“Mixed Bag” is a series where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item, they have to explain why they selected it and what it signifies. — Awais Aftab
Glenn R. Sullivan, PhD, is a professor of psychology at the Virginia Military Institute and a clinical psychologist in private practice in Lexington, Virginia. He is the co-author (with Bruce Bongar, PhD) of The Suicidal Patient: Clinical and Legal Standards of Care, and of the forthcoming The Suicidal Patient: A Guide for Clinicians (American Psychological Association, 2026). For nearly twenty years, his practice has focused on providing psychotherapy to patients recently discharged from psychiatric hospitals. You can find him on X/Twitter: @drglennsullivan
Book — The Suicidal Mind by Edwin S. Shneidman (1998)
I recommend this book to anyone interested in suicide, either clinically or phenomenologically. Dr. Shneidman is the Founding Father of the scientific study of suicide in the United States and he published this classic in 1996 as a way of summing up what he had learned over five decades of research and clinical work. The three vivid case studies featured in the book are what tend to stick in readers’ minds for years afterwards, but there are also a host of clinically valuable insights, e.g.:
[I]n order to understand suicide, we need to think about what anguish means, as well as why people entertain thoughts of death, especially death as a way of stopping unbearable misery. Suicidal death, in other words, is an escape from pain.
Shneidman asked his patients, “Where do you hurt?” and “How can I help?” He sought to chip away at the suicidal patient’s cognitive constriction, i.e., his or her tendency to see suicide as the only solution to the problem of unbearable psychological pain. In one of my favorite episodes recounted in the book, Shneidman reviews a set of blinded life histories of male participants in Lewis Terman’s famous longitudinal study of high-IQ children and accurately predicts who died by suicide and who did not. (A childhood marked by an emotionally or physically absent father, disappointment in work, and an unsupportive wife were the critical variables.)
The Suicidal Mind ends with a brief list of recommended further reading, including Goethe’s The Sorrows of Young Werther, Flaubert’s Madame Bovary, and Tolstoy’s Anna Karenina. About these books, Shneidman says only that anyone who reads them “will know a great deal about suicide.” After years of re-reading and reflecting on those works, I have come to suspect that Dr. Shneidman was subtly directing our attention to the physical horror of suicide, and to the near-instantaneous regret of suicide attempters. The young hero of Werther shoots himself in the head and is found, still breathing, six hours later with his brains protruding from his forehead. His suffering continues for six more hours and then he dies, having provoked unspeakable grief in all those around him. Emma Bovary impulsively ingests arsenic, and she also takes hours to die, terribly and horribly—vomiting blood, convulsing, eyes rolling and tongue protruding, with her physician husband standing by in helpless agony. Anna Karenina dies quickly but lives long enough to regret throwing herself under a moving train car. She is dumbfounded by her own act and wants to reverse it, but it is too late. I am reminded of the testimony of a young man who survived a plunge from the Golden Gate Bridge, who let go of the railing and then thought, “What the hell did I just do?”
Concept — Safety Planning
About 20 years ago, two very different interventions were both shown to reduce future suicide attempts in high-risk patients. Recent suicide attempters (Brown et al., 2005), who were provided with 10 sessions of cognitive therapy were less likely to make another attempt than those assigned to enhanced community case management (24% v. 42%). Patients diagnosed with Borderline Personality Disorder who completed a year of Dialectical Behavior Therapy (DBT; Linehan et al., 2006) had fewer suicide attempts during the follow-up period than patients who were treated by non-behavioral community-based experts (23% v. 46%). The common factor shared by these two treatment approaches is Safety Planning, and I believe that this is the active ingredient that reduces suicidal behavior.
Safety Planning is a collaborative process that generates a simple, brief, and easily understood guide that patients can use to manage or defuse suicidal crises. Essentially, the previously suicidal patient is asked, “What could you do if these feelings or thoughts come up again?” They list coping strategies they might employ (e.g., breathing exercises, going for a walk, taking a shower), people they might contact to distract themselves (e.g., visiting an elderly neighbor and offering to help around the house), friends or family they might contact in order to receive explicit help with their thoughts or feelings, crisis line numbers, professionals they can contact, and, finally, as the last resort, calling 911 or going to the nearest Emergency Department. These 8 to 12 steps are listed in the order they are to be tried, and if one doesn’t help to resolve the emerging crisis, then the patient turns to the next step.
Research has shown that Safety Planning interventions in psychiatric emergency departments reduce the risk of suicidal behaviors by 45% over the next 6 months, and that they more than double the chance that the patient will attend at least one follow-up mental health appointment. The U.S. Department of Veterans Affairs has a free Safety Plan app that anyone can download, but I prefer using an index card written in the patient’s own hand.
Person — Paul E. Meehl
Imagine being a trainee and losing a patient to suicide. An esteemed senior professor approaches you and asks if you would like to talk about what happened. But instead of comforting you, he questions you about the patient’s diagnosis, about pathognomonic signs that you missed, about the suicide rate of patients with that diagnosis, and after exposing your ignorance, he says, “You better read a couple of old books, and maybe next time you will be able to save somebody’s life.”
That esteemed senior professor was Paul Meehl, one of the greatest clinical psychologists of the 20th century. I read that anecdote when I was in graduate school and my immediate reaction to it was that I would do anything I could not to be that trainee. Meehl warns us not to rely solely on classroom instruction, assigned readings, or clinical supervisors. It is up to you to develop your competence as a mental healthcare provider and that endeavor is a serious and lifelong undertaking that requires your full devotion.
In his autobiography, we learn that before Meehl entered graduate school his father had died by suicide and his mother had died as a result of “medical bungling” (a brain tumor misdiagnosed as Meniere’s disease). This probably explains the intensity that Meehl brought to the interaction with the hapless trainee. It also might explain why he worked for years demonstrating the superiority of actuarial (systematic, algorithmic) over clinical (intuitive, haphazard) prediction. Used properly, psychiatric diagnosis is a powerful element in actuarial prediction. We might even say that the trainee’s fundamental error was in relying on methods that were “clinical” (e.g., “he seemed like he was doing better”) and not actuarial (e.g., “patients with this diagnosis have a suicide rate of 1-in-6”).
Article — Psychotherapy and Suicide (1981) by Herbert Hendin, MD
In this article, Dr. Hendin addresses the crucial difference between “managing” suicidal patients and helping them as a psychotherapist. Too many articles and books about suicidal patients focus on reducing access to lethal means, enlisting family members to monitor the patient’s behavior, escalating to hospitalization, etc. Hendin argues that “successful psychotherapy cannot be conducted by a “policeman.”” Rather, he says, the “best chance for helping the patient lies in understanding him and helping him with the problems that are making him suicidal, including most specifically the way in which he uses the threat of death.”
The psychotherapist must know himself before he can understand his patient, and Hendin warns that a “therapist who is threatened by the fact that a patient may kill himself while under his care is in no position to be a therapist to the patient.” Should a therapist “see the success of therapy as a life-or-death matter to his own self-esteem, his efforts are apt to be futile.” Too frequently, therapists attempt to manage their own anxieties about treating suicidal patients by 1) trying to avoid them altogether, or 2) being unempathetic towards them because “the potential for guilt is greater if the therapist is close to a patient.”
A brilliant aspect of this article is the incorporation of eight vivid and detailed case histories. Hendin notes that “most articles on suicide… seem more comfortable with abstractions than with people; they usually do not present a single suicidal individual with a view toward conveying a sense of the quality of the person’s life or wish to die. Such articles stand in startling contrast to articles on virtually any other clinical problem. The absence of such case descriptions [reflects] the distance and lack of empathy” that most commentators have toward suicidal patients.
Surprise Item — The Misfire
When I talk to professional audiences, I always remind them to assess for access to firearms regardless of whether the patient is currently suicidal, because suicide attempts are often “rapidly realized,” with up to 80% of attempters taking lethal action within 10 minutes of deciding to die. Having a firearm handy increases the risk that a suicidal crisis will end fatally.
I recently concluded a study of American veterans, most of whom had histories of mental health treatment, and found that 80% of them currently owned firearms. More disturbingly, 51% of them said that at some point in their life they had “held a loaded gun with suicide in mind.” This behavior was just as likely in veterans who reported no mental health problems as it was in those who did. The vast majority of “holding ideators” denied ever having made a suicide attempt.
One of the most surprising things I have experienced in my clinical work is having a patient reveal that they had indeed once held a loaded gun with suicide in mind, and, what’s more, that they had pointed the gun at their head or put it in their mouth, and they had pulled the trigger and—“it jammed,” or “it misfired,” or “nothing, just “click.”” The thing to know about modern handguns like the Glock is that they are highly reliable, with misfire rates of less than 0.1% (1 in 1,000 rounds). It seems statistically improbable that I keep encountering men (it’s always been men) who made a serious, deliberate suicide attempt that was averted by such a rare malfunction.
Now, improper maintenance of the weapon or using cheap or degraded ammunition could increase the chance of misfire, but in almost all of the cases I have encountered, these were experienced shooters using quality firearms, not someone grabbing grandpa’s rusty handgun out of the attic and jamming in the wrong caliber of ammo. Alcohol and drug use could have played a role; some of the “misfire” survivors could have been too drunk to remember to rack the slide back and chamber a round before pulling the trigger. Ambivalence, a feature of nearly all suicide attempts, could also have contributed; maybe the trigger pull wasn’t as strong as it needed to be to engage the firing mechanism. But at least two of the misfire survivors I knew produced physical evidence in the form of a dented primer at the base of a cartridge: “This is the round that should have killed me.”
Regardless of what caused the misfire (or whether there actually was a misfire), what is most interesting to me is what happened next to these men. In my small sample (N=6), everyone interpreted the experience as a sign of supernatural intervention, even though half had never before considered themselves religious. “God said it wasn’t my time,” one man reported. Three of the men stopped drinking or using drugs “right then, that night, that was the last time I had a drink,” even though they had been struggling with substance use for many years. None of them ever attempted suicide again or engaged in any suicide-related behaviors. Four of them thought that the experience meant that they had some special purpose in life and began actively helping others (e.g., one became a volunteer driver taking disabled veterans to their medical appointments).
I am not entirely certain what exactly I make of all this. Perhaps the astrophysicist A.S. Eddington would say of it what he said of quantum mechanics: “Not only is the universe stranger than we imagine; it is stranger than we can imagine.” Or perhaps he would not. I am thankful to Dr. Awais Aftab for the opportunity to ponder these possibilities.
See previous posts in the “Mixed Bag” series.
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Very good
I actually had a patient commiting suicide on my watch
Opened a few books after that only to realise I was doing a lot of stupid stuff - and not doing essential ones
The training was indeed very lackluster, not rejecting responsability but that was and still is an issue
I try my best so that death was not in vain
Isn’t a failure to disengage the safety the most likely cause of these “misfires?“ You mentioned other sources of human error so this seemed like a strange omission.