by Michael D. Anestis, Ph.D.
Over the past month or so, I feel as though I've seen a surge of articles recognizing suicide as the primary factor in gun related deaths in the US and promoting the utility of means restriction and means safety in preventing suicide. Our lab has been fortunate to be involved in some of those articles (New York Times, Los Angeles Times, CNN, Mississippi Public Broadcasting, Charleston Gazette), but the media coverage has extended well beyond our work. Ultimately, this coverage has rightfully touted the powerful role that firearms legislation (means restriction) and gun safety efforts (means safety) can have in preventing suicide.
This is, without question, a positive development and I want to make sure that the conversation remains almost entirely focused on that fact. When suicide is in the national conversation, that's good news for suicide prevention. When means restriction/safety is discussed as a potential tool for preventing suicide, that's remarkably good news for those suffering with thoughts of suicide. Nitpicking about errors at the expense of good coverage is a disservice to the field.
I'm still a nerd though and I can't help but feel a bit frustrated by a common thread throughout much of this news coverage: the idea that means safety works because "suicide is impulsive," so restricting access in the moment works because it prevents an unplanned and explosively emerging behavior from occurring. On an intuitive level, I can kind of see the logic there, but the data simply do not back up this assertion and this has serious clinical implications.
As I've noted several times on PBB before, we've done a lot of work on the relationship between impulsivity and suicide (here's an article I wrote summarizing some of that work a while back). What we found in a review paper published in Personality and Social Psychology Review was that:
(1) How impulsive an individual is in general has only a small relationship with prior attempts, is a poor predictor of future attempts, and is unrelated to death by suicide
(2) The small relationship between how impulsive an individual is and suicidal behavior is mediated (statistically explained) by the painful and provocative behaviors that impulsive individuals tend to encounter at a higher rate and which, over time, facilitate an individual's ability to engage in suicidal behavior
(3) Studies that have attempted to measure how impulsive specific suicide attempts have been crippled by enormous methodological problems and, for obvious reasons, are limited to non-lethal suicide attempts (which appear likely to differ from lethal suicidal behavior in a number of meaningful ways).
One of the issues to consider here is what we mean when we say a suicide attempt is impulsive. If an individual has been thinking off and on about a suicide attempt for an extended period of time, but was not thinking about it continuously in the days and weeks leading up to an attempt, how we ask the question might prompt that individual to say he or she started thinking about suicide in the moments leading up to the behavior. In some ways, you could argue then that the behavior emerged suddenly. At the same time....doesn't that describe almost all of our behaviors during a given day? How many behaviors did you plan extensively for days or even hours at a time leading up to the decision today? It seems we may be holding suicide to a different standard here, which has important clinical implications because, if suicide emerges suddenly without warning or plans, our ability to prevent it would be very stunted.
Stephanie Pennings, Tabatha Williams, and I addressed this question with a recent study in which we showed that the most common response for individuals with a suicide attempt is that they had been thinking off and on about attempting suicide using the actual method they ultimately chose (so not just thinking about it in general) for a period of years leading up to the attempt.
So....the weight of the evidence seems to support the idea that suicide is rarely if ever an impulsive and unplanned behavior. People need to stop thinking about suicide as a frantic and sudden escape from acute crises and instead think about it as a calculated pursuit of death that requires a willingness to persist through the pain, discomfort, and fear that comes along with suicidal behavior (here's David Klonsky talking about this very topic in an exceptional recent article in the Psychiatric Times)
So why is this particularly relevant to firearms suicide? Well, if we cast aside concerns regarding how the impulsiveness of a specific suicide attempt is measured, you'll note that there is a consistent finding that the more impulsive a suicide attempt is, the less lethal that attempt tends to be. If that's the case, it would indicate that impulsive attempts (if they happen) do not involve firearms, which have a lethality rate greater than 80%.
Okay then....if means restriction/means safety does not work because of impulsivity, why does it work? This question requires more research, but here's my response: suicide is hard. If you accept the "non-impulsive" model, then you can embrace the idea that individuals spend a good amount of time thinking about and preparing themselves to use a specific method that suits them to engage in a behavior that is terrifying. When you make that terrifying behavior that much more difficult, you lower the odds that it will ultimately happen. That might sound simple, but to me it seems to align with most other things in life. There are plenty of behaviors we are ambivalent about or resistant to on any given day and, when something makes them a bit harder, we often opt against doing them.
Like I said earlier, my overall feeling is that it is wonderful that the media is discussing firearms and suicide. Despite accounting for a large majority of firearm deaths in the US, suicide has historically been left out of the conversation, so this is a big step. That being said, let's not get ahead of ourselves by promoting faulty models of suicide that do not align with the data. Doing so weakens our arguments, promotes the continued survival of myths about suicide, and leaves experts arguing with each other (something I'm clearly contributing to here) rather than working together to promote suicide prevention.
Mike Anestis, Ph.D. is the Nina Bell Suggs Professor of Psychology at the University of Southern Mississippi and the director of the Suicide and Emotion Dysregulation lab.