On One Man’s Reason for Suicide

Note: I normally keep to a post every other day, but I think this post deserves to come out now, instead my next post will be on Saturday rather than Friday.

Suicide is an intensely personal decision. What drives a person to kill themselves is a question often asked of those bereaved by suicide (grieving the loss of someone important to them by suicide.) This is a question as important to those left behind as it is to those who are in the throes of a suicidal crisis.

On February 9th, 2015 a popular food blogger named Wilkes McDermid ate his last meal at the Coq d’Argent restaurant in the City of London before jumping off. He posted a final suicide note, apparently penned a year earlier, detailing his reasons for suiciding. He also attached some scientific journal articles, a “Frequently Asked Questions” section detailing some common oppositions to suicide and a previous note he wrote two years prior when he made failed plans to suicide in Cape Town, South Africa.

I thought this post would be a good opportunity to go over some of those reasons, and to offer some interpretation of how he ended up in the predicament that he did.

While his writing is longer than any blog post I have written, at 4500 words, it would take much more than that for most people to truly elucidate every reason they have for dying and explore it in the kind of depth that would convince others around them it was the right thing to do.

I’ll be the first one to say that I am no expert in suicidal autopsies or psychiatric evaluation; I can only offer my opinions based on my knowledge of cognitive behavioural therapy and my interpretations of his writing.

If you haven’t already, I suggest you take a read of his post now, so that you can get a feel for it without my words biasing your interpretation. I’d love for you to share your thoughts.

The blog post opens by noting that McDermid would like to answer the questions of his friends and family but that doing so ‘live’ would be too great a risk because the medical community “values quantity of life over quality of life.” I think this is a reasonable view; disclosing imminent suicide plans would have led to his hospitalization. I don’t think it was reasonable that the quality of his life would have remained at it’s current level, however.

Next, McDermid declares the reason for his death is that women favour men who are tall (he gives 5’10+), of Caucasian or black races and who are wealthy or have “other manifestations of power.”

He goes on to list a number of research studies demonstrating that there is a preference in women for men holding these attributes. And to his science, I don’t disagree. All else being equal, many men will choose a woman with larger breasts over a woman with smaller breasts.

However, this is where I take my first qualm: all is never equal. Rall, Greenspan & Neidich (1984) notes that physical attractiveness is relative. You’re never competing against every other man in the world, only against every other man in the room.

Personality does have a strong influence on people’s physical attractiveness of us, particularly for women evaluating men. While it would be disingenuous to assume that women are not as visual as men – particularly when we have no other information to go on (see the disaster that is online dating for that in action), both genders consistently describe situations where they met a less-than-physically attractive person who “won them over” with their personality.

For some research support to that, see Tepper & MacDonald (2014) which notes that people are less willing to reject potential romantic partners in a real-world situation (e.g. participants in a research study who are not expecting it) than they are when given hypothetical situations.

Additionally, Murray & Holmes (1997) document a sort of “illusion” effect that occurs as you begin to fall for a romantic partner. Negative elements become less emphasized, and you see an illusory version of them. This gives hope and scientific backing to the idea that your personality really can help you get a foot in the door.

McDermid continues by citing a rate of 95%~ of the interracial (Asian/white) relationships he sees being with an Asian woman and a white male, while only 5% of the time is it an Asian male and a white woman.

This may be true (I haven’t evaluated the methodology of the formal and informal studies and surveys he cites but I’ll take them at face-value), but is that such a problem? He appears to be consistently seeking out interracial relationships and refusing to settle for anything but.

Considering that the Asian population in the US is 5-6% (CDC, 2013), it’s not surprising that most Asian women would end up with white men, because non-Hispanic white and black people make up a combined ~75% of the population. These rates are similar in England, and most western countries.

McDermid dedicates a surprising amount of his blog post on refutations of straw-men arguments (“you haven’t counted everyone in the world.”) He quickly dispenses with those arguments, as anyone with basic statistical knowledge should.

It is okay to be at a disadvantage. You can still lead a fulfilling life. Myself, at 5’6 with some physical health issues (retinopathy leaving me unable to drive, scoliosis, exercise-induced asthma) have certainly faced my share of barriers but I have also had some success as well.

Looking at it from an economic perspective, people born in poverty certainly have a harder time accessing social mobility than the rest of us. But many of them do overcome those barriers. Jealousy is okay. You can want what someone else wants. You can be frustrated that you don’t have it! That is a natural, expected, human emotion.

When you’re done getting all your frustration out, though, you have to begin to move forward. If you’re 20 metres back at the starting gate, it can make the race seem pointless, because others have an advantage. But you need not concern yourself with where other people are, only with where you are yourself.

This is not easy. But it takes cognitive energy to continuously ruminate on how others have it better than you, and that energy is far better spent accomplishing something worthwhile.

It’s the latter half of the note (and I call it a note rather than an article or a post because it is a suicide communique to all who knew him, and many who don’t) that I found most interesting.

It begins,

To everyone who says “why don’t you just accept it”, I ask you this. What if your girlfriend/boyfriend/wife/husband was taken away from you through no fault of your own? How would you feel? What if you were then told “it doesn’t matter, just learn to live with it”. Then what if you were told, “it’s your fault, it’s your personality that has caused that” and “stop being so negative”. How would you react. That’s what I’m faced with continuously. I can’t stop people lying to me for the rest of my life… but I can control how long my life will be and therefore how long I will have to suffer.

He equates his pain, of not being able to find a romantic partner, to the pain of someone who has lost their partner through death. In this moment he is mourning his future, the loss of hopes and dreams. These are an extremely strong hook for those experiencing suicidal thoughts, and McDermid had laid his to rest.

He seemed to feel his entire life was suffering, because of his lack of romantic companionship. His entire life, the rest of him was meaningless and valueless because of his inability to negotiate this one element of life.

This reminds me of the classic “Six Stage Process for Coming Out”, also known as the Cass Identity Model (Cass, 1979) In this model there are six stages for a person who is coming to terms with their sexuality:

  1. Confusion
  2. Comparison
  3. Tolerance
  4. Acceptance
  5. Pride
  6. Synthesis.

Essentially, the person finds themselves confused by their sexuality, then realizes they are different from others. They tolerate these differences, then begin to celebrate them. Next, they feel proud and wish to let everyone know, and finally they synthesize their sexuality into their broader identity; it becomes merely another part of them.

Applying this to McDermid’s situation, he had passed through Confusion and was stuck on Comparison. He could not see past the advantages that others had in their life, to move on to tolerance. He was miles away from tolerating being alone, accepting it, being proud of it (if that would ever occur) and certainly nowhere near his romantic life being a single piece of his identity.

Indeed, loneliness had become his identity. It consumed him. He was not English. He was not a food blogger. He was alone. That was him. And it didn’t have to be.

At the end of the “letter” portion of his note, he signs it “Goodbye, I wish you all the best Wilkes McDermid, 03-Feb-2014”; nearly a year to the day that he wrote it, he finally pushed through his innate self-preservational instincts.

The rest of his note consists of a Frequently Asked Questions section, a biblbiography and a draft of a similar note he authored in January of 2013, where a variety of factors including the weather conspired against him. In that note, he discusses his belief that what he is doing is euthanasia, not suicide. My opinion, pro or con on that belief is not helpful, but I truly don’t believe he had exhausted all options yet.

I’d like to go over each of his frequently asked questions, because I think they make a good read for helpers talking to suicidal individuals and the kind of thinking distortions that can be present, as well as to help those considering suicide themselves realize their distorted thinking patterns.

I’ll list them all at once to make reading the page easier:

  1. “Aren’t you being selfish?”
  2. “But people care about you”
  3. “But ‘Suicide is a permanent solution to a temporary problem’”
  4. My boyfriend my [sic] be caucasian and over 5ft10 but he’s ginger… so you’re wrong…”
  5. My boyfriend my [sic] be caucasian and over 6ft2 but he’s overweight… so you’re wrong…”
  6. My boyfriend is Chinese so there, you’re wrong.”
  7. Stop being so negative”
  8. You’re talking shit, that’s simply not true”
  9. OK – You only find those results because you’re in London (Soho/Mayfair…[insert any random geographical location]).”
  10. Lots of people lead long fulfilling lives without a relationship.”
  11. I have a friend who is Oriental with a Caucasian girlfriend… so you’re wrong.”
  12. One of my female friends is white and really likes Oriental guys. So you’re clearly wrong.”
  13. You are clearly mentally ill? Why don’t you go to a psychiatrist?”
  14. But you will burn in hell! Suicide is a sin! The afterlife is real!”
  15. Remember you always have a choice”
  16. So what? You might be right… be an exception!”
  17. Suicide is the cowards way out”
  18. You’re clearly racist”
  19. You’re a Nazi. What you’re promoting is ‘Social Darwinism’”
  20. The reason why you don’t find Oriental guys with Caucasian girls is cultural”
  21. Why don’t you just use a prostitute every few weeks?”
  22. “So what would you tell someone else in the same position?”

They seem to fall into four categories:

  • Anti-Suicide Cliches (1, 2, 3, 14, 15, 17)
  • Denying The Evidence / Pointing Out Exceptions (4, 5, 6, 8, 9, 11, 12, 20)
  • Dismissing The Problem (7, 18, 19, 21)
  • Miscellanous Attempts at Helping (10, 13, 16, 22)

As you can see, the bulk of his writing is spent on trying to convince people that the evidence is as he says it is. On the other hand, those born in poverty don’t spend a lot of time trying to convince others that being in poverty makes it harder to have a middle class lifestyle; it is merely accepted as a truth. And once we’ve accepted that truth, we can begin working on other areas of ourselves so that we can cultivate hope.

I don’t believe individuals who noted that lots of people live fulfilling lives without relationships were being facetious or trying to dismiss his pain as much as they were trying to provide a role model for McDermid. He was well-liked and his blogging was well-known in his niche, but he couldn’t see past the idea that life was not worth living without someone else in it.

#13 mentions that he is mentally ill, and he should see a psychiatrist. I reject the idea that he was mentally ill; at least, I don’t think he had a DSM-IV/V mental illness. He seemed relatively rational and lucid, despite the suicidal tunnel vision.

Unfortunately, it was his rationality, his equation that was faulty. Dating and relationships are only one part of your existence, they are a piece of life. They are not all of life, and if you’re dead, how will you ever be able to find that person?

He did note that he had spent some time in a psychiatric hospital (where, coincidentally a number of patients formed relationships.) He describes the treatment he received there as pseudoscience; he doesn’t elaborate on the particulars (beyond noting that one exercise required him to “stare at an orange for an hour”) but CBT has been well-proven to help eliminate the kind of faulty reasoning that he was experiencing.

#16 discusses the idea of being an exception. This is what we all aspire to. To work hard, to get lucky (pardon the pun), and to fight against the odds. The investment advisor Chris Gardner (whose life was famously the inspiration for the film The Pursuit of Happyness) and the former US Senator and motivational speaker Les Brown, to highlight two individuals came from humble circumstances and did amazing things with their lives.

Instead of being known as the man who fought the odds, McDermid will be known as a man who gave up. Who resigned himself to a self-fulfilling fate. This is to speak nothing of the ways he could have made himself a more attractive potential mate:

  • He could have taken steps to lose the weight and to build muscle
  • He could have relocated to an area where he would be more in the median range for height rather than the lower end
  • He could have poured his efforts into his blog in an attempt to build the wealth or status that he claims is important

But instead, he chose to take his life. I am not judging him harshly, for he took the route he thought most rational in his mind at the time. But I wish he had been able to hold on, to see that his life could be more than having a partner. As a man who has struggled with romantic relationships I have been there, in that pit of despair, but you can get through it if you don’t give up.

Your life can be bigger than your disadvantages. You can rise above them. Keep your heads up, gentlemen (and ladies.)


“Asian American Populations”. (2013) Centers for Disease Control and Prevention. United States Department of Health & Human Services. May 7, 2013. Retrieved February 12, 2015 from http://www.cdc.gov/minorityhealth/populations/REMP/asian.html

Cass, V. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4 (3), 219-235.

Joel, S., Teper, R., & MacDonald, G. (2014). People Overestimate Their Willingness to Reject Potential Romantic Partners by Overlooking Their Concern for Other People. Psychological Science (Sage Publications Inc.), 25(12), 2233-2240. doi:10.1177/0956797614552828

Murray, S.L., Holmes, J.G. & Griffin, D.W. (1996) “The Self-Fulfilling Nature of Positive Illusions in Romantic Relationships: Love Is Not Blind, but Prescient” Journal of Personality and Social Psychology. 71(6):1155-1180

Rall, M., Greenspan, A., & Neidich, E. (1984). Reactions to eye contact initiated by physically attractive and unattractive men and women. Social Behavior & Personality: An International Journal, 12(1), 103-109.

Cite this article as: MacDonald, D.K., (2015), "On One Man’s Reason for Suicide," retrieved on November 15, 2018 from http://dustinkmacdonald.com/on-one-mans-reason-for-suicide/.

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Clinical and Legal Aspects of Suicidal Children and Youth

Suicide in Children and Youth

While it is well known that adolescents can struggle through turbulent periods of mental health, although very rarely do we consider the suicide risk of younger children. In fact, in Canada the coroner can’t declare a suicide of anyone aged 9 or under (Statistics Canada, 2014) these deaths are likely classified accidents.

The suicide rate in children has remained relatively steady in the period between 2007 and 2011, the most recent year that Statistics Canada data is available. (Statistics Canada, 2014) The suicide rate in children and young adults aged 10-19 was a low of 5.89% of the total suicide rate in 2010 and a high of 6.29% in 2008.

Because children and young adults are often relatively healthy, suicide is the second leading cause of death for Canadians aged 1-24 at 20% of deaths, behind accidents at 35% (Statistics Canada, 2011). It is suspected that the suicide rate is in fact under-reported, because most provinces require the coroner to rule out all other causes of death first (Casey & Hunter, 2011), leaving a number of likely suicides classified as accidents.

Legal Considerations

Because children’s health and welfare is the responsibility of their parents, it is often easier for parents to access supports than for other populations. Parents can take their children to their family physician, the ER/local hospital or to agencies focused on children’s and youth mental health.

Beyond their peers, teachers are often the first individuals that suicidal young people will confide in; therefore it is important that they receive gatekeeper training such as the Question, Persuade, Refer (QPR) training or the two-day Applied Suicide Intervention Skills Training (ASIST) to help them recognize and respond adequately to suicidal ideation.

Clinical Concerns

Girls and women tend to have a higher rate of suicide attempts, than boys and men, often two to three times higher (Statistics Canada, 2012) however men die much more often. (Statistics Canada, 2014) This is due to their choice of suicide method; while women tend to favour poisoning, which is often non-lethal, men tend to favour hanging or – especially in the United States – firearms, which are more lethal.

This trend is changing however, the rate of hanging in women has increased by several percent in recent years. (Statistics Canada, 2012)

Most youth suicides happen at night and in the home, where access to the suicide method is available (Miller & Eckert, 2009) with the lethality of the suicide attempt roughly corresponding with the intent to die (Berman et. al., 2006) For instance, a youth with a stronger intention to die is more likely to use hanging or firearms than a youth with less intent.

Deficits in the mental health system have been identified (e.g. by Renaud, 2014) that focus on continuity of care, with individuals at risk or dying by suicide often not receiving the services they needed and under-diagnosis of mental health issues in youth.

Rudd et. al (2006) identifies a number of warning signs, which, distinct from the risk factors identified below, substantially increase likelihood of immediate suicidal behaviour. They include:

  • Rage, anger, seeking revenge
  • Engaging in reckless/risky behaviour
  • Feeling trapped
  • Increased alcohol use
  • Withdrawing from peers and family
  • Anxiety or agitation
  • Large change in sleep pattern (insomnia or hypersomnia)
  • Dramatic mood changes
  • No reason to live; sense of purposelessness

Children are highest risk to suicide in the period transitioning out of hospitalization, so it should be used with caution. (Huey et al., 2004) If less intensive methods are available to stabilize the child they are preferred.

While bullying is commonly discussed in the media, a review of 94 youth suicides in Toronto showed bullying was an identified factor in the death in only 6.4% of cases, while conflict with parents, romantic and academic problems and criminal or legal problems accounted for a combined 59.5% of suicides. (Sinyor, Schaffer & Cheung, 2014)

A note on medication: While research had demonstrated that use of anti-depressants increased suicide risk in children and young adults, leading to a “black box” warning on anti-depressant medication, subsequent research showed that the resulting controversy led to under-prescribing of anti-depressants to children who actually needed them, raising the overall youth suicide rate. (BMJ, 2014)

Protective and Risk Factors (Miller & Eckert, 2009; Bridge, Goldstein & Brent, 2006)

Protective Factors

  • Seeking help
  • Strong coping skills (Walsh & Eggert, 2007)
  • Effective social support systems
  • Means restrictions
  • Safety plans

Risk Factors

  • Interpersonal conflict and loss Lethal and disciplinary problems
  • Depression and hopelessness (Dube, Bhargava & Sood, 2014)
  • Previous suicide attempts
  • Social isolation and rejection (Frederick, Kirst & Erickson, 2012)
  • Limited access to mental health facilities
  • Poor problem-solving
  • Low self-esteem (Wilburn & Smith, 2005)
  • Poor family environment

Impulsiveness is a commonly cited factor in youth suicide (Witte, et. al., 2008), and while some suicides may be legitimately impulsive it’s important to rule out that an individual may have had undetected suicidal ideation or other long-standing risk factors before sudden warning signs or suicide attempts emerge.

An additional risk factor to consider is suicide contagion. There have been documented cluster suicides where the glorification and glamorization of one youth (or celebrity’s) suicide encourages others to do the same.

Further Training / Reading

I’ve written about the Counseling on Access to Lethal Means (CALM) training, it is short, free, available online and focuses on intervention strategies with youth.

Additionally, the Children’s Hospital of Eastern Ontario (CHEO) produced a guide to help parents with suicidal children that is a valuable read.


Berman, A. L., Jobes, D. A., & Silverman, M. M. (2006). “Adolescent suicide: Assessment and intervention” Washington, DC: American Psychological Association.

BMJ. (2014) “Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study” doi: http://dx.doi.org/10.1136/bmj.g3596

Bridge, J.A., Goldstein, T.R., & Brent, D.A. (2006) Adolescent suicide and suicidal behaviour. Journal of Child Psychology and Psychiatry. 47(3/4): 372-394

Casey, L., Hunter, P. (2011) “Suicide may be substantially underreported in Ontario” Toronto Star. Retrieved electronically from http://www.thestar.com/news/gta/2011/12/02/suicide_may_be_substantially_underreported_in_ontario.html on February 9, on February 9, 2015

Dube, S., Bhargava, D., Sood, P. (2014) “Comparative Study on Mental Health Among Youth” International Journal of Multidisciplinary Approach and Studies. 1(5).

Frederick, T.J., Kirst, M., & Erickson, P.G. (2012) “Suicide attempts and suicidal ideation among street-involved youth in Toronto” Advances in Mental Health. 11(1):8-17

Huey, S.J., Jr., Henggeler, S.W., Rowland, M.D., Halliday-Boykins, C.A., Cunningham, P.B., Pickrel, S.G., et al. (2004). “Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies.” Journal of the American Academy of Child and Adolescent Psychiatry, 43, 183–190.

Miller, D., Eckert, T. (2009) “Youth Suicidal Behavior: An Introduction and Overview” School Psychology Review. 38(2):153-167

Renaud, J., Seguin, M., Lesage, A., Marquette, C., Choo, B., Turecki, G. (2014) Canadian Journal of Psychiatry. 59(10):523-530

Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M., Mandrusiak, M., et al. (2006). “Warning signs for suicide: Theory, research, and clinical applications” Suicide and Life-Threatening Behavior, 36, 255–262

Sinyor, M., Schaffer, A., Cheung, A.H. (2014) “An Observational Study of Bullying As a Contributing Factor of Youth Suicide in Toronto” Canadian Journal of Psychiatry. 59(12):632-638

Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on January 29, 2015.

Statistics Canada. (2012) “Suicide rates: an overview” Retrieved electronically from http://www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm on February 9, from February 9, 2015

Statistics Canada. (2011) “Percentage distribution for the 5 leading causes of death in Canada, 2011” from CANSIM, table 102-0561. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on February 9, 2015.

Wilburn, V.R., Smith, D.E. (2005) “Stress, Self-Esteem and Suicidal Ideation in Late Adolescents” Adolescence. 40(157).

Walsh, E., Eggert, L.L. (2007) “Suicide risk and protective factors among youth experiencing school difficulties” International Journal of Mental Health Nursing. 16:349-359

Witte, T.K., Merrill, K.A., Stellrecht, N.E., Bernert, R.A., Hollar, D.L., Schatschneider C., Joiner T.E. Jr. (2008) “’Impulsive’ youth suicide attempters are not necessarily all that impulsive.” Journal of Affective Disorders. 107(1-3):107-16

Cite this article as: MacDonald, D.K., (2015), "Clinical and Legal Aspects of Suicidal Children and Youth," retrieved on November 15, 2018 from http://dustinkmacdonald.com/clinical-and-legal-aspects-of-suicidal-children-and-youth/.

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Suicide in Hospitals and Inpatients

Note: I originally planned to write an article entitled “Suicide in Special Populations”, but as I began doing some research, I realized that each population was so filled with research that each would be better split up into individual articles. So this is the first of the series, that I hope will contain suicide in youth, suicide in the elderly, and suicide in the military and police veteran populations.

Hospitalized inpatients are often those suffering from the most severe mental health issues and hospital deaths are among those believed to be most preventable because of the high security and access to psychiatric care, and although the rate of inpatient suicides is low compared to the general population, it is markedly higher than that of non-hospitalized inpatients or those hospitalized for physical health issues.

Research on inpatient suicides is limited, but Sakinofsky (2014) noted a rate by Martin of 1.24 suicides per 1000 suicides in a Canadian psychiatric hospital.

An important consideration to inpatient suicides is that many psychiatric patients can end up in the Emergency Department (ED/ER) where the expertise is in treating physical health issues, rather than mental health ones. (Zeller, 2010)

Legal Considerations

Canadian and American laws are very strict when it comes to involuntary commitment. Even when a patient is hospitalized, physicians may discharge them without a proper assessment, which can open them up to further liability in the event of a suicide.

The exact nature and length of hospitalization depends by province or state. For instance, in Ontario there are four statuses in which you can be admitted, classified based on the number of Form (Form 1, Form 2, Form 3, and Form 4) that the police, a Justice of the Peace or a physician may fill out. (Psychiatric Patient Advocate Office, n.d.)

  • Form 1 is a 72-hour psychiatric hold
  • Form 2 is a Justice of the Peace form, with which they can use to declare you as likely to be a danger to yourself or others
  • Form 3 is a Certificate of Involuntary Admission, filled out by a physician
  • Form 4 is a Certificate of Renewal, extending your involuntary admission

Clinical Concerns

According to Sakinofsky (2014) most suicides occurring to inpatients in fact occur when the patient is out of the hospital on a day pass or weekend leave, rather than in the secure hospital environment.

Of course, suicide risk assessment requires careful training and experience and when lives are at stake, there is an important weighing of rights against safety.

Protective and Risk Factors

Protective factors to reduce suicide in inpatients include

  • Being placed under appropriate surveillance
  • Removing access to suicide methods

Risk factors increasing suicide in inpatients include:

  • History of attempted suicide
  • Agitation
  • Impulsivity
  • Being recently admitted or discharged


Psychiatric Patient Advocate Office. “Home – HOME”. Retrieved from “http://www.sse.gov.on.ca/mohltc/ppao/en/Pages/InfoGuides/MentalHealthActAdmissions_D.aspx?openMenu=smenu_MentalHealthActAdm” on February 3, 2015

Sakinofsky, I. (2014) “Preventing suicide among inpatients”. Canadian Journal of Psychiatry. (59)3: 131-40


Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on January 29, 2015.

Zeller, S. (2010) Treatment of Psychiatric Patients in Emergency Settings. Primary Psychiatry. 17(6):35-41

Cite this article as: MacDonald, D.K., (2015), "Suicide in Hospitals and Inpatients," retrieved on November 15, 2018 from http://dustinkmacdonald.com/suicide-in-hospitals-and-inpatients/.

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Review of LivingWorks suicideCare Seminar

The LivingWorks suicideCare course is a one day training focused on advanced suicide risk and case management. According to LivingWorks, the following learning outcomes are expected:

  • Building on the principles and practice of suicide first aid
  • Understanding helper issues associated with ongoing care; and
  • Demonstrating a working knowledge of intervention strategies

The training identifies a number of ‘tasks’, ‘tools’ and ‘traits’ that they feel are helpful, including describing risk, maintaining a helping alliance, working with ambivalence, living with uncertainty and showing courage to name a few.

The major categories (which will be reviewed in sequence below) are:

  1. Assumptions and Key Elements in Suicide Helping
  2. Suicide Process
  3. Suicide Helping Process: Three Helping Strategies
  4. Strategy 3: Tasks, Tools and Traits
  5. Helping Approaches: Suicide First Aid
  6. Task: Describe Risk
  7. Helping Approaches: Management
  8. Helping Approaches: Treatment
  9. Summary

Assumptions and Key Elements in Suicide Helping

This part of the seminar goes over the advantages from taking the course and what individuals will learn coming out of the seminar. I believe we discussed the Suicide Intervention Response Inventory at this point, which was part of our pre-reading for the seminar.

Suicide Process

The suicide process discusses the interplay between protective factors and risk factors, and the idea of a “suicide zone” where increased suicidal risk exists, and how intervention before this point can help reduce future risk.

They also define the acronym PAR – person at risk.

Suicide Helping Process: Three Helping Strategies

In this section the three helping strategies are discussed. The first helping strategy is to focus on the person or the suicidal act. This involves dealing with the risk elements directly, including through potential hospitalization.

The second strategy is delivering an intervention. This could involve checklists, agency protocols or other procedures. For instance, the Distress Centre protocol involves using the CPR Risk Assessment followed by the ABC Model of Crisis Intervention.

There are some interesting studies consulted in this section that would be valuable to follow up with. I won’t spoil the fun but they involve suicide rates from various treatments and types of follow-up.

The final strategy is to focus on both the person/act and the intervention, which is essentially a combination of the first two strategies, tailored to the person involved, which takes advantage of the Tasks, Tools and Traits discussed earlier.

Additionally, unproductive reactions are covered, these include:

  • Repressing the response
  • Turning their anger inward
  • Compensating
  • Projecting on to the person at risk

As well, learning your “suicide baseline”, in terms of your optimism or pessimism to suicide, and your level of comfort with permissiveness or restrictiveness. A 1994 Neimeyer study about the most common error of suicide interventionists is also cited.

Helping Approaches: Suicide First Aid

This section is a review of the Suicide Intervention Model (SIM) from the ASIST training. ASIST has been updated to a new version, ASIST 11 which I have not taken yet, so this content may be different in the latest suicideCare. If anyone has taken it, please let me know.

The CPR Model is covered here, with a comprehensive case review. I found this one of the most valuable sections of the entire seminar.

It also briefly discusses a quantitative method of estimating risk, based on severity of risk equaling time multiplied by duration. I found this part less helpful, because there is no information provided on how to assess “severity.” An interesting thought, however, was the idea of the rules of 2: estimating risk at 2 minutes, 2 hours, 2 days, 2 weeks, 2 months and 2 years.

Helping Approaches: Management

This section again starts with a comprehensive case study. This case study focuses on case management, working to remove external barriers that cause a person’s suicidality.

This is most useful for non-therapists (and obviously, case managers.) Additional skills highlighted here that would be useful is the ability to perform a Mental Status Exam (MSE). The reading materials provided with the seminar (which I am basing this review off of) includes a good MSE as part of the case study.

Like the previous case study, the depth of the material covered makes this an extremely valuable reference.

Helping Approaches: Treatment

The treatment section of the seminar focuses on internal barriers that lead to suicidality. This is separate from external barriers that are treated by case management. Instead, internal issues are treated with counselling and psychotherapy.

Because of my lack of experience provide long-term counselling (as opposed to using counselling skills which happens quite frequently), I found this section less helpful. Of course therapists and counsellors would likely be very comfortable with this material.


The summary of the course offers a birds-eye view of the material covered, and summarized the resources that have been referred to during the course. Overall, I found the suicideCare a valuable resource for a suicide interventionist looking to develop more advanced skills and I would thoroughly recommend it.

Cite this article as: MacDonald, D.K., (2015), "Review of LivingWorks suicideCare Seminar," retrieved on November 15, 2018 from http://dustinkmacdonald.com/review-of-livingworks-suicidecare-seminar/.

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How to Respond to Suicide Threats on Social Media

As social media finds a greater and greater importance and significance in our lives, it’s important that we get better at responding to suicidal threats that appear on social media sites like Twitter, Tumblr and Facebook.

Failures To Respond

There have been a number of situations where a failure to respond appropriately (or simply an inability to locate an individual in time) when threats on social media are posted has led to suicides and homicides.

In December 2014, Amber Cornwall, aged 16, died of suicide by hanging after posting on Facebook “If I died tonight, would anyone cry?” She killed herself later that night, and was found the next morning by her parents. Her parents say she was heavily bullied before her death. (WLOS News 13, 2014)

Adrian Alvarez shot himself at his school in October, 2013 after posting on Facebook that he was sorry for all the pain he caused his friends and family. The father of an infant son, he was 16 years old. (NY Daily News, 2013)

A woman from Shanghai, going by the instagram username jojostai1012 posted a series of pictures including the lines “I will haunt you day and night after I’m dead”, and burning her possessions before she jumped out of a high-rise building in March of 2014. (Daily Mail, 2014)

In each of these situations, evidence of statements of lethality was present hours before the individual took their own life. Dozens, in some cases hundreds of people saw these messages and nobody reached out to ask the individual if they were feeling suicidal.

In the case of the woman from Shanghai, the photos of her destroying her possessions represent an imminent risk factor that required immediate intervention to preserve life.

How to Respond

The process for responding to online posts that make you concerned a person may be considering ending their life is similar to the process you would take if they were in person or on the telephone.

Start by reaching out via private message (if possible), and asking the person if they are feeling okay. Incorporate an empathy statement and begin to build that rapport.

This process will be easier if you have a pre-existing relationship with the individual, but even if you don’t, getting them talking will demonstrate that someone out there does care about them.

Once you have built up a rapport and began to have a conversation about how they are feeling, ask the question! All you have to do is ask. “Sometimes when people say they’re sorry for all the pain they’ve caused, they’re thinking about suicide. Have you thought about suicide?”

Then you can move into the CPR Risk Assessment. Do they have a plan? Means and access? A timeline? Do they have any previous history of suicidal behaviour or bereavement by suicide? What kind of coping mechanisms do they have? Who in their life can they rely on?

Once you’ve determined the depth of their suicidal danger you can work collaboratively with them to establish a safety plan, as per the ABC Model of Crisis Intervention. Is there somewhere they can go (hospital, friend’s house, mental health crisis bed) for more intensive support than they can get right now? Can their access to lethal means be mitigated?

In the aftermath of the suicidal crisis, you’ll want to help them connect to counselling, case management or therapy to help them cope better in the future.

Emergency Intervention

If you have access to their location, 911 or emergency services can dispatch a police officer or paramedics to provide them with transportation to the hospital or immediate medical care. If you lack specifics, this may be a more difficult process.

Police often work with phone companies to provide the GPS of individuals in a rough area, and this may aid in your locating them if they have a cell-phone.

Facebook provides an option to report posts that are of a suicidal nature but as they point out, “If you’ve encountered a direct threat of suicide on Facebook, please contact law enforcement or a suicide hotline immediately. If the person you’re worried about is a member of the US military community, be sure to mention this so they can provide this person with custom support.”

Correct Responses

For all of the failures to help people feeling suicidal, there are some examples of proper responses online, although it’s likely most of these are not published, as the person simply stays alive rather than their death being reported in the media.

An 18 year-old man who posted “Thinking of jumping” next to a photo of the George Washington Bridge was helped by officers of the Port Authority police, after they were tipped off by a concerned friend.The Emergency Services Lieutenant sent the man his phone number, and he reached out. The officer convinced him to meet in person, and after talking he agreed to go to a local hospital for help. (CNN, 2013)

In 2009, a woman used the social networking site Twitter to send a message to the actress Demi Moore detailing her plan to kill herself using a large knife, followed up with “gbye … gonna kill myself now”.

Moore responded to the tweet publicly which led to people reporting the threats to the San Jose Police Department. The woman was found, uninjured, and taken for mental health evaluation. (ABC News, 2009)

In each of these successes, a person posted obvious statements of lethality, and individuals reached out. They reported the threats, built empathy with the persons in distress and referred them to the support they needed.

Additional Resources

The Suicide Prevention Resource Centre publishes a guide (PDF) on Suicide Threats on Social Networking Sites which provides a brief overview, some risk management pointers for helpers and social networking sites and some guidelines for both your safety and the safety of the distressed person. (Olson, 2011)


ABC (2009, Apr 3) “Did Demi Moore’s Twitter Feed Stop a Suicide? | ABC News” Accessed electronically from http://abcnews.go.com/Entertainment/AheadoftheCurve/story?id=7248406 on February 3, 2015

CNN (2013, Nov 15) “Teen’s remarks on Facebook sends cops into social media action to save a life – CNN.com” Accessed electronically from http://www.cnn.com/2013/11/15/us/social-media-suicide-stop/ on February 3, 2015

Daily Mail (2014, Mar 17) “Chinese woman appears to post her suicide on Instagram | Daily Mail Online”, accessed electronically from http://www.dailymail.co.uk/news/article-2582395/Did-hundreds-people-ignore-girls-cry-help-Chinese-woman-appears-post-suicide-Instagram.html on February 3, 2015

NY Daily News (2013, Oct 17) “Texas teen posted Facebook warning before school suicide”, accessed electronically from “http://www.nydailynews.com/news/national/texas-teen-posted-facebook-warning-school-suicide-article-1.1488343” on February 3, 2015

Olson, R., (2014) “Suicide threats on social networking sites”. Suicide Prevention Resource Centre. Accessed electronically from http://www.sprc.org/library_resources/items/suicide-threats-social-networking-sites on February 3, 2015.

WLOS. (2014. Dec 22) “Bullying Led To E. Henderson Student’s Suicide, Says Family”, accessed electronically from “http://www.wlos.com/news/features/top-stories/stories/bullying-led-e-henderson-students-suicide-says-family-18998.shtml#.VNEA6J3F-Ck” on February 3, 2015

Cite this article as: MacDonald, D.K., (2015), "How to Respond to Suicide Threats on Social Media," retrieved on November 15, 2018 from http://dustinkmacdonald.com/how-to-respond-to-suicide-threats-on-social-media/.

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