It’s Important to Talk Openly About Suicide

Ryan Grim talks to Jason Cherkis about suicide prevention.

Aaron Swartz at a Wikipedia meetup in Boston, 2009.
Aaron Swartz at a Wikipedia meetup in Boston, 2009. Photo: Sage Ross via Wikimedia Commons

Ten years ago this week, Aaron Swartz, a key figure in the fight for an open internet, died by suicide. This week we also learned of the tragic death of New York Times journalist Blake Hounshell, whose death is being investigated by police as a suicide. Ryan Grim speaks to Jason Cherkis, who’s writing a book on suicide prevention and is the author of the groundbreaking article at HuffPost Highline titled “The Best Way to Save People From Suicide.”

The National Suicide Prevention Lifeline offers 24-hour support for those experiencing difficulties or those close to them, by chat or by telephone at 988.

[Deconstructed theme music.]

Ryan Grim: Welcome to Deconstructed. I’m Ryan Grim. 

So earlier this week, we learned of the tragic death of New York Times journalist Blake Hounshell. 

His family said in a statement, “It is with great sorrow that we have to inform you that Blake has suddenly died this morning after a long and courageous battle with depression.”

A GoFundMe has been set up for Blake’s wife and his two children, and we’ll include a link to it in the show notes. I spoke earlier this week on the program Counter Points with Rep. Ro Khanna, and his reflections on Blake get at what made him different in the world of media. 

Rep. Ro Khanna: It was devastating and shocking. I mean, I had sat down with Blake actually when my book came out, and we spent an hour and a half, two hours, talking about philosophy, talking about economics. He was someone so well-read, so thoughtful, and he had texted me in December, saying: Let’s get together in the new year. 

Just totally shocking. My heart goes out to his family. He had children. And he was really one of the thinkers in journalism.

RG: Hmm. 

Emily Jashinsky: Hmm. 

RG: Right, and I think that’s well said. He did stand apart, in that way.

RK: He did. He was at the New York Times, but he also had a little bit of an independence. He had his own newsletter. He’d do longer-form pieces. It wasn’t always, for him, about the news of the day. It was about ideas — he did this wonderful piece about Jamie Raskin during the time when Jamie lost his son. And, of course, a deep irony there with the struggles that Jamie’s son had, and it seems that Blake had.

RG: And in a wrenching coinciding of tragic events, it happens that ten years ago this week, one of the leading lights of the Internet in its formative decade of the 2000s, Aaron Swartz, committed suicide under the pressure of an overzealous and reckless prosecution by U.S. Attorney Carmen Ortiz and her deputy, Stephen Heymann. 

Aaron, even as a young teen, played a key role in defending and fighting for an open internet, creating some of its key infrastructure, and later in his life, he transitioned into more targeted political activism. If you’re not familiar with him, his accomplishments in his short life are too great to list here, but I’d recommend the documentary “The Internet’s Own Boy,” which you can find free on YouTube, which Aaron would appreciate. 

We also devoted several other segments to Aaron on Counter Points this week, which you can also find free on YouTube

And today we want to talk about what never gets talked about: suicide.

And for that, I’m joined by Jason Cherkis, who’s writing a book on suicide prevention and is the author of the groundbreaking article at HuffPost Highline titled “The Best Way to Save People From Suicide.”

Jason, welcome to Deconstructed.

Jason Cherkis: Hey, Ryan, thanks for having me. 

RG: And I want to start out [with] what we want to do in this conversation, but also what we don’t want to do in this conversation. Because, while there is this incredible and promising research about ways that therapeutic interventions can reduce the incidence of suicide among people, we also don’t want to suggest that anybody who does commit suicide, necessarily could have had that prevented if only you had just done one thing differently, which I think is the thing that haunts so many family members, for so long. You’ve talked to so many family members who have lost loved ones to suicide. How should people think about that as they’re grieving?

JC: One thing that jumped out at me is — and this has happened, I know researchers who’ve lost loved ones to suicide. There was a suicide off the roof of a psych building at a university, for a researcher that I cover, and they didn’t even know about it. I mean, they were in the building when it happened. 

So I think one of the things to draw from is suicide is very, very hard to predict. There was a 2017 study that looked at all the studies on suicide and found out that we were really not much better than a coin flip in predicting who will die by suicide or make an attempt. 

There’s been all kinds of work with ai models or algorithms to better predict suicide. The military has one in use to this day in the VA. That’s pretty good. But the problem with those models is there are too many false positives. So for everyone, there’s at least a great chance that it’s an error. 

RG: Mhmm. 

JC: And so there’s been a lot of hesitancy to use them. The thing that I come back to and others have come back to in terms of using those kinds of predictive models is what do you do when you can predict that like, in the next month, a person might have a greater chance of making a suicide attempt? The big criticism of the VA was: They didn’t really know what to do. And I think as a society, we still struggle with what to do and how to provide timely resources that are effective. 

One of the big problems with suicide is that our answer to it is a very cumbersome, very clunky, very, in a way outdated model. We say: Go to therapy or call a hotline — and I’ll get to the outline in a minute — but if you think about it, someone goes to therapy, maybe once a week, it’s pretty expensive, so it pretty much limits how often you can go. Most therapists don’t take insurance. So you have to kind of bill your insurance company on your own. And that’s really hard and cumbersome to do as well. 

But you go to therapy once a week, and that’s only for 60 minutes, you’re in the presence of a therapist, and you’re opening up and you’re telling them something, or maybe you’re not telling them anything, and maybe you’re afraid to open up that day; maybe you didn’t have enough to eat that day, and you don’t want to talk; all kinds of things can be can influence that. 

My point is that once you leave that office, the therapist and you don’t really know what’s going to happen. You can have a bad day, your wife could leave you, you could be unemployed — all kinds of things. You could just get in a mood. People don’t really understand what brings on these kinds of moods as well.

So, suicide can hit you at any moment. All these kinds of factors have to come in a line, it’s like a point in time when something like this happens. And so, for a therapist to actually catch somebody in a suicidal state or what they call a suicidal mode, it’s almost impossible. It’s so rare for that to happen. And so oftentimes in therapy, they’ll do what’s called exposure therapy, where they’ll try to replicate someone’s mood. They’ll amp up their mood to sort of agitation, or stress, or anxiety to sort of almost replicate the ingredients that might lead to a suicidal feeling or a suicidal urge, and then work with them in session to sort of have them overcome those individual feelings. It’s really hard to, and almost impossible — and frankly, probably unethical — to induce a suicidal state in a person in real-time.

RG: And I wanted to say off the top that no particular intervention is guaranteed to stop any particular suicide. 

JC: Yeah. 

RG: And nobody should pretend otherwise, nobody should suggest otherwise. 

With that being said, if you look at a macro level, we can learn some things about, broadly, what doesn’t work, and broadly, what has shown some effectiveness. And so with that in mind, can you tell us a little bit about Jerome Motto? Let’s start with World War II. 

JC: Well, like so many others of his generation, he was drafted into the army. He was in ROTC in high school, and he was a quiet kid. His goal in life was to become a concert piano player. And he was really studious, and kind of nerdy. And when he joined up, he ran a truck brigade. So he ran supplies to the frontlines. 

He found himself in the midst of the Battle of the Bulge. And around that time, he started receiving letters from a woman he had met, when he was stationed stateside. They had gone on maybe a date or two, but nothing really romantic happened. But so they wrote letters back and forth during the war. 

And the letters were very commonplace — like they weren’t really romantic, they were just telling each other about their day. The woman would describe her town or sort of the activities that she had going on that week, and just kind of letting him know that she was thinking of him. At first, when he got the letters, he didn’t even really quite remember her. But he gradually grew to have some affection for her. But also, it made him feel good to get those letters. 

And years later, when he became a psychiatrist, and interested in suicide prevention, he thought about those letters. And he wondered: Well, what if somebody who was feeling stress or feeling suicidal and alone, what if they got one of those letters? Would that change the outcome? Would that help them? And he wondered how he could do that, like what would be the ethical way of doing this kind of experiment. Because he wasn’t sure if it would work. But he also wanted to make sure that it was people who, who had rejected the system, who had rejected therapy. 

And so he started recruiting in San Francisco, in five different locations or regions. He had research assistants stationed all over the city at different hospitals. And so when somebody who was suicidal had come in or had made an attempt, they would try to recruit them. And then they would be divided between people who got letters and people who didn’t get letters. But in order to get the letter, you had to have rejected therapy; like, left the hospital and said: I’m not doing anything. 

RG: And how common is that? 

JC: It’s very common. It’s as common as anything. I mean most people don’t go into therapy after that. 

RG: Right. 

JC: And so you have this, the system divided up where people who didn’t get therapy would get the letters — or some would and some wouldn’t. It was basically a form letter, like a postcard. And on the postcard, it said: It’s been a few weeks since we met, I’ve been thinking of you. Hope, you’re doing OK. Feel free to write if you want. 

That was the gist of the letter. 

And his research assistants, who had met the individuals and enrolled them, they would write the letters. The secretaries would type them up, and then the research assistants would sign them.

And that was it. This went on for years, possibly a decade or more, going through the recruitment, and all the individuals that got letters got them for five years. And after five years, he realized that at least in the first two years of getting letters, when the people were getting the most amount of letters because they were sort of staggered over time, they didn’t die by suicide, their rates dropped dramatically compared to the group that did not get the letters. And that was one of two studies that showed a decrease in suicide deaths.

RG: Studies across the board, you mean? 

JC: Yeah. 

RG: All types of interventions? 

JC: Yeah. And this includes all therapies, any therapy that’s been invented, to address suicide has never shown a way to stop suicide deaths.

RG: So what did the therapeutic community, the therapeutic industry, kind of take from that research?

JC: [Laughs.] The problem was that he wrote the paper in 1976 and he published it in the only journal devoted to suicide research. It’s called Suicide and Life-Threatening Behavior — I’m not sure if it was called that at the time, they had changed this name multiple times. It had a circulation of under 1,000. And so very few people read this paper. And I think among people that read them, kind of were in disbelief, just didn’t believe that something this simple had this much of an impact. 

And so it was generally ignored. I mean, he went to conferences after conferences speaking about this. And he’s a very eloquent, almost poetic figure. He’s a very compelling person. But people still were dismissive of this. And even later, years later, someone had sort of revived the study; I would say, the most influential suicide researcher of the last 50 years, Marsha Linehan, out in Seattle. And when she was coming up, she most famously had been in the mental health system, she had been a patient, she had been hospitalized for over a year with suicidal thoughts, and self-harm behavior. And after she was released, she wanted to devote her life to suicide research. And so it was a mission for her. 

And when I had interviewed her about Motto, she had said: I had read dozens and dozens of books and research papers, all telling me why people die by suicide, or what compelled somebody to kill themselves, but I read nothing about what prevented them from doing it. And this was the first thing I ever saw, where it showed that there was a way to stop people from harming themselves. 

And so she became very fascinated with Jerry Motto. And she reached out to him and she said: You got to publish another study. You’ve got to go back and look at your data again and do it again. And so he republished the study in a kind of longer form in 2001. And that got a lot of attention. And then he got attention from around the world. So he would get emails from researchers in England, and New Zealand, and Washington State, and all over, asking him, in kind of disbelief: Tell me how you did it. There has to be some secret way — 

RG: [Chuckles.]

JC: — some kind of trick that you pulled on everybody. And he would just say: No, I wrote these letters. And he would share examples of the letters with the people that wrote them. And then, gradually, people started to replicate his work around the world. 

My favorite study was done in Tehran, with greeting cards — really, really ornate and sort of flowery greeting cards with famous sayings or poems or famous quotes, like one had a quote from John Kennedy, from President Kennedy. 

RG: Hmm!

JC: So it was really interesting work. And it all showed a reduction in symptoms or reduction in hospitalizations. A lot of the studies, if not all of them, could not show a reduction in death because they did not last long enough. Suicide is such a rare occurrence that you need the study to go for years in order to show that. But they did show a reduction in symptoms and reduction in hospitalizations.

RG: That actually reminds me a little bit about how much trouble they were having, finding efficacy in the vaccine for Covid among young kids, because an actual significant adverse Covid event was so, so rare. 

JC: Mhmm. 

RG: And it was really hard for the intervention, then, to prove that it was intervening. 

So let me ask you about Ursula Whiteside. How common is her approach to therapy? And how was she influenced by Motto?

JC: Well, she was mentored by Marsha Linehan. And so she kind of came up as a student knowing his work, but kind of setting it aside. 

So when you’re working in a lab, you’re in this sort of bubble as a student. You’re not in the real world. And so she got to learn how to do this very complicated therapy, very intense therapy, for people who were suicidal, through Marsha Linehan’s work. And when she took an internship at a hospital, it was sort of this very, very harsh reality of: you got to move them through quick, there’s not a lot of hand holding, there’s not a lot of services, not a lot of intervention. It’s a pretty cold place because they just have too many patients that they have to get through. 

And she would see people that she had met in the emergency room who had made suicide attempts, very serious suicide attempts, and then be discharged in a few days. And she worried about them and wondered: I need to follow up with these guys. 

And she was talking to her therapist, and she realized in the session: Hey, wait a minute, Jerry Motto! I could do Motto. I could just do that.

And so she decided to incorporate what’s now called caring messages into her practice. So she not only reached out to people that she had met in the hospitals to check in on them. But when she started her private practice, she began texting her patients as needed, or kind of randomly over the phone. So somebody might have issues on a particular day or a particular time of day, and she would send them a text: Thinking of you. 

RG: And that would be the whole text?

JC: Yeah, basically. Or because it’s the sort of time we’re living in, and it’s text, they often came with a funny GIF, or emoji — a cat joke or something. And she worked really hard to figure out what people liked. Because she didn’t wanna make people mad — I don’t like cats, or whatever. And so it was this really kind of goofy stuff that sort of reflected her personality — but it also implied a relationship that she had with her patients. It wasn’t necessarily strictly doctor-patient, it was this relationship that she’s trying to foster. 

One of the things that she talks about, and others, is that when you’re suicidal, you have a hard time trusting others or building relationships because you don’t want to talk about your suicidal thoughts that might turn somebody away from you. Or you might have gone through a lot of relationships and have been alone, and you might be alone. And so by doing these text messages, these caring messages, she’s sort of fostering these relationships and teaching her clients how to trust other people and have these kinds of communications. And so it works in a number of different ways. 

One of her colleagues has her clients send caring messages to other people. So she will say: I just sent you one, you have to send one to somebody else that you know in your life. Text your uncle that you’re thinking of them, as a way to keep it going.

RG: And one of the more profound insights I took away from your piece was the way that Motto and Ursula talked about not wanting to put an additional burden on people who were going through these deeply hard times — a burden so little as, in the some of the initial letters, correct me if I’m wrong, there was sometimes a request from the hospital, say: Hey, let us know how you’re doing — which is obviously well-meaning, but then would leave people feeling like, oh, here’s another thing that I’m failing at, like another obligation that I have to somebody who cares about me that I’m not fulfilling — and it would drive them, in fact, deeper. 

And I’m somebody who has difficulty completing little tasks. I can do big things; little things are a lot harder for me. And I can actually get into a place where being asked to reply would be triggering in some ways. I don’t have the depressive tendencies that are going to send me in that direction, but I can picture it. 

How did they get to a place where they were able to relieve the burden? And talk a little bit about the stamp, too — that, to me, was a rather striking indication of what we’re talking about?

JC: He sent, I think, a self-addressed envelope with the letter, but not a stamp, because he did not want people to feel that extra burden like: Oh, they spent money on a stamp for me, and I’m not going to write them back. 

I mean, this is a concept, he was one of the earliest researchers that I can find, that actually followed up on suicidal people after they left the hospital and asked them what it was like. He studied the mental health system’s care of suicidal people in ways that people still to this day don’t really do. And he also spent a lot of time at the San Mateo, California suicide hotline. He sat with them and studied with them for a long time, because he wanted to know what it was like to talk to individuals in crisis, to get an insight into how to talk to them, and what they were going through. 

And I think he intuited from all of his study of this is that he didn’t want to burden them, he didn’t want them to feel like a burden. That’s one of the things that I think generally people view as a risk factor for people who are suicidal, the feeling of being a burden. And so this was one thing he did not want to make them feel like — a burden to others.

Or, also, the system makes a lot of demands on people and he wanted the relationship to be free of demand, and also to feel real. You don’t make demands on friends. You have unconditional love and unconditional friendship. And that’s what he wanted to sort of replicate.

RG: Yeah, his analysis of the system was also one of those things that is, on the one hand, super obvious, but on the other hand, seems to not make it into a lot of the kind of academic literature. In other words — when we think about treatments and interventions, we think exclusively about the time that you’re spending inside the therapist’s office, or inside the hospital or whatever the intervention is, but you don’t think about everything around it that is necessary to get there — all the paperwork, all the phone calls, the bills, getting punted from one office to another. And he seemed to be able to kind of incorporate that and to understand that. 

And as you reported on it further, what’s your sense of what the kind of thicket of our system — what the effect of the thicket of our system is on people who are trying to hack their way to help?

JC: I think two things one just jumps out is that what Dr. Whiteside and Jerome Motto both thought, both intuited, is that there was this whole large amount of space in which people weren’t operating in the system — they weren’t going to therapy, they were in between sessions — where they could be in distress. And that these things, these kinds of messages, could address that in-between time. 

But I think one example of how the thicket of the system is a problem is that when they finally came around to sort of mainstreaming Motto — after my story came out, and others and there were other studios that came out later that endorsed Motto — systems, try to use it, try to do it. And often those come in the form of: Hey, you missed your appointment, you really need to call us and make another appointment. So if you miss an appointment, you could get a fake caring letter, like how Motto sent a letter, but in the form of: Hey, you missed your appointment, we’re worried about you — which is terrible. 

I was with a source in Nashville. And she showed me — it can also come from text messages or voicemails — and she showed me her phone, and it had like 30 messages from her fucking provider. And it was all reminding her to show up. It’s like: This is caring messages? 

And we all get it now. I mean, you can’t go to a dentist without getting three reminders. And then afterward a survey: How did we do? That’s the worry of all these researchers that I’ve talked to you who study Motto was that they were going to skip over the non-demanding part, that they were going to attach it to letters that remind people to show up for therapy, or that you missed therapy, that it was going to essentially becomes spam. And in a lot of cases it has, and that’s a real problem. 

I mean, Dr. Whiteside is often worried about what other colleagues might say about her practice because she’s texting, she’s kind of personal, she’s really kind of mixing it up in a way with her patients in a real human way that I think therapists don’t understand is important. And I think that that’s an issue. It’s like, if what she’s doing is a problem, then the system is a problem. 

And among all of the people that I’ve interviewed, who have gone through suicide attempts and survived them, or are suicidal and struggling, when I’ve asked them: What has made the difference? It’s often the people that they met along the way within the system that were rebelling against the system while they were there. That they were doing something they shouldn’t have for this person, they were giving them extra time or extra attention, that they took them for a walk off the grounds of the hospital, that during therapy, they said: Let’s go get a coffee, let’s not be in this office. 

It was like the little moments that showed that they were human beings, that that’s what mattered most, not the sort of day-to-day grind of being in the system itself.

RG: It’s funny you say that. I interviewed previously John Lubecky, who is a veteran who had attempted suicide multiple times. And he told a story of being at the VA and the official they’re telling him: Look, you know, here’s the waitlist, there’s really not a whole lot we can do. And then when nobody’s looking, the guy wrote down an MDMA study that he could be eligible for and wrote it down on a piece of paper, and slipped it across the desk to him. It was completely legal for him to enter into this phase 1 or phase 2 clinical trial relative to MDMA. But the VA official really had to go around the rules to kind of let him know about it. And he ended up enrolling in it. He credits it with saving his life. He’s now a lobbyist on behalf of MDMA for a veterans organization. 

So it’s interesting you say that, because that suggests that it doesn’t speak well of the system, if you’re inside, and you have to be bucking it in order to provide help to people. 

JC: Yeah. It reminds me, I had talked to this emergency room doctor who has been working in the ER for decades; a total veteran, well-respected in her practice. And she confided in me that she had suffered from suicidal thoughts and I think might have made an attempt. And she said: What does it say to you that I’m insisting on being off the record and being anonymous? What does it tell you about how the system would see me and my fear of what the system would do to me, if they found out that I had made an attempt?

RG: You also wrote in your story that among Western nations, the United States was alone in a rising suicide rate? I’m curious how much that has to do with any unique American characteristics, and how much it just has to do with the prevalence of guns, which, you write a lot about suicide attempts that fail — and the problem with pervasive gun ownership is that it’s much harder to fail. 

JC: Yeah. 

RG: Whereas with pills or other approaches, you find people who are able to be saved, like the person that you write about at the very top of your story, for instance.

JC: Yeah, I mean, I think the prevalence of guns is a huge factor. Also, the lack of universal, affordable health care is another factor. 

In the story, I go to Switzerland, where they have a form of universal health care where people who were in the hospital got sent to this relatively new intervention. And it was pretty seamless, it was kind of right down the street from the hospital. But there was sort of a seamless connection.

None of the people that I had interviewed in Switzerland talked about that struggle to find a therapist. They didn’t talk about the struggle to find healthcare. So that’s an issue. I mean that’s part of the stress of this. 

I mean, I recently took a job working on a suicide hotline. I wanted to know what that was like, because it is the sort of main intervention for all people with suicide risk, or people who are contemplating suicide. And I haven’t been on the hotline for that long, but I was struck by how many people were calling, asking: How do I find a therapist? And where do I find one? 

Because it’s just not well-known. It’s harder to find a therapist or the mental health system is somehow more inscrutable than the rest of healthcare. And so I had a mother calling up asking about: Where can I find services for my son? Two mothers, actually, calling. 

I think that that’s something that I kept coming back to in my research for the book is families are often shut out of this. I mean, if you start from the beginning of care with children who might exhibit suicidal thoughts or suicidal feelings, they’re most likely are in school. And the people that are there in school, like the counselors, or maybe if you’re lucky, a social worker in school, that social worker is not really a social worker. They’re probably on their way to becoming one, but most likely, they have almost no experience in the field at all. They’re there to get training. 

Schools often hire people fresh out of school or fresh out of college right away to handle the toughest cases — suicidal kids. And so from there, it can only get worse. Schools are very much interested in liability [laughs] and worried about liability and don’t want to be sued. So often, counselors won’t offer much because they might want the child to not be in school, not be in that school. You see that all the time. It’s a very common and very kind of horrifying practice that universities do. 

I recommend a great story in The Washington Post that William Wan did recently about Yale University and their practices of essentially evicting students who have made suicide attempts. So you have this kind of hot potato effect where no one really wants to treat you if you say that you’re suicidal, from the beginning in schools, like middle school and high school, through college. And then it’s pretty common for therapists, once they know that you’re suicidal to say: I can’t help you. I’m not experienced with that, or I don’t want to help you. 

So many people that I’ve interviewed have had their therapist quit on them, or their psychiatrist quit on them when they’re in the middle of a crisis: I can’t handle it! 

And so I think one of the things we need to do —

RG: What do you mean? 

JC: Go ahead. 

RG: What do you mean? They just say: “This is too hard for me”?

JC: “I’m out.” Yeah. “I’m out.” Yeah. This happens all the time. Yeah. 

I had one person I’m following, she was in a crisis and her psychiatrist said: I can’t do it. I’m done. And she was very much concerned about the medication she was taking, this person. And so there was an issue around whether she was taking the medications or not. But the psychiatrist bailed, like, pretty quickly. She just said: I’m out. I’m not going to do it anymore.

RG: When people ask you over the suicide hotline what services there are for them, like, how can I find a therapist? Is that something the hotline is set up to help them navigate? 

JC: Yeah. 

RG: Or are you just like — yeah. So, how hard is that? 

JC: It’s not that hard. I mean, the harder part is the work afterwards. So we have a database that we can pull from, resources, phone numbers, that kind of thing. And we can also direct them to — there’s definitely some databases on Google. Psychology Today keeps one. I don’t know how up-to-date it is. I doubt it’s very good. I doubt it’s very up-to-date. But there’s definitely key search terms you can use. I always offer and tell people: The best way to find a legitimate therapist is to search for a therapist who is proficient in CBT, because that is the gold standard of therapy for all therapy.

RG: How often do you get calls from people who are kind of figuratively on the ledge?

JC: I don’t think it’s that common. But I know from my limited experience on the hotline right now. 

RG: You’ve been there since, like, December or so? 

JC: Yeah. Since December. And so I would say that at least once a shift, someone’s getting a call that there’s a person who is in a real, serious crisis. That’s not to say that the crisis reaches the level of calling the police, because that’s very, very, very rare. I would say that’s discouraged at all costs. And there’s definitely callers who will say: Don’t call the police. Don’t do this to me. 

And — I will honor that wish. But I think that there are people that do call in real crisis, and then it’s just a matter — I’ve had a few people call who I felt were in real crisis. And I had one person call me and the first thing he said was: I’m gonna kill myself tomorrow. And then we just worked from there. And then we talked for, I think, over an hour and he ended up being OK. 

RG: What do you say to them? Do you work them into small talk? How do you get from a place of “I’m gonna kill myself tomorrow” to them hanging up in a better place?

JC: Well, I think one thing that we learned, and I think therapists like Dr. Whiteside’s emphasis as well, as well as the clinic I mentioned in the story in Switzerland, is it so often people that are suicidal are afraid to talk about it, nor are they asked to talk about it. So they’re afraid to tell their therapist because they’re worried about being hospitalized, having the cops show up at their door. And so the hotline provides a safe space for people to open up in a real way in anonymity. And so the first thing you generally ask is: What brought you to the hotline and how can I help you? So you want them to tell you a story, a narrative, of what led them there. 

And then from that story, you can start to ask follow-up questions, reflect back to them what they’re saying, and then ask them: Have you felt this way before? And very likely they have, and they’ve gotten out of it. And so you ask them: The last time you had this, what did you do to get yourself out of this state?

Very often people who are suicidal feel that there’s no escape from their pain. That’s something that we’ve heard, I hear, over and over again, this feeling of being entrapped or feeling trapped. One researcher describes it being in a house that’s on fire. And what’s the quickest way to get out of a house on fire? You jump out the window. And so what you’re trying to do is provide them a safe alternative, a safe way out of the house. And just show them that there’s an escape route that they haven’t thought of. 

And really, it’s a very collaborative process. I think that most people — and we learned this in our training — is you can’t just offer them advice, because it’s usually bad. It’s usually dumb, stupid. And so the advice that you want to give them is stuff that they’ve already thought of, that they’ve already done, and that works for them.

RG: Right. What about for the people who don’t call? Is there any concern among researchers that the ubiquity of the hotline actually puts a burden on some people?

JC: I would say that’s like one of the number one problems that that all suicide researchers face, but also the mental health system faces, and has faced since the beginning. Since hotlines started, there was always the question of: Are we really helping the people that need to be helped? There was a sense from the beginning — and I’ve interviewed the people that took the first calls in the ’50s in America — and they were struck by the ambivalence of their callers. That people were on the fence about dying, that they kind of needed a reason to live, and these calls were going to help them find that reason. 

And so the scary part about suicide is that most people that die by suicide probably don’t call the hotline. A little bit more than 50 percent of people that die by suicide don’t have a mental health diagnosis. So that means they’ve never been seen by a mental health person. They’ve never been in the system at all. They never experienced therapy. They’ve never tried. They just live their life. They tried to white knuckle it until they couldn’t. And very often, when they couldn’t, there’s a gun nearby. 

That is one of the other big problems — as you mentioned earlier, and we both touched on a little bit — is just the access to guns is just so high. I did a story last year for The Guardian about the limits of virtual therapy. And I profiled a kid who had a teenager who had died by suicide in Tennessee, and he had gotten virtual therapy. It was pretty limited in what he could do; it wasn’t video, it was just on the phone, it wasn’t even in private, there was no real privacy. And it felt really bad one day, and his parents thought the gun was locked away in a safe and it wasn’t. And he found the gun, and in a heartbreaking moment, he killed himself.

RG: It feels like intuitively, there would be a high prevalence of alcohol intersecting here, too.

JC: Mhmm. 

RG: Because if you say that everything has to kind of line up in the worst possible coincidence, where you’re at the depth of the feeling of being in a burning house, you have access to a weapon, and you’re super drunk. It just feels like with your inhibitions lifted, is that when you’re at the greatest risk?

JC: Alcohol is certainly an issue. I would say it’s definitely an accelerant to that fire in that house. I am not as familiar with the research on that. But I know that it’s like a huge problem, that when any therapist has a person who is suicidal, but also has some kind of addiction, whether it’s opioid use disorder or alcoholism, it just makes it that much harder. The reliability is not there, the reliability to use the skills that they’ve learned to sort of tamp down those feelings are gone; as you mentioned, inhibition is gone. That’s definitely been a factor in people that I’ve interviewed who have made suicide attempts. 

It’s certainly an issue for people who are in recovery as well. People who are at a really high risk or feeling really suicidal when they’re coming off opioids when they’re in detox, that’s a huge, huge, huge, scary kind of moment for people.

RG: And for people who aren’t therapists, and also for people who don’t have suicidal tendencies themselves, but know people close to them who do, what would you say to them from what you’ve gleaned from all the people you’ve spoken to, from the hotline and from the research?

JC: OK, this is something that I’ve had to learn as well. This is a great question. 

When I was doing my research early on, and talking to people who were suicidal, I would always hesitate to use the word suicide. And I would be afraid to ask them about it, because I’m like: Maybe I’m gonna hurt them in some way, or they’re gonna want to do it, because I’m telling them about it, I’m asking them about it.

RG: And that’s kind of the implication of putting the hotline on every story that involves suicide. It’s like the media feels like: OK, we said the word. 

JC: Yeah. 

RG: Now we’re going to trigger people to do it. So now we’ll leave the hotline —

JC: Yeah. There’s no evidence that saying the word suicide or asking a friend about suicide or if they’re suicidal, ever makes people suicidal. 

There was a study recently done by a great, very young researcher up at Harvard, who as part of his study had to ask people about their suicidality like dozens of times a day. And he was able to show that it did not change their suicidality one bit. And so even when you’re asking somebody 12 times a day, it doesn’t really impact what they’re going through. And so by just asking somebody if they’re feeling that way, it’s not going to hurt them, it’s not going to plant the seed in them, it’s not going to make them, it’s not going to encourage them to make an attempt or to die by suicide. 

What I would say, my advice, is to be open with friends and to start having those conversations, but also, even if you have friends that you know are kind of in low places, just reach out to them and call them, or ask them how they’re doing, or that you’re thinking of them. And that should be enough. You don’t have to have a deep conversation about suicide risk with your friends. But you could have just more introspective conversations with them, or just reach out to people who are kind of on the edges of friendship, on the edges of your life that may be going through some things and sort of recognize that there’s these very little things that you can do that have a potential to have a big impact, such as texting somebody. Just saying: Hey, man. Thought about you today. Hope you’re doing OK. That’s enough.

RG: Well, Jason, this is hard stuff. And I’m glad you’re doing it. And I really appreciate you taking time to join me here today.

JC: Thanks for having me, Ryan.

[End credits music.]

RG: That was Jason Cherkis and that’s our show. Deconstructed is a production of First Look Media and The Intercept. Our supervising producer is Laura Flynn. The show was mixed by William Stanton. Our theme music was composed by Bart Warshaw. Roger Hodge is The Intercept’s editor in chief.

And I’m Ryan Grim, D.C. bureau chief of The Intercept. If you’d like to support our work, go to — your donation, no matter what the amount, makes a real difference.

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