Suicide 101:

Lessons Before Dying

Type “suicide” into an Internet search engine, and among the sites advertising therapy, hotlines and antidepressants, you’ll find a handful of pages where suicidal strangers counsel each other on the best way to die.

The largest site, called alt.suicide.holiday, or ASH, combines a public newsgroup, chat rooms and guide files instructing visitors on how to kill themselves using everything from aspirin to rat poison.

Local news reports have so far linked ASH to three suicides. Wired News was able to confirm another seven deaths associated with the site in interviews with relatives over the last month. In addition, ASH itself lists another 14 suicides as “success stories,” but those could not be verified because of the anonymous screen names used by the people who allegedly died.

Evidence exists that at least one person downloaded carbon monoxide poisoning instructions from the site before killing herself.

The ASH site, which started as a Usenet bulletin board in 1991, has spun off a related newsgroup and chat rooms.

In addition to the main newsgroup, a kind of online diary whose participants vent feelings of unhappiness and comment on each other’s suicide plans, visitors can find advice on funeral arrangements, writing goodbye letters and an agony calculator that computes the pain and lethality factors of various types of suicide.

‘Let me get this straight: You’re looking for advice for dealing with hopelessness and depression from someone who’s hopeless and depressed? How logical is that?’ — a psychiatrist interviewed for his reaction to this phenomenon, which is the first part of a three-part series in Wired. The second part is here: No one asked why he wanted to die. My reaction is abit more complicated than a neat soundbite, I hope. It starts from first principles — the mission of mental health professionals is not to prevent all suicide but only preventable suicides. It sounds like a tautology (it isn’t proven preventable until you prevent it, right?) but, believe me, even though we don’t have a crystal ball, it isn’t. Certain psychiatric illness is a terminal disease, the suicide associated with it inevitable; certain suicide is a rational choice, not a product of the impaired judgment, thought, impulse control or emotion of a mental illness; certain self-injurious behavior is nonetheless not of suicidal proportion; and certain seemingly suicidal ideation is merely “as-if”.

To construe one’s mission as preventing all suicide would be not only impossible, of course, but worthy of the type of paternalistic society a John Ashcroft envisions, clicking neatly with the nondiscerning and obsolescent attitudes (of Ashcroft or his ilk, my guess is) which consider suicide either a crime, a sin, or both. If you believe in free will, it would be a mistake, although one readily made in grief and bewilderment after a suicide, to blame anyone external for providing the know-how or even the means, even if they are actively encouraging. This is only a new issue insofar as it is web-based; the Hemlock Society has fought for the right to publish how-to manuals for suicide for a long time. Even if you believe they intend them to be used only to alleviate the suffering of those with painful fatal medical conditions, others certainly have access to them.

I train other mental health professionals in suicide assessment and prevention, and certainly feel it is our burden to thoughtfully evaluate the potential self-lethality of anyone expressing suicidal thoughts who comes our way. In many instances that requires the person’s voluntary participation; in others they can be confined against their will. I believe that the commitment statutes for involuntary hospitalization to prevent self-harm have wisdom in insisting that committability depends on having a mental illness, not merely expressing the wish to end one’s life. I see the statutes abused in several ways — first, to confine people who, although they harm themselves in other ways, do not represent a threat to their lives or intend to end their lives; and second, to confine people who do not have a legitimate mental illness. I am particularly troubled by the “attention-getting” patient who makes gestural suicidal pronouncements or self-injurious acts but is at no greater than baseline suicide risk; our response merely reinforces the pathological attention-seeking and wastes increasingly scarce mental health resources. But in a litigious society, no one wants to take the risk of liability for having been wrong in their assessment of whether someone is truly self-lethal (and, of course, even a gesture can go wrong and mistakenly kill oneself), so nondiscerning crisis services and outpatient providers have everyone locked up — which is exactly why ASHers don’t talk to health professionals about how they feel. In this sense, groups like ASH may actually do a service, in several ways. First, by providing accurate information about suicide methodology, they may dissuade some from attempting at all, or influence them to postpone an otherwise impulsive act. Secondly, by making it clear how lethal various methods are, they make it less likely that a “gesturer” will mistakenly choose a lethal method. Thirdly, and most importantly, they tolerate how the person with suicidal ideation feels nonjudgmentally and supportively. This is what mental health professionals were once taught to do as the sine qua non in treating the suicidal patient, but it is a task at which we fall woefully short (for a coalescence of reasons enumerating which would be a treatise in itself). Often, not being heard or tolerated is the proximal precipitant to someone’s crossing the line and taking thir life.