in-londons-radical-history-mental-patients-union-founded-to-oppose-psychiatric-oppression-1973/.
- "What's Medicare?" Medicare.gov: the Official U.S. Government Site for Medicare | Medicare. Accessed July 29, 2020. https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare.
- "Where Does Fentanyl Come From?" The Recovery Village. Last modified January 20, 2020. https://www.therecoveryvillage.com/fentanyl-addiction/where-does-fentanyl-come-from/ .
- "Why I Am Closing My Pain Practice — Pain News Network." Pain News Network. Last modified January 17, 2018. https://www.painnewsnetwork.org/stories/2018/1/17/why-i-am-closing-my-pain-practice. Accessed 8/11/2020
- Aaron Swartz. https://www.aaronsw.com . Accessed 8/11/2020.
- ABC News. "Aaron Swartz' Death Fuels MIT Probe, White House Petition to Oust Prosecutor." ABC News. Last modified January 14, 2013. https://abcnews.go.com/Technology/aaron-swartz-death-fuels-mit-probe-white-house/story?id=18210596 . Accessed 8/11/2020.
- Abraham, A. "Remembering Mad Pride, The Movement That Celebrated Mental Illness." VICE 18 November 2016. https://www.vice.com/en_uk/article/7bxqxa/mad-pride-remembering-the-uks-mental-health-pride-movement. Accessed 8/4/2020.
- Abrams, K. & Kong, F. "The Variables Most Closely Associated With Academic Achievement: A Review of the Research Literature." Progressive Research Institute of Nebraska. September 2012. http://prineb.org/wp-content/uploads/2017/05/lit_rev_for_lc_10-18-12.pdf
- Abrutyn, Seth, and Anna S. Mueller. "Toward a cultural-structural theory of suicide: Examining excessive regulation and its discontents." Sociological theory 36, no. 1 (2018): 48-66. https://journals.sagepub.com/doi/full/10.1177/0735275118759150
- Adinkrah, Mensah. "Anti-Suicide Laws in Nine African Countries: Criminalization, Prosecution and Penalization." African Journal of Criminology & Justice Studies 9, no. 1 (2016). https://www.umes.edu/uploadedFiles/_WEBSITES/AJCJS/Content/VOL9.%20ADINKRAH%20FINAL.pdf
- Ahern, Jennifer. "Minimum wage policy protects against suicide in the USA." J Epidemiol Community Health (2020). https://jech.bmj.com/content/early/2020/01/26/jech-2019-213647.full
- Ajdacic–Gross, Vladeta, Matthias Bopp, Michael Gostynski, Christoph Lauber, Felix Gutzwiller, and Wulf Rössler. "Age–period–cohort analysis of Swiss suicide data, 1881–2000." European archives of psychiatry and clinical neuroscience 256, no. 4 (2006): 207-214. https://doc.rero.ch/record/310870/files/406_2005_Article_627.pdf
- Alquraini, Hussain, and Richard J. Auchus. "Strategies that athletes use to avoid detection of androgenic-anabolic steroid doping and sanctions." Molecular and cellular endocrinology 464 (2018): 28-33. https://www.sciencedirect.com/science/article/abs/pii/S0303720717300412
- Amone-P'Olak, Kennedy, Ask Elklit, and Sarah Bøgelund Dokkedahl. "PTSD, mental illness, and care among survivors of sexual violence in Northern Uganda: Findings from the WAYS study." Psychological trauma: theory, research, practice, and policy 10, no. 3 (2018): 282. https://psycnet.apa.org/record/2017-32724-001
- Andrews, M. "Despite Law, Health Plans Refuse Medical Claims Related To Suicide." NPR.org. Last modified February 18, 2014. https://www.npr.org/sections/health-shots/2014/02/18/279014945/despite-law-health-plans-refuse-medical-claims-related-to-suicide. Accessed 7/29/2020.
- Andriessen, Karl, Bayzidur Rahman, Brian Draper, Michael Dudley, and Philip B. Mitchell. "Prevalence of exposure to suicide: A meta-analysis of population-based studies." Journal of Psychiatric Research 88 (2017): 113-120. https://www.sciencedirect.com/science/article/abs/pii/S0022395616304836
- Arensman, Ella. "Suicide prevention in an international context. "Crisis, 38(1), 1–6 (2017)
- Arensman, Ella. "Suicide prevention in an international context." (2017). https://econtent.hogrefe.com/doi/full/10.1027/0227-5910/a000461
- Arensman, Ella. "Suicide prevention in an international context." Crisis, 38, pp. 1-6(2017). https://econtent.hogrefe.com/doi/full/10.1027/0227-5910/a000461
- Armstrong, Thomas. "The myth of the normal brain: Embracing neurodiversity." AMA journal of ethics 17, no. 4 (2015): 348-352. https://journalofethics.ama-assn.org/article/myth-normal-brain-embracing-neurodiversity/2015-04
- Austin, R.D & Pisano G.P. "Neurodiversity Is a Competitive Advantage." Harvard Business Review. Last modified May 1, 2017. https://hbr.org/2017/05/neurodiversity-as-a-competitive-advantage. Accessed in 8/5/2020.
- Baklien, Børge, and Rob Bongaardt. "The quest for choice and the need for relational care in mental health work." Medicine, Health Care and Philosophy 17, no. 4 (2014): 625-632. https://pubmed.ncbi.nlm.nih.gov/24760340/
- Ban, Thomas A. “Academic psychiatry and the pharmaceutical industry.” Progress in neuro-psychopharmacology & biological psychiatry vol. 30,3 (2006): 429-41. doi:10.1016/j.pnpbp.2005.11.014 https://pubmed.ncbi.nlm.nih.gov/16442686/
- Baron, David A., David M. Martin, and Samir Abol Magd. "Doping in sports and its spread to at-risk populations: an international review." World Psychiatry 6, no. 2 (2007): 118. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219897/
- Bates, L., and T. Stickley. "Confronting Goffman: how can mental health nurses effectively challenge stigma? A critical review of the literature." Journal of psychiatric and mental health nursing 20, no. 7 (2013): 569-575. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2850.2012.01957.x
- Bauman, Sheri, Russell B. Toomey, and Jenny L. Walker. "Associations among bullying, cyberbullying, and suicide in high school students." Journal of adolescence 36, no. 2 (2013): 341-350. https://d1wqtxts1xzle7.cloudfront.net/48551481/Associations_among_bullying_cyberbullyin20160903-30207-19nrdq9.pdf
- Baumeister, Alan A, and Mike F Hawkins. “Continuity and discontinuity in the historical development of modern psychopharmacology.” Journal of the history of the neurosciences vol. 14,3 (2005): 199-209. doi:10.1080/096470490512562 https://pubmed.ncbi.nlm.nih.gov/16188699/
- Baumeister, Roy F. "Suicide as escape from self." Psychological review 97, no. 1 (1990): 90. https://pubmed.ncbi.nlm.nih.gov/2408091/
- Bazelon Center for Mental Health Law. Last modified July 13, 2020. https://www.bazelon.org. Accessed in 7/20/2020.
- Benatov, Joy, Anat Brunstein Klomek, Barzilay Shira, Alan Apter, Vladimir Carli, Camilla Wasserman, Christina W. Hoven et al. "Doing nothing is sometimes worse: comparing avoidant versus approach coping strategies with peer victimization and their association to depression and suicide ideation." Journal of school violence (2020): 1-14. https://www.tandfonline.com/doi/abs/10.1080/15388220.2020.1738941
- Bennett, E. "Peer Abuse Know More!: Bullying from a Psychological Perspective." Infinity, 2006.
- Berbegal‐Mirabent, Jasmina, Ferran Sabaté, and Antonio Cañabate. "Brokering knowledge from universities to the marketplace." Management Decision (2012). https://www.emerald.com/insight/content/doi/10.1108/00251741211247012/full/html
- Beresford, Peter. "‘Mad’, Mad studies and advancing inclusive resistance." Disability & Society (2019): 1-6. https://www.tandfonline.com/doi/full/10.1080/09687599.2019.1692168
- Beresford, Peter. "A failure of national mental health policy and the failure of a Global Summit." British Journal of Mental Health Nursing 7, no. 5 (2018): 198-199. https://www.magonlinelibrary.com/doi/full/10.12968/bjmh.2018.7.5.198
- Bernardo, Allan BI. "Extending hope theory: Internal and external locus of trait hope." Personality and individual differences 49, no. 8 (2010): 944-949.
- Besnard, Philippe. "Durkheim’s squares: types of social pathology and types of suicide." The Cambridge Companion to Durkheim (2005): 70-79.
- Biel, Marloes. "On the Possibility of Rational Suicide. Can Competent, Rational Agents Commit Suicide?." Master's thesis. Leusden, 2019.
- Blevins, Steve M., and Michael S. Bronze. "Robert Koch and the ‘golden age’of bacteriology." International Journal of Infectious Diseases 14, no. 9 (2010): e744-e751. https://www.sciencedirect.com/science/article/pii/S1201971210023143
- Bogen, James. "Theory and observation in science." Stanford Encyclopedia of Philosophy (2009).
- Bohnert, Amy SB, and Mark A. Ilgen. "Understanding links among opioid use, overdose, and suicide." New England journal of medicine 380, no. 1 (2019): 71-79. https://www.nejm.org/doi/full/10.1056/NEJMra1802148
- Bohnert, Amy SB, and Mark A. Ilgen. "Understanding links among opioid use, overdose, and suicide." New England journal of medicine 380, no. 1 (2019): 71-79. https://www.nejm.org/doi/full/10.1056/NEJMra1802148
- Bonvechio, T. "20 Signs You're Too Strong for a Commercial Gym." Last modified September 24, 2013. https://bonvecstrength.com/2013/09/24/20-signs-youre-too-strong-for-a-commercial-gym/ . Accessed in 7/27/2020.
- Botelho, Marissa, Jennifer Lemos, Jessica Souza, and Roger Clark. "The drug overdose epidemic: deaths of despair or deaths of addiction?." Sociology Between the Gaps: Forgotten and Neglected Topics 3, no. 1 (2017): 4. https://digitalcommons.providence.edu/cgi/viewcontent.cgi?referer=https://scholar.google.com/&httpsredir=1&article=1030&context=sbg
- Bracken, Patrick, and Philip Thomas. "Postpsychiatry: a new direction for mental health." Bmj 322, no. 7288 (2001): 724-727. https://www.bmj.com/content/322/7288/724.short
- Brainerd, Elizabeth. "Economic reform and mortality in the former Soviet Union: a study of the suicide epidemic in the 1990s." European economic review 45, no. 4-6 (2001): 1007-1019. https://www.sciencedirect.com/science/article/pii/S0014292101001088
- Brake, C. Alex, Sasha M. Rojas, Christal L. Badour, Courtney E. Dutton, and Matthew T. Feldner. "Self-disgust as a potential mechanism underlying the association between PTSD and suicide risk." Journal of anxiety disorders 47 (2017): 1-9. https://www.sciencedirect.com/science/article/abs/pii/S0887618516301566
- Brake, C. Alex, Thomas G. Adams, Caitlyn O. Hood, and Christal L. Badour. "Posttraumatic mental contamination and the interpersonal psychological theory of suicide: Effects via DSM-5 PTSD symptom clusters." Cognitive therapy and research 43, no. 1 (2019): 259-271. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615747/
- Branscombe, Nyla R., and Daniel L. Wann. "Collective self‐esteem consequences of outgroup derogation when a valued social identity is on trial." European Journal of Social Psychology 24, no. 6 (1994): 641-657. https://onlinelibrary.wiley.com/doi/abs/10.1002/ejsp.2420240603
- Braslow, Joel T, and Stephen R Marder. “History of Psychopharmacology.” Annual review of clinical psychology vol. 15 (2019): 25-50. doi:10.1146/annurev-clinpsy-050718-095514 https://pubmed.ncbi.nlm.nih.gov/30786241/
- Braslow, Joel. "Therapeutic effectiveness and social context: the case of lobotomy in a California state hospital, 1947-1954." Western journal of medicine 170, no. 5 (1999): 293. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305592/pdf/westjmed00320-0047.pdf
- Bredemeier, Keith, and Ivan W. Miller. "Executive function and suicidality: a systematic qualitative review." Clinical psychology review 40 (2015): 170-183. https://www.sciencedirect.com/science/article/abs/pii/S0272735815000951
- Bredemeier, Keith, and Ivan W. Miller. "Executive function and suicidality: a systematic qualitative review." Clinical psychology review 40 (2015): 170-183. https://www.sciencedirect.com/science/article/abs/pii/S0272735815000951
- Breggin, Peter R. Psychiatric drugs. New York: Springer, 1983.
- Brent, David A., Joshua A. Perper, Grace Moritz, Laura Liotus, Doreen Richardson, Rebecca Canobbio, Joy Schweers, and Claudia Roth. "Posttraumatic stress disorder in peers of adolescent suicide victims: Predisposing factors and phenomenology." Journal of the American Academy of Child & Adolescent Psychiatry 34, no. 2 (1995): 209-215. https://www.sciencedirect.com/science/article/abs/pii/S089085670963759X
- Brent, David A., Joshua A. Perper, Grace Moritz, Laura Liotus, Joy Schweers, Claudia Roth, Lisa Balach, and Chris Allman. "Psychiatric impact of the loss of an adolescent sibling to suicide." Journal of Affective Disorders 28, no. 4 (1993a): 249-256. https://www.sciencedirect.com/science/article/abs/pii/016503279390060W
- Brent, David A., Joshua Perper, Grace Moritz, Chris Allman, Laura Liotus, J. O. Y. Schweers, Claudia Roth, Lisa Balach, and Rebecca Canobbio. "Bereavement or depression? The impact of the loss of a friend to suicide." Journal of the American Academy of Child & Adolescent Psychiatry 32, no. 6 (1993): 1189-1197. https://www.sciencedirect.com/science/article/abs/pii/S0890856709645184
- Burke, Mashall, Ceren Basan, Felipe Gonzalez, Patrick Baylis, Sam Heft-Neal, Sanjay Basu, and Solomon Hsiang. ", Warming increases suicide rates in the United States and Mexico." Nature Climate Change (2017). http://repository.essex.ac.uk/25387/10/suicides-ncc-accepted.pdf
- Campbell P: Challenging loss of power. In: Read J, Reynolds J (eds). Speaking our minds: An anthology. London: MacMillan, 1996
- Canguilhem, Georges. On the Normal and the Pathological. Vol. 3. Springer Science & Business Media, 2012.
- Canner, J. K., K. Giuliano, S. Selvarajah, E. R. Hammond, and E. B. Schneider. "Emergency department visits for attempted suicide and self harm in the USA: 2006–2013." Epidemiology and psychiatric sciences 27, no. 1 (2018): 94-102. https://www.saferhomescollaborative.org/wp-content/uploads/2019/06/Canner-ED-Self-Harm-2006-2013-NEDS-2018-Epi-Psych-Sci61418.pdf .
- Carey, B. "Suicide Prevention Sheds a Longstanding Taboo: Talking About Attempts." The New York Times - Breaking News, World News & Multimedia. Last modified April 14, 2014. https://www.nytimes.com/2014/04/14/us/suicide-prevention-sheds-a-longstanding-taboo-talking-about-attempts.html?_r=0. Accessed 7/30/2020.
- Carleton, Tamma A. "Crop-damaging temperatures increase suicide rates in India." Proceedings of the National Academy of Sciences 114, no. 33 (2017): 8746-8751.
- Carleton, Tamma A. "Crop-damaging temperatures increase suicide rates in India." Proceedings of the National Academy of Sciences 114, no. 33 (2017): 8746-8751. https://www.pnas.org/content/114/33/8746/
- Castrodale, Mark Anthony. "Mad matters: A critical reader in Canadian mad studies." (2015): 284-286. https://www.sjdr.se/articles/10.1080/15017419.2014.895415/#:~:text=As%20the%20authors%20state%2C%20%27Mad,and%20being%27%20(13).
- Chamberlin, Judi. "The ex-patients' movement: Where we've been and where we're going." The journal of Mind and Behavior (1990): 323-336. Republished at the National Empowerment Center. Last modified February 7, 2017. https://power2u.org/the-ex-patients-movement-where-weve-been-and-where-were-going/
- Chamberlin, Judi. On our own: Patient-controlled alternatives to the mental health system. McGraw-Hill, 1978. https://books.google.com/books/about/On_Our_Own.html?id=ogPbAAAAMAAJ
- Chapman, Adrian. "Re-Coopering anti-psychiatry: David Cooper, revolutionary critic of psychiatry." Critical and radical social work 4, no. 3 (2016): 421-432. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125513/
- Chatard, Armand, and Leila Selimbegović. "When self-destructive thoughts flash through the mind: Failure to meet standards affects the accessibility of suicide-related thoughts." Journal of Personality and Social Psychology 100, no. 4 (2011): 587. https://psycnet.apa.org/record/2011-02002-001
- Cherlin, Andrew J. "Psychological health and socioeconomic status among non-Hispanic whites." Proceedings of the National Academy of Sciences 115, no. 28 (2018): 7176-7178. https://www.pnas.org/content/115/28/7176.full
- Choi, Hyundo. "Technology-push and demand-pull factors in emerging sectors: evidence from the electric vehicle market." Industry and Innovation 25, no. 7 (2018): 655-674. https://www.tandfonline.com/doi/abs/10.1080/13662716.2017.1346502
- Choi, Hyundo. "Technology-push and demand-pull factors in emerging sectors: evidence from the electric vehicle market." Industry and Innovation 25, no. 7 (2018): 655-674. https://www.tandfonline.com/doi/abs/10.1080/13662716.2017.1346502
- Christo, Paul J. “Opioids May Be Appropriate for Chronic Pain.” The Journal of Law, Medicine & Ethics 48, no. 2 (June 2020): 241–48. https://journals.sagepub.com/doi/abs/10.1177/1073110520935335#articleCitationDownloadContainer
- Clarke, D M. “Autonomy, rationality and the wish to die.” Journal of medical ethics vol. 25,6 (1999): 457-62. https://pubmed.ncbi.nlm.nih.gov/10635498/
- Coffey, R.M., T. Mark, E. King, H. Harwood, D. McKusick, J. Genurardi, J. Dilonardo, and J. Buck. 2000. National Estimates of Expenditures for Mental Health and Substance Abuse Treatment. Rockville, Md.: U.S. Department of Health and Human Services, July.
- Cohen, O. "The Power of 'Healing Voices'." The Mighty. Last modified August 4, 2020. https://themighty.com/2017/03/healing-voices-mad-pride/. Accessed om 8/4/2020.
- Colin, T "Aborigines, sport and suicide", Sport in Society, 15:7, 922-935 (2012). https://www.tandfonline.com/doi/abs/10.1080/17430437.2012.723352
- Collins, Harry M. "Epistemological Chicken HM Collins and Steven Yearley." (1992).
- Comacchio, Anna, Sara Bonesso, and Claudio Pizzi. "Boundary spanning between industry and university: the role of Technology Transfer Centres." The Journal of Technology Transfer 37, no. 6 (2012): 943-966. https://link.springer.com/article/10.1007%2Fs10961-011-9227-6
- Conrad, Peter. "Medicalization and social control." Annual review of Sociology 18, no. 1 (1992): 209-232. https://www.ericlhsu.com/uploads/9/1/2/1/91214674/assr_week_11_conrad_medicalization.pdf
- Conway, Paul Maurice, Annette Erlangsen, Thomas Clausen, Elsebeth Stenager, Anne Helene Garde, Åse Marie Hansen, Reiner Rugulies, and Annie Høgh. "Workplace bullying and suicide risk: A register-based study of 78,972 participants in Denmark." (2017). https://www.forskningsdatabasen.dk/en/catalog/2352679610
- Coolidge, Frederick L., and Thomas Wynn. "Executive functions of the frontal lobes and the evolutionary ascendancy of Homo sapiens." Cambridge archaeological journal 11, no. 2 (2001): 255-260. https://www.researchgate.net/profile/Frederick_Coolidge/publication/259438202_Executive_Functions_of_the_Frontal_Lobes_and_the_Evolutionary_Ascendancy_of_Homo_Sapiens/links/0deec53aae806da7dc000000.pdf
- Cooper D. The death of the family. Harmondsworth: Penguin (1974).
- Cooper, D. Psychiatry and Anti-Psychiatry. Tavistick, London (1967).
- Corrigan, Patrick W., David Roe, and Hector WH Tsang. Challenging the stigma of mental illness: Lessons for therapists and advocates. John Wiley & Sons, 2011.
- Coursolle, A. "Medicaid Offer Critical Support for People Who Are Experiencing Behavioral Health Crises During the COVID-19 Pandemic." National Health Law Program. Last modified May 29, 2020. https://healthlaw.org/medicaid-offer-critical-support-for-people-who-are-experiencing-behavioral-health-crises-during-the-covid-19-pandemi/.
- Coutinho, M. "Intimidation and the Fitness Industry." Elitefts, 2018. Accessed July 23, 2020. https://www.elitefts.com/education/intimidation-and-the-fitness-industry/ .
- Crane, Tim. "Is perception a propositional attitude?" The Philosophical Quarterly 59, no. 236 (2009): 452-469. https://academic.oup.com/pq/article-abstract/59/236/452/1438014
- Creative Commons. "State of the Commons" https://stateof.creativecommons.org Accessed 8/11/2020
- Cresswell, M. "Asylum to Action, Survivors' History, and the Symbols of a Movement." The journal of critical psychology, counselling and psychotherapy 9, no. 4 (2009): 217. http://studymore.org.uk/cresshsp.pdf
- Cresswell, Mark, and Helen Spandler. "The engaged academic: academic intellectuals and the psychiatric survivor movement." Social Movement Studies 12, no. 2 (2013): 138-154. https://www.tandfonline.com/doi/abs/10.1080/14742837.2012.696821
- Crossley, Nick. "RD Laing and the British anti-psychiatry movement: a socio–historical analysis." Social science & medicine 47, no. 7 (1998): 877-889. https://www.sciencedirect.com/science/article/abs/pii/S0277953698001476
- Csikszentmihalyi, M. Beyond Boredom and Anxiety. San Francisco, Jossey-Bass Publishers, 1975
- Curran, Emma, Gary Adamson, Maurice Stringer, Michael Rosato, and Gerard Leavey. "Severity of mental illness as a result of multiple childhood adversities: US National Epidemiologic Survey." Social psychiatry and psychiatric epidemiology 51, no. 5 (2016): 647-657. https://link.springer.com/article/10.1007/s00127-016-1198-3
- Curtis, John M., and Mimi J. Curtis. "Factors related to susceptibility and recruitment by cults." Psychological reports 73, no. 2 (1993): 451-460. https://journals.sagepub.com/doi/abs/10.2466/pr0.19126.96.36.1991
- Curtis, Theodore R., Robert Dellar, Esther Leslie, and Ben Watson, eds. Mad pride: A celebration of mad culture. Spare Change Books, 2000.
- Cvinar, Jacqueline G. "Do suicide survivors suffer social stigma: a review of the literature." Perspectives in psychiatric care 41, no. 1 (2005): 14-21. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.0031-5990.2005.00004.x
- Darden, Ellington. "Sixteen personality factor profiles of competitive bodybuilders and weightlifters." Research Quarterly. American Association for Health, Physical Education and Recreation 43, no. 2 (1972): 142-147. https://shapeamerica.tandfonline.com/doi/abs/10.1080/10671188.1972.10615125#.XpR11jfQiUk
- Dascal, Marcelo, ed. Cultural relativism and philosophy: North and Latin American perspectives. Vol. 7. Brill, 1991.
- de Leon-Casasola, Oscar A. "Opioids for chronic pain: new evidence, new strategies, safe prescribing." The American journal of medicine 126, no. 3 (2013): S3-S11. https://www.sciencedirect.com/science/article/abs/pii/S0002934312009205
- Deisenhammer, Eberhard A., Chy-Meng Ing, Robert Strauss, Georg Kemmler, Hartmann Hinterhuber, and Elisabeth M. Weiss. "The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt?." Journal of Clinical Psychiatry 70, no. 1 (2009): 19. https://www.saferhomescollaborative.org/wp-content/uploads/2019/06/Deisenhammer-2009-Duration-of-suicidal-process61420.pdf
- Delezie, Julien, and Christoph Handschin. "Endocrine crosstalk between skeletal muscle and the brain." Frontiers in neurology 9 (2018): 698. https://www.frontiersin.org/articles/10.3389/fneur.2018.00698/full
- Department of Health and Human Services. Office of the Secretary. 45 CFR Part 88. RIN 0945‐AA10. Protecting Statutory Conscience Rights in Health Care; Delegations of Authority. Office for Civil Rights (OCR), Office of the Secretary, HHS. Final Rule. 2018. https://www.hhs.gov/sites/default/files/final-conscience-rule.pdf
- Desai, N. G. “Antipsychiatry: Meeting the challenge.” Indian journal of psychiatry vol. 47,4 (2005): 185-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921130 /
- Diamond, Adele. "Executive functions." Annual review of psychology 64 (2013): 135-168. https://www.annualreviews.org/doi/abs/10.1146/annurev-psych-113011-143750
- Dimant, E. & Deutscher, D. "The Economics of Corruption in Sports: The Special Case of Doping." Edmond J. Safra Center for Ethics. Last modified 18, 2015. https://ethics.harvard.edu/blog/economics-corruption-sports-special-case-doping . Accessed in 07/23/2020.
- Dine, Ranana Leigh. "You shall bury him: burial, suicide and the development of Catholic law and theology." Medical humanities (2019): medhum-2018. https://mh.bmj.com/content/early/2019/07/25/medhum-2018-011622
- Dudley, Edward, and Maximillian E. Novak, eds. The Wild Man Within: An Image in Western Thought from the Renaissance to Romanticism. University of Pittsburgh Pre, 1972.
- Duntas, L. H. "New insights into the hypothalamic-pituitary-thyroid axis." Acta Endocrinologica (Bucharest) 12, no. 2 (2016): 125. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535279/
- Durkheim, Emile (1897) . Suicide : a study in sociology. The Free Press
- Dzeng, Elizabeth, and Steven Z. Pantilat. "What are the Social Causes of Rational Suicide in Older Adults?." Journal of the American Geriatrics Society 66, no. 5 (2018): 853. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5992051/
- Eddy, David M. "The origins of evidence-based medicine: A personal perspective." AMA Journal of Ethics 13, no. 1 (2011): 55-60. https://journalofethics.ama-assn.org/article/origins-evidence-based-medicine-personal-perspective/2011-01
- Eghigian, Greg. "A “sickness of our time”: How suicide first became a research question." Psychiatric Times 35, no. 4 (2018): 11-13.
- Emanuel, Ezekiel J., Bregje D. Onwuteaka-Philipsen, John W. Urwin, and Joachim Cohen. "Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe." Jama 316, no. 1 (2016): 79-90. https://jamanetwork.com/journals/jama/article-abstract/2532018
- Evidence-Based Medicine Working Group. "Evidence-based medicine. A new approach to teaching the practice of medicine." Jama 268, no. 17 (1992): 2420. https://pubmed.ncbi.nlm.nih.gov/0001404801/
- Farber, Seth. The spiritual gift of madness: The failure of psychiatry and the rise of the mad pride movement. Simon and Schuster, 2012.
- Fenton, Andrew, and Tim Krahn. "Autism, Neurodiversity, and Equality Beyond the" Normal"." (2007). Journal of Ethics in Mental Health. 2:2 (2007) https://philpapers.org/rec/FENANA
- Fink, Daniel. "A new definition of noise: noise is unwanted and/or harmful sound. Noise is the new ‘secondhand smoke’." In Proceedings of Meetings on Acoustics 178ASA, vol. 39, no. 1, p. 050002. Acoustical Society of America, 2019. https://asa.scitation.org/doi/abs/10.1121/2.0001186
- Finn, Molly. In the Case of Bruno Bettelheim. First Things 74 (June/July 1997): 44-48, 1997. http://www.leaderu.com/ftissues/ft9706/articles/finn.html
- Firestone, Robert W., and Richard H. Seiden. "Suicide and the continuum of self-destructive behavior." Journal of American College Health 38, no. 5 (1990): 207-213. https://www.tandfonline.com/doi/abs/10.1080/07448481.1990.9936189
- Foot, John. "Franco Basaglia and the radical psychiatry movement in Italy, 1961–78." Critical and radical social work 2, no. 2 (2014): 235. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430803/pdf/emss-63127.pdf
- Foucault, Michel. Madness and civilization: A history of insanity in the age of reason. Vintage, 1988.
- Frank, Richard G., Rena M. Conti, and Howard H. Goldman. "Mental health policy and psychotropic drugs." The Milbank Quarterly 83, no. 2 (2005): 271-298. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-0009.2005.00347.x
- Freud, "Formulations on the two principles of mental functioning.", 1911, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII, 1958
- Freud, Sigmund. "Beyond the pleasure principle." Psychoanalysis and History 17, no. 2 (2015a): 151-204.
- Freud, Sigmund. "Formulations on the two principles of mental functioning." In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, pp. 213-226. 1958.
- Freud, Sigmund. "Mourning and melancholia." In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, pp. 237-258. 1957.
- Freud, Sigmund. Civilization and its discontents. Broadview Press, 2015b.
- Gallagher, Mark. "From mental patient to service user: deinstitutionalisation and the emergence of the Mental Health Service User Movement in Scotland, 1971-2006." PhD diss., University of Glasgow, 2017. http://theses.gla.ac.uk/8078/1/2017GallagherPhD.pdf
- Gallup. "U.S. Uninsured Rate Rises to Four-Year High." Gallup.com. Last modified January 23, 2019. https://news.gallup.com/poll/246134/uninsured-rate-rises-four-year-high.aspx.
- Garatachea, Nuria, Alejandro Santos-Lozano, Fabian Sanchis-Gomar, Carmen Fiuza-Luces, Helios Pareja-Galeano, Enzo Emanuele, and Alejandro Lucia. "Elite athletes live longer than the general population: a meta-analysis." In Mayo Clinic Proceedings, vol. 89, no. 9, pp. 1195-1200. Elsevier, 2014. https://www.sciencedirect.com/science/article/abs/pii/S0025619614005199
- George, Sarah E., Andrew C. Page, Geoffrey R. Hooke, and Werner GK Stritzke. "Multifacet assessment of capability for suicide: Development and prospective validation of the Acquired Capability With Rehearsal for Suicide Scale." Psychological assessment 28, no. 11 (2016): 1452. https://psycnet.apa.org/doiLanding?doi=10.1037%2Fpas0000276
- Georgetown University Center on Education and the Workforce, Born to Win, Schooled to Lose: Why Equally Talented Students Don’t Get Equal Chances to Be All They Can Be, 2019. https://1gyhoq479ufd3yna29x7ubjn-wpengine.netdna-ssl.com/wp-content/uploads/FR-Born_to_win-schooled_to_lose.pdf Accessed in 7/27/2020
- Gibbons, M., C. Limoges, H. Nowotny, S. Schwartzman, P. Scott and M. Trow. "The new production of knowledge. The dynamics of science and research in contemporary societies". London, Sage, 1994.
- Gibson, Lorena. "Anthropology as Respair: Anthropological Engagements with Hope and its Others." Anthropological Quarterly 92, no. 2 (2019): 575-585. https://muse.jhu.edu/article/729309/summary
- Gifford, Sanford. "Notes on Felix Deutsch as Freud's Personal Physician." American Imago 74, no. 4 (2017): 483-518. https://muse.jhu.edu/article/682314
- Glaser, G. "‘Mad Pride’ Fights a Stigma." The New York Times - Breaking News, World News & Multimedia. Last modified May 11, 2008. https://www.nytimes.com/2008/05/11/fashion/11madpride.html . Accessed in 8/4/2020
- Godin, B., and J. P. Lane. "Pushes and Pulls”: The Hi (story) of the Demand Pull Model of Innovation, Project on the Intellectual History of Innovation (Working Paper No. 13)." (2013). http://www.csiic.ca/PDF/Demand-pull.pdf
- Godin, B., and J. P. Lane. "Pushes and Pulls”: The Hi (story) of the Demand Pull Model of Innovation, Project on the Intellectual History of Innovation (Working Paper No. 13)." (2013). http://www.csiic.ca/PDF/Demand-pull.pdf
- Goldblatt, Mark J. "The psychodynamics of hope in suicidal despair." The Scandinavian Psychoanalytic Review 40, no. 1 (2017): 54-62. https://www.tandfonline.com/doi/abs/10.1080/01062301.2017.1312219
- Goodman, Steve. Sonic warfare: Sound, affect, and the ecology of fear. MIT Press, 2012.
- Gordon, Brett R., Cillian P. McDowell, Mark Lyons, and Matthew P. Herring. "The effects of resistance exercise training on anxiety: a meta-analysis and meta-regression analysis of randomized controlled trials." Sports Medicine 47, no. 12 (2017): 2521-2532. https://link.springer.com/article/10.1007/s40279-017-0769-0
- Gross, Georgina M., Silvia Ronzitti, Joan L. Combellick, Suzanne E. Decker, Kristin M. Mattocks, Rani A. Hoff, Sally G. Haskell, Cynthia A. Brandt, and Joseph L. Goulet. "Sex differences in military sexual trauma and severe self-directed violence." American journal of preventive medicine (2020). https://www.sciencedirect.com/science/article/abs/pii/S0749379720300179
- Halevy, Nir. "Preemptive strikes: Fear, hope, and defensive aggression." Journal of Personality and Social Psychology 112, no. 2 (2017): 224. https://psycnet.apa.org/buy/2016-46785-001
- Hall, Edward Twitchell. "The hidden dimension ." (1966).
- Hamlin, Cynthia Lins, and Robert J. Brym. "The return of the native: a cultural and social-psychological critique of Durkheim's suicide based on the Guarani-Kaiowá of southwestern Brazil." Sociological Theory 24, no. 1 (2006): 42-57. https://journals.sagepub.com/doi/abs/10.1111/j.0735-2751.2006.00263.x
- Han, Beth, Wilson M. Compton, Carlos Blanco, Lisa Colpe, Larke Huang, and Richard McKeon. "National trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults." Journal of the American Academy of Child & Adolescent Psychiatry 57, no. 1 (2018): 20-27. https://www.sciencedirect.com/science/article/abs/pii/S0890856717318294
- Harangozó, Judit. "On Postpsychiatry." Psychiatria Hungarica: A Magyar Pszichiatriai Tarsasag tudomanyos folyoirata 34, no. 4 (2019): 403-410. https://europepmc.org/article/med/31767800
- Hargadon, Andrew B. "Firms as knowledge brokers: Lessons in pursuing continuous innovation." California management review 40, no. 3 (1998): 209-227. http://www.personal.psu.edu/faculty/g/i/gis1/551/Hargadon.pdf
- Harris KM et al. “The ABC’s of Suicide Risk Assessment: Applying a Tripartite Approach to Individual Evaluations”. PLoS ONE 10, no.6(2015): e0127442. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4452484/pdf/pone.0127442.pdf
- Hassan, S. "What is a Cult? Whiteboard Animation Explaining the BITE Model." Freedom of Mind Resource Center. Last modified December 16, 2018. https://freedomofmind.com/what-is-a-cult-whiteboard-animation-explaining-the-bite-model/ . Accessed in 7/27/2020
- Healy, David. "The structure of psychopharmacological revolutions." Psychiatr Dev 4 (1987): 349-76. https://pdfs.semanticscholar.org/d9c0/d9a61c9819ee30e34afdea0e789c6b4bb040.pdf
- Henderson, James T. "Hope and Self-Destruction: The Ratio of External Threat to Feelings of Personal Competence on the Underlying Continuum of Self-Destructive Behavior." (1976). https://eric.ed.gov/?id=ED142889
- Hendin, Herbert, and Ann Pollinger Haas. "Suicide and guilt as manifestations of PTSD." American Journal of Psychiatry 148, no. 5 (1991): 586-591. https://www.researchgate.net/profile/Herbert_Hendin/publication/21138169_Suicide_and_guilt_as_manifestations_of_PTSD_in_Vietnam_war_veterans/links/09e41500ed0316f495000000.pdf
- Hertz, Marci Feldman, Ingrid Donato, and James Wright. "Bullying and suicide: a public health approach." Journal of Adolescent Health 53, no. 1 (2013): S1-S3. https://www.jahonline.org/article/S1054-139X(13)00270-X/abstract
- Hinduja, Sameer, and Justin W. Patchin. "Connecting adolescent suicide to the severity of bullying and cyberbullying." Journal of school violence 18, no. 3 (2019): 333-346. https://www.tandfonline.com/doi/abs/10.1080/15388220.2018.1492417
- Hirshbein, Laura. "Historical essay: electroconvulsive therapy, memory, and self in America." Journal of the History of the Neurosciences 21, no. 2 (2012): 147-169. https://pubmed.ncbi.nlm.nih.gov/22428737/
- Hoermann, Rudolf, John EM Midgley, Rolf Larisch, and Johannes W. Dietrich. "Homeostatic control of the thyroid–pituitary axis: perspectives for diagnosis and treatment." Frontiers in endocrinology 6 (2015): 177. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653296/
- Hofmann, Wilhelm, Malte Friese, and Fritz Strack. "Impulse and self-control from a dual-systems perspective." Perspectives on Psychological Science 4, no. 2 (2009): 162-176. https://journals.sagepub.com/doi/abs/10.1111/j.1745-6924.2009.01116.x
- Hoge, Charles W., Christopher G. Ivany, and Amy B. Adler. "Suicidal behaviors within army units: Contagion and implications for public health interventions." JAMA psychiatry 74, no. 9 (2017): 871-872. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2645495
- Holliday, S.B. "The Relationship Between Mental Health Care Access and Suicide." Rand Corporation, March 2, 2018. https://www.rand.org/research/gun-policy/analysis/essays/mental-health-access-and-suicide.html. Accessed 7/29/2020.
- Holmes, Nicholas P., and Charles Spence. "The body schema and multisensory representation (s) of peripersonal space." Cognitive processing5.2 (2004): 94-105. https://link.springer.com/article/10.1007/s10339-004-0013-3
- Holt, Jeanie, and Joan S. Reeves. "The meaning of hope and generic caring practices to nurture hope in a rural village in the Dominican Republic." Journal of transcultural nursing 12, no. 2 (2001): 123-131. https://psycnet.apa.org/record/2001-14820-003
- Hom, Melanie A., Ian H. Stanley, Peter M. Gutierrez, and Thomas E. Joiner Jr. "Exploring the association between exposure to suicide and suicide risk among military service members and veterans." Journal of affective disorders 207 (2017): 327-335. https://www.sciencedirect.com/science/article/abs/pii/S016503271631254X
- Human Connectome Project | Mapping the Human Brain Connectivity. Accessed July 22, 2020. https://www.humanconnectomeproject.org.
- Huskey, Richard Wayne. "Intrinsic reward motivates large-scale shifts between cognitive control and default mode networks during task performance." PhD diss., UC Santa Barbara, 2016. https://escholarship.org/content/qt5f95n824/qt5f95n824.pdf
- Huskey, Richard, Shelby Wilcox, and René Weber. "Network neuroscience reveals distinct neuromarkers of flow during media use." Journal of Communication 68, no. 5 (2018): 872-895. https://cogcommscience.com/wp-content/uploads/2018/10/huskey_wilcox_weber_2018.pdf
- Ingram, Richard A. "Doing mad studies: Making (non) sense together." Intersectionalities: A Global Journal of Social Work Analysis, Research, Polity, and Practice 5, no. 3 (2016): 11-17. https://journals.library.mun.ca/ojs/index.php/IJ/article/viewFile/1680/1327
- Irigoyen, María, Alejandro Porras-Segovia, Leonardo Galván, Margarita Puigdevall, Lucas Giner, Santiago De Leon, and Enrique Baca-García. "Predictors of re-attempt in a cohort of suicide attempters: a survival analysis." Journal of affective disorders 247 (2019): 20-28. https://www.sciencedirect.com/science/article/abs/pii/S0165032718313831
- Jamison, K.R. Night Falls Fast : Understanding Suicide. New York, Knopf, 1999.
- Jamison, Kay Redfield. Night falls fast: Understanding suicide. Vintage, 2011.
- Jones, Mark R., Omar Viswanath, Jacquelin Peck, Alan D. Kaye, Jatinder S. Gill, and Thomas T. Simopoulos. "A brief history of the opioid epidemic and strategies for pain medicine." Pain and therapy 7, no. 1 (2018): 13-21. https://link.springer.com/article/10.1007/s40122-018-0097-6
- Kamienski, L. "The Drugs That Built a Super Soldier." The Atlantic. Last modified April 8, 2016. https://www.theatlantic.com/health/archive/2016/04/the-drugs-that-built-a-super-soldier/477183/ . Accessed in 7/28/2020
- Kaplow, J.B., Gipson, P.Y., Horwitz, A.G. et al. Emotional Suppression Mediates the Relation Between Adverse Life Events and Adolescent Suicide: Implications for Prevention. Prev Sci 15, 177–185 (2014). https://link.springer.com/article/10.1007%2Fs11121-013-0367-9#citeas
- Kapp, Steven K. Autistic community and the neurodiversity movement: Stories from the Frontline. Springer Nature, 2020. https://library.oapen.org/handle/20.500.12657/23177
- Kattimani, Shivanand, Siddharth Sarkar, Vikas Menon, Avin Muthuramalingam, and Premkumar Nancy. "Duration of suicide process among suicide attempters and characteristics of those providing window of opportunity for intervention." Journal of neurosciences in rural practice 7, no. 04 (2016): 566-570. https://www.thieme-connect.com/products/ejournals/abstract/10.4103/0976-3147.185505
- Kaufman, John A., Leslie K. Salas-Hernández, Kelli A. Komro, and Melvin D. Livingston. "Effects of increased minimum wages by unemployment rate on suicide in the USA." J Epidemiol Community Health 74, no. 3 (2020): 219-224. http://press.psprings.co.uk/jech/january/jech212981.pdf
- Kawa, Shadia, and James Giordano. "A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: issues and implications for the future of psychiatric canon and practice." (2012): 1-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282636/
- Kecmanovic, Dusan. "Postpsychiatry: How to throw out the baby with the bathwater." Psychiatria Danubina 21, no. 3 (2009): 276-282. http://www.psychiatria-danubina.com/UserDocsImages/pdf/dnb_vol21_no3/dnb_vol21_no3_276.pdf
- Kelleher, Eric, Margaret Fitzsimons Kelleher, and Onja Grad. "Effects of patient suicide on the multidisciplinary care team." The Lancet Psychiatry 1, no. 3 (2014): 174-175. https://www.sciencedirect.com/science/article/abs/pii/S2215036614702998
- Kertesz, Stefan G., Sally L. Satel, James DeMicco, Richard C. Dart, and Daniel P. Alford. "Opioid discontinuation as an institutional mandate: Questions and answers on why we wrote to the Centers for Disease Control and Prevention." Substance abuse 40, no. 4 (2019): 466-468. https://www.tandfonline.com/doi/abs/10.1080/08897077.2019.1635973
- Kidwell, Donna K. "Principal investigators as knowledge brokers: A multiple case study of the creative actions of PIs in entrepreneurial science." Technological Forecasting and Social Change 80, no. 2 (2013): 212-220. https://www.sciencedirect.com/science/article/abs/pii/S0040162512001163
- Kim, Young Shin, and Bennett Leventhal. "Bullying and suicide. A review." International journal of adolescent medicine and health 20, no. 2 (2008): 133. https://d1wqtxts1xzle7.cloudfront.net/34266437/research_3.pdf
- Kim, Young Shin, and Bennett Leventhal. "Bullying and suicide. A review." International journal of adolescent medicine and health 20, no. 2 (2008): 133. https://d1wqtxts1xzle7.cloudfront.net/34266437/research_3.pdf
- Klein CE. The Hypothalamic-Pituitary-Gonadal Axis. In: Kufe DW, Pollock RE, Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker; 2003. Available from: https://www.ncbi.nlm.nih.gov/books/NBK13386/
- Kline, Thomas. "SUICIDES Associated with Forced Tapering of Opiate Pain Treatments." Medium. Last modified August 29, 2019. https://medium.com/@ThomasKlineMD/opioidcrisis-pain-related-suicides-associated-with-forced-tapers-c68c79ecf84d. Accessed 8/11/2020.
- Klonsky, E. David, Alexis M. May, and Boaz Y. Saffer. "Suicide, suicide attempts, and suicidal ideation." Annual review of clinical psychology 12 (2016). https://www.annualreviews.org/doi/pdf/10.1146/annurev-clinpsy-021815-093204
- Koons, C. & Tozzi, J. As Suicides Rise, Insurers Find Ways to Deny Mental Health Coverage. Bloombert, May 16, 2019. https://www.bloomberg.com/news/features/2019-05-16/insurance-covers-mental-health-but-good-luck-using-it. Accessed 7/29/2020
- Korolenko, Tsezar P., and Tatyana A. Shpiks. "POSTPSYCHIATRY: NEW WAYS OF ASSESSMENT AND DIAGNOSE OF MENTAL STATES AND MENTAL DISORDERS." Neurological Bulletin 48, no. 4 (2016): 61-63. https://journals.eco-vector.com/1027-4898/article/view/14027
- Koyanagi, Ai, Hans Oh, Andre F. Carvalho, Lee Smith, Josep Maria Haro, Davy Vancampfort, Brendon Stubbs, and Jordan E. DeVylder. "Bullying victimization and suicide attempt among adolescents aged 12–15 years from 48 countries." Journal of the American Academy of Child & Adolescent Psychiatry 58, no. 9 (2019): 907-918. https://www.sciencedirect.com/science/article/abs/pii/S0890856719302096
- Kuhn, Thomas S. "The Structure of Scientific Revolutions." Chicago: University of Chicago Press. (1962).
- Kurshumlia, Mimoza, and Yllka Kurshumlia. "When Loud Music Threats Human Well Being." Available at SSRN 3421958 (2019). https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3421958
- Latour, B. Science in Action: How to Follow Scientists and Engineers Through Society. Milton Keynes: Open University Press, 1987.
- Leenaars, Antoon A. "Edwin S. Shneidman on suicide." Suicidology online 1, no. 1 (2010): 5-18. http://www.suicidology-online.com/pdf/SOL-2010-1-5-18.pdf
- Lemez, Srdjan, and Joseph Baker. "Do elite athletes live longer? A systematic review of mortality and longevity in elite athletes." Sports medicine-open 1, no. 1 (2015): 16. https://link.springer.com/article/10.1186/s40798-015-0024-x
- Lester, D. et al. "Participation in sports activities and suicide prevention". Int. J. Sport Psychol., 41: 58-72 (2010) http://www.ijsp-online.com/abstract/view/41/58
- Lester, David. "Participation in sports activities and suicidal behaviour: A risk or a protective factor?." International Journal of Sport and Exercise Psychology 15, no. 1 (2017): 103-108. https://www.tandfonline.com/doi/abs/10.1080/1612197X.2015.1073340
- Lezine, D.L. "Moving Forward with Attempt Survivors." Suicide Prevention Resource Center, April 30, 2014. https://www.sprc.org/news/moving-forward-attempt-survivors. . Accessed 7/30/2020
- Lindqvist, A‐S., Tommy Moberg, Christer Ehrnborg, Bengt O. Eriksson, Claudia Fahlke, and Thord Rosén. "Increased mortality rate and suicide in S wedish former elite male athletes in power sports." Scandinavian journal of medicine & science in sports 24, no. 6 (2014): 1000-1005. https://onlinelibrary.wiley.com/doi/abs/10.1111/sms.12122
- Lisa, Belzak, and Halverson Jessica. "Evidence synthesis-The opioid crisis in Canada: a national perspective." Health promotion and chronic disease prevention in Canada: research, policy and practice 38, no. 6 (2018): 224. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034966/
- Live Through This. Last modified July 15, 2020. https://livethroughthis.org. Accessed 7/30/2020
- Locci, Andrea, and Graziano Pinna. "Social isolation as a promising animal model of PTSD comorbid suicide: neurosteroids and cannabinoids as possible treatment options." Progress in neuro-psychopharmacology and biological psychiatry 92 (2019): 243-259. https://www.sciencedirect.com/science/article/abs/pii/S0278584618305839
- Locke, Edwin A. "Setting goals for life and happiness." Handbook of positive psychology 522 (2002): 299-312.
- Lutgen-Sandvik, Pamela. "Vicarious and secondary victimization in adult bullying and mobbing: Coworkers, target-partners, children, and friends." Workplace Bullying and Mobbing in the United States [2 volumes] (2018): 171-200.
- Maennig, Wolfgang. "On the economics of doping and corruption in international sports." Journal of sports economics 3, no. 1 (2002): 61-89. https://journals.sagepub.com/doi/abs/10.1177/1527002502003001005
- Maltsberger, John T. "Self break-up and the descent into suicide." Relating to self-harm and suicide: psychoanalytic perspectives on practice, theory and prevention (2008): 38-44.
- Maltsberger, John T. "The descent into suicide." The International Journal of Psychoanalysis 85, no. 3 (2004): 653-668. https://www.tandfonline.com/doi/abs/10.1516/3C96-URET-TLWX-6LWU
- Maltsberger, John T. "The descent into suicide." The International Journal of Psychoanalysis 85, no. 3 (2004): 653-668. https://www.tandfonline.com/doi/abs/10.1516/3C96-URET-TLWX-6LWU?journalCode=ripa20
- Mark, T., R. Coffey, R. Vandivort-Warren, H. Harwood, E. King. 2005. U.S. Spending for Mental and Substance Abuse Treatment, 1991–2001. Health Affairs (web exclusive).W5: 133–42. March 29, 2005.
- Marra, Realino, and Marco Orrù. "Social images of suicide." British Journal of Sociology (1991): 273-288. https://www.jstor.org/stable/590371?seq=1
- Masters, Ryan K., Andrea M. Tilstra, and Daniel H. Simon. "Mortality from suicide, chronic liver disease, and drug poisonings among middle-aged US white men and women, 1980–2013." Biodemography and social biology 63, no. 1 (2017): 31-37. https://www.tandfonline.com/doi/abs/10.1080/19485565.2016.1248892
- Math, Suresh Bada, Anupam Gupta, Ravi Yadav, and Dhaval Shukla. "The rights of persons with disability bill, 2014: Implications for neurological disability." Annals of Indian Academy of Neurology 19, no. Suppl 1 (2016): S28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109757/
- Mayo, D J. “The concept of rational suicide.” The Journal of medicine and philosophy vol. 11,2 (1986): 143-55 https://pubmed.ncbi.nlm.nih.gov/3734649/
- McCoy, Matthew S., Michael Carniol, Katherine Chockley, John W. Urwin, Ezekiel J. Emanuel, and Harald Schmidt. "Conflicts of interest for patient-advocacy organizations." New England Journal of Medicine 376, no. 9 (2017): 880-885. https://www.nejm.org/doi/full/10.1056/NEJMsr1610625
- McDonnell, Roberta. "Service Users in Perspective." In Creativity and Social Support in Mental Health, pp. 63-75. Palgrave Macmillan, London, 2014. https://link.springer.com/chapter/10.1057/9781137345486_4
- McGirr, Alexander, Gabriel Diaconu, Marcelo T. Berlim, Jens C. Pruessner, Rebecca Sablé, Sophie Cabot, and Gustavo Turecki. "Dysregulation of the sympathetic nervous system, hypothalamic–pituitary–adrenal axis and executive function in individuals at risk for suicide." Journal of psychiatry & neuroscience: JPN 35, no. 6 (2010): 399. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2964370/
- McGorry, Patrick D., Ian B. Hickie, Alison R. Yung, Christos Pantelis, and Henry J. Jackson. "Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions." Australian and New Zealand Journal of Psychiatry 40, no. 8 (2006): 616-622. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1440-1614.2006.01860.x
- McKinney, Jessica M., Jameson K. Hirsch, and Peter C. Britton. "PTSD symptoms and suicide risk in veterans: Serial indirect effects via depression and anger." Journal of affective disorders 214 (2017): 100-107. https://www.sciencedirect.com/science/article/abs/pii/S0165032716318043
- Menand, L., 2020. Why Freud Survives. [online] The New Yorker. Available at: <https://www.newyorker.com/magazine/2017/08/28/why-freud-survives> [Accessed 11 July 2020].
- Mendonca, James D., and Ronald R. Holden. "Are all suicidal ideas closely linked to hopelessness?."Acta Psychiatrica Scandinavica 93, no. 4 (1996): 246-251. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1600-0447.1996.tb10642.x
- Menninger, Karl A. 1938. Man against himself. New York: Harcourt, Brace.
- Menozzi, Filippo. "Fanon's letter: Between psychiatry and anticolonial commitment." Interventions 17, no. 3 (2015): 360-377. https://www.tandfonline.com/doi/abs/10.1080/1369801X.2014.991417
- Menzies, Robert, Brenda A. LeFrançois, and Geoffrey Reaume. "Introducing mad studies." Mad matters: A critical reader in Canadian mad studies (2013): 1-22. https://d1wqtxts1xzle7.cloudfront.net/31471868/Introducing_Mad_Studies.pdf
- Mezzich, Juan E. "The dialogal basis of our profession: psychiatry with the person." World Psychiatry 6, no. 3 (2007): 129. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174591/
- Mills, China. "Sly normality: Between quiescence and revolt." Psychiatry disrupted: Theorizing resistance and crafting the (r) evolution (2014): 208-224.
- Milona, Michael. "Philosophy of Hope." In Historical and Multidisciplinary Perspectives on Hope, pp. 99-116. Springer, Cham, 2020.
- Minkowitz, Tina. "CRPD Advocacy by the World Network of Users and Survivors of Psychiatry: The Emergence of an User/Survivor Perspective in Human Rights." Survivor Perspective in Human Rights (August 14, 2012) (2012). https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2326668
- Minkowitz, Tina. "CRPD Advocacy by the World Network of Users and Survivors of Psychiatry: The Emergence of an User/Survivor Perspective in Human Rights." Survivor Perspective in Human Rights (August 14, 2012) (2012). https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2326668
- Mishara, Brian L., and David N. Weisstub. "The legal status of suicide: A global review." International journal of law and psychiatry 44 (2016): 54-74. https://pubmed.ncbi.nlm.nih.gov/26375452/
- Monteith, Lindsey L., Ryan Holliday, Alexandra L. Schneider, Jeri E. Forster, and Nazanin H. Bahraini. "Identifying factors associated with suicidal ideation and suicide attempts following military sexual trauma." Journal of affective disorders 252 (2019): 300-309. https://www.sciencedirect.com/science/article/abs/pii/S0165032718327757
- Moore, K. "The American Lobotomy" Designed by Contexture International | http://www.contextureintl.com. . Accessed July 19, 2020. https://lobotomy.umwblogs.org .
- Morrell, Stephen, Richard Taylor, Susan Quine, and Charles Kerr. "Suicide and unemployment in Australia 1907–1990." Social science & medicine 36, no. 6 (1993): 749-756. https://www.sciencedirect.com/science/article/abs/pii/0277953693900353
- Morrell, Stephen, Richard Taylor, Susan Quine, and Charles Kerr. "Suicide and unemployment in Australia 1907–1990." Social science & medicine 36, no. 6 (1993): 749-756. https://www.sciencedirect.com/science/article/abs/pii/0277953693900353
- Morrison, Linda J. Talking back to psychiatry: The psychiatric consumer/survivor/ex-patient movement. Routledge, 2013. https://books.google.com/books?id=_eHaAAAAQBAJ&lpg=PP1&pg=PR7#v=onepage&q&f=false
- Mortier, Philippe et al. “Catalonia Suicide Risk Code Epidemiology (CSRC-Epi) study: protocol for a population-representative nested case-control study of suicide attempts in Catalonia, Spain.” BMJ open vol. 10,7 e037365. 12 Jul. 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359191/
- Mulder, Roger T., Annette L. Beautrais, Peter R. Joyce, and David M. Fergusson. "Relationship between dissociation, childhood sexual abuse, childhood physical abuse, and mental illness in a general population sample." American Journal of Psychiatry 155, no. 6 (1998): 806-811. https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/ajp.155.6.806
- Murray, Hannah L. "Survivor guilt in a posttraumatic stress disorder clinic sample." Journal of Loss and Trauma 23, no. 7 (2018): 600-607. https://ora.ox.ac.uk/objects/uuid:f54a4e52-3987-4fb1-8bb6-043f76dbef1a/download_file?safe_filename=Murray%25202019.pdf&file_format=application%2Fpdf&type_of_work=Journal+article
- Nakamura, J., & Csíkszentmihályi, M. “The concept of flow”. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 89–105). New York, NY, Oxford University Press (2002).
- Nasrallah, H.A. "The Antipsychiatry Movement: Who and Why." Current Psychiatry 10(12): 4-53 (2011) https://www.mdedge.com/psychiatry/article/64548/practice-management/antipsychiatry-movement-who-and-why
- Nasser, Mervat. "The rise and fall of anti-psychiatry." Psychiatric Bulletin 19, no. 12 (1995): 743-746. https://www.cambridge.org/core/journals/psychiatric-bulletin/article/rise-and-fall-of-antipsychiatry/C7BA890894B48BE211FFA12F8527A4C9
- National Action Alliance for Suicide Prevention, R. T. F. "A prioritized research agenda for suicide prevention: An action plan to save lives." Rockville, MD: National Institute of Mental Health and the Research Prioritization Task Force (2014). https://theactionalliance.org/sites/default/files/agenda.pdf
- Navarro, J. "Dangerous Cult Leaders." Psychology Today. Last modified August 25, 2012. https://www.psychologytoday.com/us/blog/spycatcher/201208/dangerous-cult-leaders. Accessed in 7/27/2020.
- Nbn2r.com - NBN New Knowledge, New Nomenclature. https://nbn2r.com . Accessed 8/14/2020.
- Nbn2r.com - NBN New Knowledge, New Nomenclature. https://nbn2r.com . Accessed 8/14/2020.
- Nicole, Wendee. "Hot Temperatures and Suicide Risk: New Insight into a Complex Topic." Environmental Health Perspectives 128, no. 7 (2020): 074005. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384755/
- Nock, Matthew K., Guilherme Borges, Evelyn J. Bromet, Jordi Alonso, Matthias Angermeyer, Annette Beautrais, Ronny Bruffaerts et al. "Cross-national prevalence and risk factors for suicidal ideation, plans and attempts." The British Journal of Psychiatry 192, no. 2 (2008): 98-105. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/crossnational-prevalence-and-risk-factors-for-suicidal-ideation-plans-and-attempts/BDD6458A563389FFE7E5226B7533BE98
- O’Connor, E., B. Gaynes, B. Burda, C. Williams, and E. Whitlock. "Screening for suicide risk in primary care: A systematic evidence review for the US Preventive Service Task Force Agency for Healthcare Research and Quality." Report 158 (2013): 741-754. https://www.ncbi.nlm.nih.gov/books/NBK137739/
- O'Connor, Patrick J., Matthew P. Herring, and Amanda Caravalho. "Mental health benefits of strength training in adults." American Journal of Lifestyle Medicine 4, no. 5 (2010): 377-396. https://journals.sagepub.com/doi/10.1177/1559827610368771
- Ohayi, Samuel Robsam. "“Doctor, please don’t say he died by suicide”: exploring the burden of suicide survivorship in a developing country." Egyptian Journal of Forensic Sciences 9, no. 1 (2019): 48. https://link.springer.com/article/10.1186/s41935-019-0153-3
- Open Access. "History of the Open Access Movement" https://open-access.net/en/information-on-open-access/history-of-the-open-access-movement . Accessed 8/11/2020.
- Ortiz, Bianca I., Kelly M. Shields, and Kevin A. Clauson. "HISTORY OF PHARMACOLOGICAL TREATMENTS FOR MENTAL HEALTH." (2015). https://d1wqtxts1xzle7.cloudfront.net/44106406/History_of_Pharmacological_Treatments_for_Mental_Health.pdf
- Pao, M., Mournet, A.M., Horowitz, L.M. "Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings." Psychiatric Times. Last modified July 23, 2020. https://www.psychiatrictimes.com/view/implementation-challenges-universal-suicide-risk-screening-adult-patients-general?eKey=bWVydG9uLm16bUBnbWFpbC5jb20=
- Pärssinen, M., U. Kujala, E. Vartiainen, S. Sarna, and T. Seppälä. "Increased premature mortality of competitive powerlifters suspected to have used anabolic agents." International journal of sports medicine 21, no. 03 (2000): 225-227. https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-2000-304
- Paschall, Mallie J., and Diana H. Fishbein. "Executive cognitive functioning and aggression: A public health perspective." Aggression and Violent Behavior 7, no. 3 (2002): 215-235. https://www.sciencedirect.com/science/article/abs/pii/S1359178900000446
- Pedersen, Bente Klarlund. "Physical activity and muscle–brain crosstalk." Nature Reviews Endocrinology 15, no. 7 (2019): 383. https://www.nature.com/articles/s41574-019-0174-x
- Pergolizzi, Joseph V., Melanie Rosenblatt, and Jo Ann LeQuang. "Three years down the road: the aftermath of the CDC guideline for prescribing opioids for chronic pain." Advances in therapy 36, no. 6 (2019): 1235-1240. https://link.springer.com/article/10.1007/s12325-019-00954-1
- Perlin, Michael L. "International human rights and comparative mental disability law: The role of institutional psychiatry in the suppression of political dissent." Isr. L. Rev. 39 (2006): 69. https://digitalcommons.nyls.edu/cgi/viewcontent.cgi?article=2090&context=fac_articles_chapters
- Petrosky, Emiko, Rafael Harpaz, Katherine A. Fowler, Michele K. Bohm, Charles G. Helmick, Keming Yuan, and Carter J. Betz. "Chronic pain among suicide decedents, 2003 to 2014: findings from the national violent death reporting system." Annals of internal medicine 169, no. 7 (2018): 448-455. https://www.acpjournals.org/doi/full/10.7326/M18-0830
- Phillips, Julie A. "A changing epidemiology of suicide? The influence of birth cohorts on suicide rates in the United States." Social Science & Medicine 114 (2014): 151-160. https://www.sciencedirect.com/science/article/abs/pii/S0277953614003323
- Phillips, Julie A. "A changing epidemiology of suicide? The influence of birth cohorts on suicide rates in the United States." Social Science & Medicine 114 (2014): 151-160. https://www.sciencedirect.com/science/article/abs/pii/S0277953614003323
- Pitman, Alexandra, Hedvig Nesse, Nicola Morant, Valeriya Azorina, Fiona Stevenson, Michael King, and David Osborn. "Attitudes to suicide following the suicide of a friend or relative: A qualitative study of the views of 429 young bereaved adults in the UK." BMC psychiatry 17, no. 1 (2017): 400. https://link.springer.com/article/10.1186/s12888-017-1560-3
- Pitman, Alexandra, Hedvig Nesse, Nicola Morant, Valeriya Azorina, Fiona Stevenson, Michael King, and David Osborn. "Attitudes to suicide following the suicide of a friend or relative: A qualitative study of the views of 429 young bereaved adults in the UK." BMC psychiatry 17, no. 1 (2017): 400. https://link.springer.com/content/pdf/10.1186/s12888-017-1560-3.pdf
- Plotsky, Paul M., Michael J. Owens, and Charles B. Nemeroff. "Psychoneuroendocrinology of depression: hypothalamic-pituitary-adrenal axis." Psychiatric Clinics of North America 21, no. 2 (1998): 293-307. https://d1wqtxts1xzle7.cloudfront.net/55753811/ПСИХОНУРНОЭНДОКРИНОЛОГ.pdf
- Plutchik, Robert. "The nature of emotions: Human emotions have deep evolutionary roots, a fact that may explain their complexity and provide tools for clinical practice." American Scientist 89, no. 4 (2001): 344-350. https://www.jstor.org/stable/27857503?seq=1
- Poland, Scott, Richard Lieberman, and Marina Niznik. "Suicide contagion and clusters—Part 1: What school psychologists should know." Communique 47, no. 5 (2019). https://www.nova.edu/suicideprevention/suicide_contagion_and_clusters_part_1_what_school_psychologists_should_know.pdf
- Portacolone, Elena, Steven P. Segal, Roberto Mezzina, Nancy Scheper-Hughes, and Robert L. Okin. "A tale of two cities: The exploration of the Trieste public psychiatry model in San Francisco." Culture, Medicine, and Psychiatry 39, no. 4 (2015): 680-697. https://pubmed.ncbi.nlm.nih.gov/25998781/
- Power Unlimited. Directed by Gabriel Sorensen. 2007. Iron Bug Productions, 2007. Film. http://www.powerunlimitedthemovie.com
- Powerlifting Motivation. "Planet Fitness Throws Out a Powerlifter". Youtube, Jan 20, 2016. https://youtu.be/v7IYULzyPM0 . Accessed in 7/27/2020.
- Pritchard, Colin, Wajid Iqbal, and Rosslyn Dray. "Undetermined and accidental mortality rates as possible sources of underreported suicides: population-based study comparing Islamic countries and traditionally religious Western countries." BJPsych Open 6, no. 4 (2020). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7345585/
- Public Library of Science. "PLOS". https://plos.org/ Accessed 8/11/2020.
- Putnam, Hilary. "The nature of mental states." The philosophy of mind: Classical problems/contemporary issues (1992): 51-58.
- Quinnett, Paul. "QPR gatekeeper training for suicide prevention: The model, theory, and research." Unpublished manuscript (2013).
- Quinnett, Paul. "QPR: Police suicide prevention." FBI L. Enforcement Bull. 67 (1998): 19. https://qprinstitute.com/uploads/instructor/Police-Chapter-June-1st.pdf
- Racine, Mélanie. "Chronic pain and suicide risk: A comprehensive review." Progress in Neuro-Psychopharmacology and Biological Psychiatry 87 (2018): 269-280. https://www.sciencedirect.com/science/article/abs/pii/S0278584617304670
- Ralley, Oliver Josef Dumolo. "The rise of anti-psychiatry: A historical review." History of Medicine Online (2012). https://priory.com/history_of_medicine/Anti-Psychiatry.htm
- Ramstrand, Nerrolyn, Terje Gjøvaag, Inger Marie Starholm, and David F. Rusaw. "Effects of knee orthoses on kinesthetic awareness and balance in healthy individuals." Journal of rehabilitation and assistive technologies engineering 6 (2019): 2055668319852537. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683322/
- Rao, Ashwin L., and Eugene S. Hong. "Understanding depression and suicide in college athletes: emerging concepts and future directions." (2016): 136-137. https://bjsm.bmj.com/content/50/3/136.short
- Rao, Ashwin L., Irfan M. Asif, Jonathan A. Drezner, Brett G. Toresdahl, and Kimberly G. Harmon. "Suicide in National Collegiate Athletic Association (NCAA) athletes: a 9-year analysis of the NCAA resolutions database." Sports health 7, no. 5 (2015): 452-457. https://journals.sagepub.com/doi/abs/10.1177/1941738115587675
- Rashed, M.A. the relationship between anti-psychiatry and mental health activism. Abridged Transcript of a Talk Delivered at the Freud Museum, London, on the 3rd of May 2019
- Rashed, Mohammed Abouelleil. "In defense of madness: the problem of disability." In The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, vol. 44, no. 2, pp. 150-174. US: Oxford University Press, 2019 (a). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420721/
- Rashed, Mohammed Abouelleil. "The Identity of Psychiatry and the Challenge of Mad Activism Rethinking the Clinical Encounter." Journal of Medicine and Philosophy, in press, 2020. https://d1wqtxts1xzle7.cloudfront.net/61634899/Rashed.M.A.JMP.Identity.of.Psychiatry20191229-107196-13nw1vy.pdf
- Rashed, Mohammed Abouelleil. Madness and the demand for recognition: A philosophical inquiry into identity and mental health activism. Oxford University Press, 2019 (b).
- Reaume, Geoffrey. "Lunatic to patient to person: nomenclature in psychiatric history and the influence of patients' activism in North America." International Journal of Law and Psychiatry (2002). https://pubmed.ncbi.nlm.nih.gov/12613052/
- Renter, E. "What Medicare Doesn't Cover: A Preretiree's Guide." Next Avenue. Last modified September 16, 2014. https://www.nextavenue.org/what-medicare-doesnt-cover-preretirees-guide/.
- Reynald, Danielle M., and Henk Elffers. "The Future of Newman's Defensible Space Theory Linking Defensible Space and the Routine Activities of Place." European Journal of Criminology 6.1 (2009): 25-46 https://journals.sagepub.com/doi/abs/10.1177/1477370808098103
- Riek, Blake M., Eric W. Mania, and Samuel L. Gaertner. "Intergroup threat and outgroup attitudes: A meta-analytic review." Personality and social psychology review 10, no. 4 (2006): 336-353. http://www.people.fas.harvard.edu/~banaji/people/labmembers/Pictures%20of%20Old%20Lab/Pers%20Soc%20Psychol%20Rev-2006-Riek-336-53.pdf
- Roberts, Ron, and Theodor Itten. "Laing and Szasz: Anti-psychiatry, capitalism, and therapy." The Psychoanalytic Review 93, no. 5 (2006): 781-800. https://guilfordjournals.com/doi/pdf/10.1521/prev.2006.93.5.781
- Robinson, Emma. "Psychopharmacology: From serendipitous discoveries to rationale design, but what next?." Brain and Neuroscience Advances 2 (2018): 2398212818812629. https://journals.sagepub.com/doi/full/10.1177/2398212818812629
- Rolles, Stephen, and Craig McClure. After the war on drugs: Blueprint for regulation. Transform Drug Policy Foundation, 2009. https://transformdrugs.org/wp-content/uploads/2020/07/Blueprint-1.pdf
- Rosino, Michael L., and Matthew W. Hughey. "The War on Drugs, Racial Meanings, and Structural Racism: A Holistic and Reproductive Approach." American Journal of Economics and Sociology 77, no. 3-4 (2018): 849-892. https://d1wqtxts1xzle7.cloudfront.net/57657563/RosinoHughey.2018.pdf
- Rubinstein, Gidi. "Macho man: Narcissism, homophobia, agency, communion, and authoritarianism--a comparative study among Israeli bodybuilders and a control group." Psychology of Men & Masculinity 4, no. 2 (2003): 100. https://pdfs.semanticscholar.org/6a9d/a9ee17f92b465b4a12b5a8ff866d5738000e.pdf
- Sade, Robert M. "Introduction: Opioid Controversies: The Crisis—Causes and Solutions." The Journal of Law, Medicine & Ethics 48, no. 2 (2020): 238-240. https://journals.sagepub.com/doi/abs/10.1177/1073110520935334
- Samet, Jeffrey H., and Stefan G. Kertesz. "Suggested paths to fixing the opioid crisis: directions and misdirections." JAMA Network Open 1, no. 2 (2018): e180218-e180218. https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2682874
- Saxby Pridmore, Garry Walter. "Suicide and forced marriage." The Malaysian journal of medical sciences: MJMS 20, no. 2 (2013): 47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743999/
- Saxena, Shekhar, Michelle Funk, and Dan Chisholm. "World health assembly adopts comprehensive mental health action plan 2013–2020." The Lancet 381, no. 9882 (2013): 1970-1971 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61139-3/fulltext
- Schlich, Thomas. "Asepsis and bacteriology: a realignment of surgery and laboratory science." Medical history 56, no. 3 (2012): 308-334. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426977/
- Schneid, Iris, and Aviad E. Raz. "The mask of autism: Social camouflaging and impression management as coping/normalization from the perspectives of autistic adults." Social Science & Medicine 248 (2020): 112826. https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13296
- Scull, Andrew. "Contested jurisdictions: Psychiatry, psychoanalysis, and clinical psychology in the United States, 1940–2010." Medical history 55, no. 3 (2011): 401-406. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143860/
- Scutchfield, F. Douglas, and C. William Keck. "Deaths of despair: Why? what to do?." American journal of public health 107, no. 10 (2017): 1564. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607684/
- Severinsen, Mai Charlotte Krogh, and Bente Klarlund Pedersen. "Muscle–Organ Crosstalk: The Emerging Roles of Myokines." Endocrine Reviews 41, no. 4 (2020): bnaa016. https://academic.oup.com/edrv/article/41/4/594/5835999
- Shanahan, Lilly, Sherika N. Hill, Lauren M. Gaydosh, Annekatrin Steinhoff, E. Jane Costello, Kenneth A. Dodge, Kathleen Mullan Harris, and William E. Copeland. "Does despair really kill? A roadmap for an evidence-based answer." American journal of public health 109, no. 6 (2019): 854-858. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506367/
- Shanahan, Lilly, Sherika N. Hill, Lauren M. Gaydosh, Annekatrin Steinhoff, E. Jane Costello, Kenneth A. Dodge, Kathleen Mullan Harris, and William E. Copeland. "Does despair really kill? A roadmap for an evidence-based answer." American journal of public health 109, no. 6 (2019): 854-858. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506367/
- Shatan, Chaim. "Unconscious motor behavior, kinesthetic awareness and psychotherapy." American journal of psychotherapy 17, no. 1 (1963): 17-30. https://psychotherapy.psychiatryonline.org/doi/abs/10.1176/appi.psychotherapy.19188.8.131.52?journalCode=apt
- Sherouse, Perry. "Skill and masculinity in Olympic weightlifting: Training cues and cultivated craziness in Georgia." American Ethnologist 43, no. 1 (2016): 103-115. https://anthrosource.onlinelibrary.wiley.com/doi/abs/10.1111/amet.12266
- Shiels, Meredith S., Pavel Chernyavskiy, William F. Anderson, Ana F. Best, Emily A. Haozous, Patricia Hartge, Philip S. Rosenberg, David Thomas, Neal D. Freedman, and Amy Berrington de Gonzalez. "Trends in premature mortality in the USA by sex, race, and ethnicity from 1999 to 2014: an analysis of death certificate data." The Lancet 389, no. 10073 (2017): 1043-1054. https://www.sciencedirect.com/science/article/abs/pii/S0140673617301873
- Shiva, Vandana. Biopiracy: The plunder of nature and knowledge. North Atlantic Books, 2016.
- Shorter, Edward. "History of psychiatry." Current opinion in psychiatry 21, no. 6 (2008): 593. https://pubmed.ncbi.nlm.nih.gov/30786241/
- Smith, E. et al "Convergence Mental Health: A New Pathway for Transdisciplinary Innovation and Entrepreneurship". Psychiatric Times, 37:7 (2020) https://www.psychiatrictimes.com/view/convergence-mental-health-new-pathway-transdisciplinary-innovation-entrepreneurship?eKey=
- Smith, Hilary A., Andrea L. Wolfe-Clark, and Craig J. Bryan. "An exploratory study of the mental toughness psychological skills profile psychometrics, and the mediating effect of social support sources on mental toughness and suicidal ideation among military police." Journal of Police and Criminal Psychology 31, no. 4 (2016): 295-303. https://link.springer.com/article/10.1007/s11896-016-9192-y
- Smith, Sean M., and Wylie W. Vale. "The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress." Dialogues in clinical neuroscience 8, no. 4 (2006): 383. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181830/
- Smolik, Petr. "Validity of nosological classification." Dialogues in clinical neuroscience 1, no. 3 (1999): 185. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181576/
- Snyder, C. Rick, Susie C. Sympson, Florence C. Ybasco, Tyrone F. Borders, Michael A. Babyak, and Raymond L. Higgins. "Development and validation of the State Hope Scale." Journal of personality and social psychology 70, no. 2 (1996): 321. https://psycnet.apa.org/record/1996-01717-010
- Snyder, Charles R., Kevin L. Rand, and David R. Sigmon. "Hope theory: A member of the positive psychology family." (2002). https://psycnet.apa.org/record/2002-02382-019
- Soreanu, Raluca. "Something was lost in Freud’s Beyond the pleasure principle: A Ferenczian reading." The American Journal of Psychoanalysis 77, no. 3 (2017): 223-238.
- Spandler, Helen. Asylum to action: Paddington day hospital, therapeutic communities and beyond. Vol. 16. Jessica Kingsley Publishers, 2006. https://books.google.co.uk/books?id=asWmvO6XHOIC&lpg=PA167&dq=%22Scottish%20Union%20of%20Mental%20Patients%22&pg=PA167#v=onepage&q=%22Scottish%20Union%20of%20Mental%20Patients%22&f=false
- Sporns, Olaf, Giulio Tononi, and Rolf Kötter. "The human connectome: a structural description of the human brain." PLoS Comput Biol 1, no. 4 (2005): e42. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1239902/
- Stack, Steven. "Suicides linked to warming." Nature plants 3, no. 10 (2017): 763-764. https://www.nature.com/articles/s41477-017-0029-1/
- Staff, WIRED. "White House Must Respond to Petition to Remove U.S. Attorney in Aaron Swartz Case." WIRED. Last modified January 15, 2013. https://www.wired.com/2013/01/aaron-swartz-prosecutor/ . Accessed 8/11/2020.
- Stein, Dan J., Crick Lund, and Randolph M. Nesse. "Classification systems in psychiatry: diagnosis and global mental health in the era of DSM-5 and ICD-11." Current opinion in psychiatry 26, no. 5 (2013): 493. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4270276/
- Stickings, Tim. "Horror of the Lobotomy is Revealed in Before-and-after Images." Mail Online. Last modified February 25, 2019. https://www.dailymail.co.uk/news/article-6742297/Horror-lobotomy-revealed-images.html. Accessed in 7/19/2020.
- Stone, M., H. O’Bryant, J. Garhammer, and J. McMillan. "Biomechanical characteristics of movement phases of snatch style in performace weightlifting." (2013). https://www.analefefs.ro/anale-fefs/2013/s1/pe-autori/45.pdf
- Stupak, Radosław, and Krzysztof Dyga. "Postpsychiatry and postmodern psychotherapy: Theoretical and ethical issues in mental health care in a Polish context." Theory & Psychology 28, no. 6 (2018): 780-799. https://d1wqtxts1xzle7.cloudfront.net/57518481/0959354318802973.pdf
- Substance Abuse and Mental Health Services Administration. Suicide Clusters within American Indian and Alaska Native Communities: A review of the literature and recommendations. HHS Publication No. SMA17-5050. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2017. https://store.samhsa.gov/sites/default/files/d7/priv/sma17-5050.pdf
- Sullivan, Peter. "What Sports Have the Worst Doping Problems?" Foreign Policy. Last modified June 29, 2013. https://foreignpolicy.com/2013/06/29/what-sports-have-the-worst-doping-problems/#:~:text=Over%20those%20eight%20years%2C%20cycling,rate%20of%20
- Suokas, J., and J. Lönnqvist. "Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms." Acta Psychiatrica Scandinavica 91, no. 1 (1995): 36-40. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1600-0447.1995.tb09739.x
- Swann, Christian, David Piggott, Matthew Schweickle, and Stewart A. Vella. "A review of scientific progress in flow in sport and exercise: normal science, crisis, and a progressive shift." Journal of Applied Sport Psychology 30, no. 3 (2018): 249-271. https://www.tandfonline.com/doi/abs/10.1080/10413200.2018.1443525
- Swann, Christian. "Flow in sport." In Flow experience, pp. 51-64. Springer, Cham, 2016.
- Szasz, T. The Myth of Mental Illness. New York, Harper, 1961.
- The Antipsychiatry Coalition. https://www.antipsychiatry.org. Accessed 8/9/2020.
- Thiblin, Ingemar, Bo Runeson, and Jovan Rajs. "Anabolic androgenic steroids and suicide." Annals of Clinical Psychiatry 11, no. 4 (1999): 223-231. https://link.springer.com/article/10.1023/A:1022313529794
- Tobias, M. L., and J. Lalich. "Captive minds, captive hearts." Alameda, CA: Hunter House Inc. Publishers (1994).
- Torrey, E Fuller. “Patients, clients, consumers, survivors et al: what's in a name?.” Schizophrenia bulletin vol. 37,3 (2011): 466-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080679/pdf/sbq102.pdf
- Trenton, Adam J., and Glenn W. Currier. "Behavioural manifestations of anabolic steroid use." CNS drugs 19, no. 7 (2005): 571-595. https://link.springer.com/article/10.2165/00023210-200519070-00002
- Tuck, Andrew. "Why Did American Psychiatry Abandon Psychoanalysis? Authority and the Production of Knowledge in Twentieth Century Science." PhD diss., 2014. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/107788/antuck.pdf?sequence=1
- Tuthill, J.C, & E. Azim. "Proprioception". Current Biology, 28:5, pr194-203, 2018. https://www.cell.com/current-biology/fulltext/S0960-9822(18)30097-6
- Uhlén, Mathias et al. “The human secretome.” Science signaling vol. 12,609 eaaz0274. 26 Nov. 2019 https://pubmed.ncbi.nlm.nih.gov/31772123/
- UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS. Indictment. UNITED STATES OF AMERICA v. AARON SWARTZ, Defendant. July 14, 2011. http://s3.documentcloud.org/documents/217115/20110719-schwartz.pdf . Accessed 8/11/2020.
- US Department of Health and Human Services. "Hipaa privacy rule and sharing information related to mental health." Office for Civil Rights. https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf (2014).
- US Drug Enforcement Administration (USDEA). "2018 National Drug Threat Assessment." https://www.dea.gov/sites/default/files/2018-11/DIR-032-18%202018%20NDTA%20final%20low%20resolution.pdf
- Vernon, Laura. "Mind and muscle: Considering weightlifting as a contemplative practice." The Journal of Contemplative Inquiry 5, no. 1 (2018). https://journal.contemplativeinquiry.org/index.php/joci/article/view/142
- Wagshul, Yitzchok D. "Effect of external locus‐of‐hope on acquired capability for suicide." Suicide and Life‐Threatening Behavior 49, no. 6 (2019): 1541-1551. https://onlinelibrary.wiley.com/doi/abs/10.1111/sltb.12539
- Ward, Colleen A., Stephen Bochner, and Adrian Furnham. The psychology of culture shock. Psychology Press, 2001.
- Weber, René, Richard Huskey, and Britney Craighead. "FLOW EXPERIENCES AND WELL-BEING." The Routledge handbook of media use and well-being: International perspectives on theory and research on positive media effects (2016). https://www.researchgate.net/profile/Richard_Huskey/publication/305163274_Flow_experiences_and_well-being_A_media_neuroscience_perspective/links/5785484908ae3949cf538c6c/Flow-experiences-and-well-being-A-media-neuroscience-perspective.pdf
- Welle S. "Endocrine, Paracrine, and Autocrine Regulation." In: Human Protein Metabolism. Springer, New York, NY (1999). https://link.springer.com/chapter/10.1007/978-1-4612-1458-8_6#citeas
- Westside vs. the World. Directed by Michael Fahey. 2019. Film. https://www.westsidevstheworld.com
- Whitaker, Robert. Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill. Basic Books, 2001. https://www.madinamerica.com https://en.wikipedia.org/wiki/Mad_in_America
- White, Ross G., and Sivasankaran Pi Sashidharan. "Towards a more nuanced global mental health." The British Journal of Psychiatry 204, no. 6 (2014): 415-417. https://eprints.gla.ac.uk/93553/1/93553.pdf
- Whitley, Rob. "The antipsychiatry movement: dead, diminishing, or developing?." Psychiatric Services 63, no. 10 (2012): 1039-1041. https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201100484
- Whitworth, James W., Sanaz Nosrat, Nicholas J. SantaBarbara, and Joseph T. Ciccolo. "Feasibility of resistance exercise for posttraumatic stress and anxiety symptoms: a randomized controlled pilot study." Journal of Traumatic Stress 32, no. 6 (2019): 977-984. https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.22464
- Widiger, Thomas A., and Douglas B. Samuel. "Diagnostic categories or dimensions? A question for the Diagnostic and statistical manual of mental disorders--." Journal of abnormal psychology 114, no. 4 (2005): 494. https://psycnet.apa.org/record/2005-15138-002
- Wilson, Coralie J. "A caution for suicide prevention focused on help-seeking in young people." Aust. NZJ Psychiatry 51 (2017): 1255. https://www.researchgate.net/profile/Coralie_Wilson/publication/319758264_A_caution_for_suicide_prevention_focused_on_help-seeking_in_young_people/links/5a0019d8a6fdcca1f29f1937/A-caution-for-suicide-prevention-focused-on-help-seeking-in-young-people.pdf
- Witvliet, Daniel, Ben Mulcahy, James K. Mitchell, Yaron Meirovitch, Daniel K. Berger, Yuelong Wu, Yufang Liu et al. "Connectomes across development reveal principles of brain maturation in C. elegans." bioRxiv (2020). https://www.biorxiv.org/content/10.1101/2020.04.30.066209v2
- Wong, S. F. "The Influence of Unwanted Entrainment with Low Frequencies in Techno Music on Performance and Mental Exhaustion." Master's thesis, 2018. https://dspace.library.uu.nl/handle/1874/367379
- World Health Organization (WHO) (2014) Preventing suicide. A global imperative. World Health Organization: Geneva. Available at: http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/
- World Health Organization. "Mental health action plan 2013-2020." (2013). https://apps.who.int/iris/bitstream/handle/10665/89966/9789241506021_eng.pdf
- World Health Organization. Neurological disorders: public health challenges. World Health Organization, 2006. https://www.who.int/mental_health/neurology/neurodiso/en/
- World Health Organization. World report on disability 2011. World Health Organization, 2011. https://apps.who.int/iris/bitstream/handle/10665/44575/9789240685215_eng.pdf
- World Network of Users and Survivors of Psychiatry. "Implementation manual for the United Nations Convention on the Rights of Persons with Disabilities." (2008). http://www.wnusp.net/documents/WNUSP_CRPD_Manual.pdf
- World Network of Users and Survivors of Psychiatry. "Implementation manual for the United Nations Convention on the Rights of Persons with Disabilities." (2008). http://www.wnusp.net/documents/WNUSP_CRPD_Manual.pdf
- Wright, M. D., and A. Bruce. "An historical review of electroconvulsive therapy." Jefferson Journal of Psychiatry 8, no. 2 (1990): 10. https://jdc.jefferson.edu/cgi/viewcontent.cgi
- Yen, Shirley, Kevin Kuehn, Katherine Tezanos, Lauren M. Weinstock, Joel Solomon, and Anthony Spirito. "Perceived family and peer invalidation as predictors of adolescent suicidal behaviors and self-mutilation." Journal of child and adolescent psychopharmacology 25, no. 2 (2015): 124-130. https://www.liebertpub.com/doi/abs/10.1089/cap.2013.0132