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What about China?

By David Covington, L.P.C., M.B.A., Chief of Adult Services, Maricopa County Regional Behavioral Health Authority, Magellan Health Services

It was 1996 when I started working nights as a behavioral health assessor but I still remember what it was like being awoken by the beep-beep-beep of my pager that a local Emergency Department was requesting a consult. Late one particular night I was called because a 17 year old had made a suicide “gesture.” When I arrived, I overheard the physician telling the charge nurse that it was not medically necessary, but that he had ordered a charcoal lavage nonetheless “to teach her a lesson.”

I walked into the room to find the young woman with a large bore tube down her throat. As we attempted to communicate, she would have to stop periodically to spit up black chunks of charcoal. I would later learn that the procedure is not without serious safety risks, but I didn’t need to know that to draw the conclusion that the response was inhumane. The medical staff had already made their own psychological assessment prior to the first behavioral health question ever being asked.

“Individuals who commit suicide and suicide attempters are two completely different groups that bear no resemblance to one another.” This is the myth that formed the foundation of their thinking. She had made a non-lethal suicide attempt, and so she must be attention-seeking or manipulative. Either way, she was wasting their valuable time and distracting them from individuals who really needed their care.

Fifteen years later, this myth persists, and it is understandable why. Take one look at the demographics and it seems clear. Nearly 80% of those who die are males, but women make three times as many attempts. The American Association of Suicidology estimates that teenagers make one to two hundred attempts for every suicide death while older people experience death every four attempts. Most who attempt suicide do not die, though most that die by suicide die on their first attempt.

In September, Dr. John Draper, Dr. Richard McKeon, Dr. Brian Mishara, Eduardo Vega, and I will travel to Beijing, China for the XXVI World Congress conducted by the International Association of Suicide Prevention. We will present a paper on standards for helping those at imminent risk of suicide, guidelines that have been developed by the National Suicide Prevention Lifeline in concert with SAMHSA. They represent the follow-up to the Suicide Risk Assessment Standards (SRAS) that were published in the Journal of Suicide and Life-threatening Behavior in 2007.

The SRAS core principles contained the answer to the riddle above with the new concept of “capability,” which was introduced by Dr. Thomas Joiner in his 2005 groundbreaking work Why People Die by Suicide. Prior to that time, the suicide prevention field simply did not have an answer to the demographics dichotomy described above. However, if anyone believed the two group myth, it might be Dr. Thomas Joiner (see Chapter One regarding his father’s suicide in 1996). Instead, Joiner argued that the internal psychiatric experience was the same for those who attempt and those who die.

The “Interpersonal Theory of Suicide” suggested the key difference was the presence of capability, defined as a combination of acquired fearlessness and competency. In general, males and older adults tend to have training and experiences that prepare them to tackle these barriers of self-preservation in ways females and younger people do not.

What about China? I challenge those who cling to the two group myth to explain the demographics of suicide in China, where it is estimated nearly one suicide death occurs for every two that occur in the rest of the world combined (300,000 deaths annually). The problem for the two group myth: China is the only country in the world in which the female suicide death rate is higher than the male rate. Women commonly drink pesticide to end their lives, which is readily available in rural areas.

Columbia University’s Dr. Madelyn Gould is one of the nation’s top experts in suicide prevention among adolescents. She disagrees with the myth, stating that her analysis of teenage psychiatric profiles among those who die and those who attempt is remarkably similar.

It is time for a more accurate and humane response than the artificial boxing of the two group myth, that supports all those who struggle with emotional pain so great that ending their life seems the only way out. Above all, it is time to listen to those who struggle with the desire to die, but find ways to overcome. We have missed a tremendous opportunity to learn more about those who have died from those who are still alive. Let’s not waste another moment.

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