Keywords

Assisted suicide; mental illness and stigma; caregiver fatigue; blue zones; resilience; protective factors; suicide prevention

Factors That Lead to Longevity

It may seem strange to talk about longevity in a book focusing on premature, self-inflicted death. However, if we examine the factors that lead to longevity we perhaps can see what was missing in some individuals’ lives that may have led them to suicide. Dan Buettner (2015) assembled a team of health professionals and academics to determine what factors contribute to a longer and better quality of life in five “blue zones,” areas around the world where people with the greatest longevity reside. Buettner (2015) identified nine common characteristics among the communities, which can be grouped into four areas. He arranged these factors into a pyramid with belonging forming the foundation, followed by eating wisely, having the right outlook and moving naturally.

In terms of belonging, people in the blue zones had a tremendous amount of social support. First, they belonged to social circles that supported healthy behaviors. They saw friends or family nearly every day for a pleasant activity. Second, most of them were involved in faith-based communities; any denomination was beneficial. Third, they put their families first. As Buettner (2015) describes, “They keep aging parents and grandparents nearby or in the home, which also lowers disease and mortality rates of their children. They commit to a life partner (which can add up to three years of life expectancy), and they invest in their children with time and love, which makes the children more likely to be caretakers when the time comes” (pp. 21–22).

Social support serves a protective function at all ages. Middle-aged women were interviewed about their social relationships and the greater their social integration, the less likely they were to commit suicide (Tsai, Lucas, & Kawachi, 2015). In fact, women who were not socially well integrated had a three-fold higher risk for suicide than those who were well integrated. In Alaska, “for every 5-degree increase in northerly latitude, suicide rates increased 18 percent” (Rosen, 2013). As social isolation increased, so did rates of suicide. According to the Centers for Disease Control and Prevention (CDC) statistics for 2014, the three states with the highest suicide rates were (in order) Wyoming, Alaska, and Montana, states with small communities and vast rural areas (CDC, 2014). Theorists have identified “thwarted belongingness” as one of the causes for suicide (Joiner, 2005); it makes sense that communities which provide opportunities and conditions for belonging have fewer suicides than those without.

One of our note writers wrote over a dozen notes to friends and family. In addition, he asked his parents to let anyone read a long generic note he had written explaining his reasons for suicide. Towards the end of the note, he asked readers for a few “favors.” His first favor read, “Please turn your T.V. set’s off more, and talk to each other a little more. You’ll like it I swear.” Although this writer appears to have had a lot of social support, the number of notes may not have reflected the quality of his social support. In his final communications, he is asking readers to engage in more social support. Numerous note writers recognized the devastating effect of isolating themselves or longed for more or better social support. If there is one factor that might have mitigated most suicides, this would be it. In blue zones, almost all of the people who lived to be over 100 years old enjoyed conversation with others on a daily basis.

The second area identified was eating wisely, and although these factors are important to longevity, they may not seem as crucial for prevention of or intervention in suicidal behavior as enhancing social support. Still, many individuals in our sample were dealing with the effects of poor health habits, or substance use or abuse, which contributed to their decline. Moreover, dietary patterns can lead to chronic health problems and pain, and many people who kill themselves wish to escape pain. Frazao (1999) noted the cycle of stress and poor quality of life that often contributed to poor dietary habits, which in turn contributed to more stress and poor quality of life. With suicide in the top 10 causes of death in the United States, improving one’s diet and the diet of one’s family seems like a positive step for suicide prevention.

The third area focused on having the right outlook on life, including having a sense of purpose and finding a way to deal with stress. Most people in blue zones had routines to deal with stress, so that when stressful situations occurred they had a response in place, whether it was taking a nap, praying, or having a happy hour. In this way, stress was overcome with something natural to one’s habits and environment. Lack of purpose presents a deep problem in modern society, and in blue zones work alone was never enough. People found their purpose in their communities and among their loved ones. Among the suicide victims in our study, there were frequent references in the notes to life having no meaning.

One 32-year-old who hanged himself expressed his regret that he had no purpose. “I wish I could go back and change everything. We all know I cant so I am sorry to bring pain to everyone. My life has no meaning any more all I do is drag everyone around me down.” A 60-year-old female left a note that said, “The life I have to look forward to had no meaning to me. I’d rather be dead.” She asphyxiated herself with carbon monoxide. Others looked for meaning, but it eluded them. With a history of Crohn’s disease, depression, anxiety, diabetes, and impotency, a 47-year-old man despaired of finding any purpose. “I’ve studied and read, but maybe I’m just a nihilist, existentialist at heart. Maybe there is no meaning in the universe.”

Viktor Frankl (1946) spoke of how having a sense of purpose kept him alive in a Nazi concentration camp. He believed finding meaning in one’s life was central to having a reason to continue living. To find meaning, Frankl wrote, one needed a combination of work, love, and the ability to rise above oneself. One’s reason to live may seem inconsequential to others, but if the individual believes that s/he has a purpose in life, a motivation to endure follows. This sense of purpose was lacking for many suicide victims.

A related concept is called future time perspective (FTP). Chin and Holden (2013) suggest FTP can be a protective factor that may mitigate suicide. FTP has three components: future thinking, optimism, and future connectedness—envisioning how one’s present actions affect the future. They recruited college students who had symptoms of depression and suicidal ideation and found FTP “attenuated the relationships between hopelessness and suicide motivation, as well as depressive symptoms and suicide motivation” and moderated “the impact of depressive symptoms on suicide preparation” (pp. 401–402). They noted that it may not have been FTP alone that served the protective function, but FTP may have been aided by other characteristics, such as having a reason for living.

The last area in Buettner’s blue zone study, moving naturally, focuses on exercising the body, not through extreme activities, but rather by taking advantage of opportunities to move. These include walking when doing errands, walking to a friend’s house or gardening. It is movement the body craves and it can be beneficial without extreme measures. Not only do these activities promote physical health, they can lead to stress reduction, healthy coping, and social support. The positive effects of exercise on depression are documented for all age groups. Older people often develop poorly responsive depressive disorder, and one study found a 30% decline in it when people attended group exercise activities (Mather et al., 2002). A recent study found also that spending time in nature, just taking a simple hike, decreases obsessive, negative thoughts by a significant margin (Bratman, Hamilton, Hahn, Daily, & Gross, 2015). The exercise does not have to be rigorous or difficult to provide a benefit.

All four areas Buettner outlines are important, but two are critical for the prevention of suicide: helping an individual find purpose in life and enhancing social support. Some people in our sample felt they had lost their purpose and could not begin the process of finding a new one. Many of them suffered from depression and trying to find or re-create a purpose in life was too overwhelming. For others, like the school superintendent who had seemingly lost everything due to a DUI, it was impossible to believe life could ever have purpose again. Yet a sense of purpose can come from being responsible for a pet or providing volunteer services. Where the social support system is intertwined with the search for a purpose, people live longer. When at-risk adolescents were engaged in personally meaningful extracurricular activities, they were less likely to report suicidal ideation (Armstrong & Manion, 2013). Finding a sense of purpose can also lead to enhanced social support as the individual becomes linked with community systems.

In 2014, the World Health Organization (WHO) published a report titled Preventing Suicide: A Global Imperative. The report stemmed from the 2013 World Health Assembly which adopted the first-ever Mental Health Action Plan. A main focus of the plan was suicide prevention with a goal of reducing the suicide rate by 10% by 2020. Their findings underscore Buettner’s conclusions regarding factors leading to health and longevity. Like Buettner they found that strong personal relationships, religious or spiritual beliefs, and positive coping strategies enhance resilience. Although they recognized that some religions have prohibitions against suicide and stigma attaches to it, involvement in a community is what provides a protective function. Positive coping included healthy lifestyle choices related to diet, sleep, exercise, and management of stress. Development of positive well-being also increases the chances that someone will ask for help when needed.

Factors That Lead to Lives Cut Short

In United States football, the chances of scoring a touchdown are statistically higher in an area near the end zone known as the “red zone.” The area is not marked on the field, but commentators and advertisers know where it is. Just as blue zones exist in which people have high longevity, red zones also exist where people have a statistically higher chance of dying young. They are not marked on a map, but experts know where they are. And once they are pointed out, it’s easy to understand why.

Most blue zones are not wealthy areas, but neither are they areas with the poor social and economic conditions that embody the term “poverty.” Premature death appears in areas with higher “poverty rates,” i.e., lower incomes. Metro areas with the shortest life expectancy at birth also have poverty rates often higher than the national rate (Frohlich, Kent, Comen, & Stebbins, 2015). Behavior and biology also contribute to lower longevity. Cities with higher obesity and smoking and the fewest hours of exercise saw shortened lifespans for their residents. Gadsden, Alabama, which has low income and high rates of obesity, has the lowest life expectancy of any city in the United States, at just over 72 years (Frohlich et al., 2015).

Just as some communities have low life expectancy, some communities in the United States have higher rates of suicide than others. These are not typically cities with low life expectancy on the whole. Las Vegas is the city with the highest suicide rate, at 34.5 per 100,000 people. Las Vegas’s particular allure for the suicidal seems predictable, but the other cities that appeared in the top 15 in 2011 had rates of suicide that varied widely from year to year and lacked any obvious characteristic associated with suicide. Tulsa, Phoenix, Fresno, Portland (OR), Pittsburgh, Wichita, Jacksonville, Denver, Miami, Tucson, Mesa (AZ), Albuquerque, Sacramento, and Colorado Springs were on the list. Many of these cities are thriving places, and at least 10 are often sunny and warm. While some of the cities had high crime (Pittsburgh) or high unemployment (Wichita, Jacksonville), these cities did not have the highest rates nationwide for those problems (Giang & Lubin, 2011). What makes a community suicide-prone?

One study of Brazilian and American cities found that, as cities grew, so did their mortality rates from car accidents and murders. Suicide rates, on the other hand, declined (Melo, Moreira, Battista, Makse, & Andrade, as cited in Khazan, 2014). Cities provide opportunity for social interaction. The researchers, citing Durkheim, opined that the decision to kill oneself, like the decision to commit murder, “instead of being purely a consequence of individual choices, might have strong correlations with the underlying complex social organization and interactions” (p. 2). It is possible that larger cities provide some of the things that blue zones do: more social interaction and greater productivity (and thus a sense of purpose), but more study is needed. Cities may also offer greater access to health care, education, and services that help people cope with stress. The 15 United States cities identified as having the highest rates of suicide were mostly midsized cities, some of them in states lately strained to provide medical services. Arizona, e.g., ranked 50th among the states in mental health care (Stuart, 2015). Florida ranked 17th among the states in suicide deaths, and had two cities in the top 15, but its small towns were the places where suicide was especially high. Miller and Klingener (2015) found that isolation, poverty, access to firearms, and a lack of mental health resources were the causes of the increased suicide rate in small towns.

As many communities struggle with dwindling state budgets, it may seem like a daunting task to create new measures to combat suicide. Yet implementing health literacy policies is one solution that need not be expensive. Health literacy is a new concept that involves educating people about their health in ways that are useful and understandable. If information is delivered but people are not able to turn it into practical application, it will have little effect. Health literacy programs seek to provide information that several components of a community then put to use. If a community wishes to improve eating habits, e.g., a collective effort between schools, health centers, workplaces, and retailers might focus on healthy eating activities so that the delivery of information coincides with a positive intervention in practices (Nutbeam, 2000). Applying this to suicide intervention is even more complex than applying it to dietary habits, but with strong civic leaders committed to suicide prevention, health literacy can become an important new tool.

Most states already have community health centers, and using these to their fullest capacity in suicide prevention is critical. Many states are reducing their spending on mental health care and on community health; some states are privatizing care and limiting the scope of their community health centers. Given the reduction of fiscal resources, it may not seem reasonable to expect community health centers to do more, but it requires strategy as well as collaborative will.

Community resilience is something we witness whenever natural disasters occur, for example. A town is destroyed by a tornado, and neighbors and strangers get together to rebuild. This same model of community resilience, researchers posit, might “serve as a sustainable paradigm for organizing public health and medical preparedness, response, and recovery” (Wulff, Donato, & Lurie, 2015, p. 361). Communities in disaster often receive help from outside, including money and materials. In normal times, however, subsistence is all stakeholders expect. That needs to change. Wulff et al. (2015) suggest that the first thing that needs to be done is to convince stakeholders that by “strengthening health systems, meeting the needs of vulnerable populations, and promoting organizational competence, social connectedness, and psychological health,” (p. 361) everyone benefits. “Community resilience encourages actions that build preparedness, promote strong day-to-day systems, and address the underlying social determinants of health” (p. 361). Community resilience needs to become part of the normal routine of our communities. With respect to suicide that means implementing prevention objectives at all levels and treating all of the risk areas, from the individual to the communal. Access to counseling for individuals, couples, and families, as well as the creation of strong social bonds in the community as a whole, can prevent suicide.

In trying to create communities that by their very structure promote well-being and prevent the risk factors for suicide, we cannot ignore that death comes for everyone, and sometimes, for those with agonizing illnesses, it may not come soon enough. This has prompted four states to enact, and many others to consider enacting, legislation to allow for physician-assisted suicide. As the movement grows, it raises ethical and medical questions with which families and communities must grapple.

Death With Dignity

The vast majority of individuals in this project would have benefited from many of the protective factors discussed here, such as increased social support or finding a sense of purpose. Nevertheless, one group ostensibly would not have been affected by most of these protective factors—people who were suffering from a physical illness. They generally appeared to have a good social support system and were neither suffering from a mental illness nor searching for a purpose in life. They were simply unable to endure the illness and/or pain any longer. Their chronic pain affected their bodies, minds and spirits: “Mindy Sweetheart—My Nerves have snapped—Never thought would do this but I can’t take any more of this punishment!! I see no help in getting well.” “I know you’ll miss me at first, but if it helps think of me up in heaven pain free.” “I couldn’t stand the pain any longer. Thanks for all you done for me.” “I’m ready to be done here. I don’t know what awaits me, if anything, but I’ve had all I can bear and I want the pain to stop.”

Some of these individuals may have opted for a “death with dignity” option if they lived in a state that allowed it. Death with Dignity is a nonprofit organization that “expands the freedom of all qualified terminally ill Americans to make their own end-of-life decisions, including how they die” (“About Us–Death with Dignity,” n.d.). The notion of dying with dignity has been referred to by numerous other terms such as assisted suicide or right to die. National debate about the topic gained momentum in 2014 when Brittany Maynard, a 29-year-old woman diagnosed with a stage-four glioblastoma, was told she had six months to live. Unlike other advocates for assisted suicide, Maynard was young and vivacious and gained national attention for the cause. Maynard lived in California, a state that did not provide for assisted suicide, so she moved to Oregon where they had enacted a Death with Dignity law in 1994. She also partnered with Compassion & Choices, establishing the Brittany Maynard fund to promote assisted suicide legislation in states where it is not legal (Compassion & Choices, 2016). Eventually, in 2015, Maynard’s home state of California approved legislation for death with dignity. Washington State and Vermont are the other states that have laws allowing for it and Montana allows for assisted suicide by a Supreme Court ruling. It should be noted that since it was enacted in 1994, only about 50 people per year have taken advantage of the Oregon law.

Gleckman (2015) suggests that the Death with Dignity discussion should focus on how to allow people to live the best life they can. Often, when someone has a chronic illness they lose social support at the very time when they need it the most. He suggests, “This is not about death with dignity, as the physician-assisted movement describes itself. It is about life with dignity. And, as a society, we do far too little to preserve it.” Although the laws provide a way for people to have a sense of control over their deaths, Gleckman suggests the focus should be on allowing them to live life. Even for these individuals, social support is key. Does that mean they will reach a point where they do not want to die? Maybe or maybe not. However, social support may prolong life satisfaction and even in death, social support eases the transition. Brittany Maynard died surrounded by those she loved.

Some institutions and groups oppose “right to die,” “death with dignity,” or euthanasia legislation. Twenty-six states and the Commonwealth of Puerto Rico have legislation prohibiting assisted suicide. Belgium, the Netherlands, and Luxembourg are examples of European countries that allow it; throughout the western world legislative bodies have debated it. The Roman Catholic Church remains opposed to all forms of assisted suicide or euthanasia for any reason, but not all Christians believe it to be wrong. Muslims, Hindus, and Jains accept it under certain circumstances. Political opposition exists as well, especially among people who associate it with the former Nazi regime in Germany. Disability activists such as Not Dead Yet object to laws which they say provide not just for terminally ill patients to kill themselves, but for patients with chronic, nonfatal illnesses (Not dead yet, 2016).

The “death with dignity” movement challenges the idea that suicide is always something to be prevented, or the popular perception that only the mentally ill commit suicide. Many factors, from ethical concerns to the fact that suicide is still associated with sin and stigma, have prevented this type of legislation from becoming universal.

Living With Thoughts of Death

On social media such as Facebook, one of the activities many users engage in is taking quizzes. These are often silly, with no real right or wrong answers. One popular quiz is “How Well Do You Know X?” and individuals post this on their “timelines” (home pages) to see if their friends really know them. The individual selects answers to several questions, and when his or her friends take the quiz, they see if they match. In this quiz, one of the questions, after asking whether money or chocolate is one’s favorite, is “What kind of death does X fear most?” Then there are choices: suffocating, being burned alive, plane crash, drowning, and lastly, “X does not fear death” (Heroquizz, 2016). Although the question is asked in jest, it is exactly one of the things we need to know when we are assessing someone’s risk of suicide.

Most human beings have a strong desire to live. In the abstract, we may say we do not “fear” death, but unless we are faced with imminent death, we often are not too sure of our feelings. When a person is diagnosed with a terminal illness, e.g., the news is received and processed in stages. Kubler-Ross (1969) was the first to articulate what she called the five stages of loss and grief in which a person who is terminally ill, or one who loses another to terminal illness, responds with denial and isolation, anger, bargaining, depression, and acceptance. While some debate about the stages is found among scholars, few deny that change over time occurs from the first instance the news is received to the end when the patient finally dies. At the end, acceptance often comes, but even with no acceptance, the patient will die.

With the suicidal person, the natural order of dying may appear to be overturned. This was a person who could have lived! Those who knew the individual may have been taken completely by surprise. Many suicides are impulsive, but even when they are planned, the plans are kept from family and friends. The time between the decision or impulse and the completion of the act is often not long, though occasionally people plan their suicides for years or months. In either case, no stages of death and dying seem to be present.

With suicides that are well planned, it seems probable the person might have been able to proceed through the stages, with the only difference between the terminally ill patient and the suicide being the inevitability of the act. Still, it is possible that in every suicide the stages of death and dying have been completed, even in the impulsive act. Instead of thinking of suicide as an abnormal act counter to human nature, perhaps instead we should think of it as a different way of dying, incorporated by the individuals into an “ordinary” process that moves through stages to the point of acceptance.

Kübler-Ross (1969) described the five stages in linear fashion but in later years emphasized that the stages are not in a particular order or on a particular timetable (Kübler-Ross & Kessler, 2014). The first stage, denial and isolation, is one in which the dying person goes numb, feels overwhelmed, and withdraws. The denial is not necessarily of death itself, but can be denial of one’s feelings of pain and grief about one’s impending death. The Yale Bereavement Study changed the name of this stage to disbelief to indicate the surprise and shock one feels (Maciejewski, Zhang, Block & Prigerson, 2007). Anger is a stage in which the person can direct wrath at himself, his friends, his family or anyone, even God. It may open up other emotions as well. Bargaining before death often involves “if I am spared, then I will do that” thinking. It is a period in which the individual tries to negotiate for his or her life or a reduction in pain. Depression sets in, with thoughts about whether it makes sense to go on. Acceptance is not a state of being “OK” with death, but a realization that it is coming. While some people may find peace in acceptance, it is also possible for people to have good days and bad days as they get used to the idea that they are going to die. Some scholars do not agree that the stages laid out by Kübler-Ross are “stages,” but instead think of them as emotions in the dying or grieving process (Stillion & McDowell, 2015). Whether stages or emotions, none of these is outside the norm for persons who are suicidal, and they could certainly experience them. In the minds of those with suicidal intent, they are dying.

Suicide victims’ notes show evidence both of thinking about death for a long time and of working through the stages of dying. One 60-year-old woman left a note telling her family that “[t]his was not a sudden decision. It was made years ago. Hope I haven’t waited too long.” Some notes ran through the stages in one sitting. Nick, discussed in Chapter 5, Grief and Failure, started to face the idea of dying while he was studying for a course in economics. His notes for the course stop and the notes to himself about dying take up. He works through his failures and discusses his isolation. He examines his lack of belonging rather dispassionately, but then becomes angry, finally letting out some of the anger he had toward his parents. He previously made some half-hearted attempts at suicide with Tylenol, a kind of bargaining. “I ASKED FOR A SIGN NOT TO DO THIS,” he wrote, “THERE WAS NOTHING.” Finally, his note indicates a resignation to his fate.

Some individuals bargained with God or the cosmos, but often they bargained with themselves. One young man, discussed in Chapter 2, Findings, wrote, “IF YOU DON’T DIE IN THE NEXT 48 HOURS YOU MUST…” and then listed items like “GET A JOB.” If he could get a job, he did not have to die. But he could not get a job. His poems reflect all the other stages of grief at the inevitability of his death: isolation: “lately I’m so desperate for a reader, a listener”; anger: “Another fucking journal entry, poor-excuse-for-a-poem. I’m so angry”; bargaining: “I could just keep writing, I could write without ever stopping…you could be entertained, and I could be of some use…”; depression: “The storm passes, The lightning and thunder is gone though the rain might continue all night”; and acceptance: “This is the end, this is all there is.”

Individuals often acknowledged their acceptance of death in their notes. “I don’t know where I go from here, And I don’t care,” wrote Jasmina. “If I end up in a alley somewhere dead That is on me.” When one elderly man scrawled, “I Relise I’ Am Never Going To be The SAME,” he accepted death. Another man wrote, “Time has come for me to leave.” In order to come to acceptance, the victims probably went through stages that were not visible to others then, or at least were not identifiable as stages or emotions of death and dying.

When Kübler-Ross introduced her stages in 1969, the objective was to make death for the dying and the grieving more humane. Health professionals were taught how to recognize the stages and even prepare people for them. Health professionals who recognize these stages or emotions in cancer patients perhaps could be trained to recognize them in suicidal patients, as could family and friends, if it could be supported that suicide victims did pass through such a process. When people give their possessions away, could that not be seen as fitting into these stages?

Much more research would need to be done to see if in fact distinguishable signs exist that a person is in the “stages” of suicide that echo the stages of grief identified by Kübler-Ross. The stages were devised for two groups, the dying and grieving. For the grieving group especially, the stages were supposed to be healing. For the dying, they were supposed to be therapeutic. For people who have embarked on a path toward suicide, the stages are not healing. The stages allow suicidal individuals to come to terms with their deaths, but if suicide is to be prevented, the stages need to be interrupted.

Stillion and McDowell (2015) have identified what they call “a trajectory of suicide” quite distinct from a Kübler-Ross model of stages of dying. They identified essential points on a path toward killing oneself. At some point in a person’s life a foundation of risk factors arises: biological, psychological, cognitive, and environmental. A person needs only one but may have more. Upon that foundation is laid suicidal ideation. Once the idea is formed that death might be desirable and possible, it needs to be followed by triggering events which are mirrored by warning signs, usually verbal or action clues to suicidality. Ultimately, in completed suicides, this is followed by the suicidal behavior that ends one’s life.

Whatever path or stages one follows toward suicide, if no interruptions of the trajectory, no stages of recovery, or no protective factors happen to counter risk factors, then suicide may occur.

Protective Factors

Psychologists and sociologists have identified protective factors for those with mental illness and for suicidal ideation. These are hope, goals, pathways, agency, religiosity, and resilience. Many of the studies we consulted were conducted on special populations such as racial or sexual minorities, but the protective factors they identified are arguably not unique to these populations.

Davidson, Wingate, Slish, & Rasmus, (2010) compared African Americans and Caucasians to determine if African Americans, who have a low incidence of suicide, had more protective factors than Caucasians, who are at higher risk for suicide. They were testing Joiner’s interpersonal theory. The researchers turned to positive psychology, the study of human strengths. They first looked at hope theory.

Hope is a cognitive motivational construct, like escape, but it is also part of goal-setting. Davidson et al. (2010) examined studies from the 1990s and 2000s that showed hope predicted lower levels of thwarted belongingness and perceived burdensomeness, but that it also predicted a greater capability for suicide. The finding surprised them. If hope was a protective factor, it was strange to see that it might also contribute to suicide. The researchers posited that because hope increased goal-setting and allowed people to take up challenges, individuals might have put themselves in situations at greater risk for both emotional and physical pain. They tested this hypothesis and found evidence that African Americans had higher levels of hope than whites. These protective factors may have buffered them from suicidal ideation, suicide attempts and completions, but in some individuals hope was not entirely protective. Other studies have found that hope is the major protective factor among African Americans. They attribute the power of hope in the black community to the unique history of oppression African Americans have endured (Hollingsworth, Wingate, Tuker, O’Keefe, & Cole, 2016).

Researchers have also examined hope as a protective factor against suicide in gay men diagnosed with HIV (Siegel & Meyer, 1999). Newly diagnosed HIV-positive men were at higher risk for suicide than non-HIV-positive men. Siegel and Meyer (1999) found that among gay men who attempted or contemplated suicide, the experience of the attempt or the serious contemplation of suicide “provoked a process of coping” among the men (p. 53). They posited that having frank discussions about suicide after the diagnosis and suicidal attempts or contemplations may have allowed the men to “move toward acceptance and commitment to life” (p. 53) and gave them a sense of control.

Davidson et al. (2010) also examined religiosity as a protective factor against suicide. African Americans reported a higher intrinsic religiosity than whites. Higher religiosity has been shown to have a higher protective value against suicide in African Americans, but the researchers called for more study, as the evidence is not unequivocal, and gender could also be a variable. Women may have gained more protection than men from religiosity. They did find that intrinsic religiosity may have been an even larger protective factor than extrinsic religiosity or social support, though both offered some protection.

Social support was also found to be a protective factor for transgender individuals who were suicidal, as were gender identity–related factors (such as coming out), transition-related factors, individual difference factors, and reasons for living. Among the individual difference factors were resilience, coping and problem solving, life evaluations, and optimism. Religiosity or spirituality was a protective factor for trans adults (Moody, Fuks, Peláez, & Smith, 2015).

Holm and Severinsson (2011) examined factors that helped women with borderline personality disorder (BPD) who were suicidal recover from their attempts. They found that the women benefited from assuming responsibility for themselves and others, giving them a reason to live, and from their search for strength, safety and their true selves.

The suicide rate among members of the US Army has increased significantly over the past several years and now exceeds that of the general population (Nock et al., 2013). Yet the period of highest risk was not during or after combat but just two months after starting military service. According to a study of more than 163,000 men and women in the Army, “61% of those who tried to take their own lives had not yet been deployed” (Fox, 2016). Nock et al. (2013) studied protective factors such as “resilience, stoicism, character strength, life satisfaction, positive moods, self-esteem, autonomy, hope (optimism), zest, gratitude, capacity to love (ability to form reciprocated relationships), and a sense of meaning and purpose” (p. 107). They identified coping skills, problem solving, and social support as key factors for soldiers’ self-protection. Researchers who found that suicide attempts were highest in the first year think that the period of transition before deployment is the most difficult, because soldiers are still thinking of home and have not yet undertaken the responsibilities of the battlefield. More stress and even physical illness can occur in the first six months after joining the military (Fox, 2016). After that, soldiers’ skills are more tested.

While more studies are needed on protective factors, those that exist highlight the same concepts. Coping skills and problem solving may combat feelings of being overwhelmed as well as prevent the development of constricted thinking. Hope or optimism may be hard to teach, but they are associated with goal seeking. The more goal-oriented a person becomes, the more protection he may receive. Having a reason for being was also important in every study. One of the factors that has received a lot of attention in the popular media today also featured largely in these studies: resilience. While the media is focused on resilience as a quality millennials (the generation that grew up in the 1980s and 1990s) allegedly do not have (Lipman, 2016), psychologists and social workers are seeking to understand how it protects against suicide (Gutierrez et al., 2012).

Resilience

The American Psychological Association indicates that people who are resilient adapt well to tragedy, trauma, stress and other forms of adversity. Other researchers have defined resilience as “‘a stable pattern of healthy adjustment’ following an aversive event” (Nock et al., 2013, p. 108). Resilience was identified in almost all studies of protective factors against suicide, but how one acquired resilience was not described.

Researchers did try to measure it. Osman et al. (2004) developed the Suicide Resilience Inventory–25 (SRI-25). Analysis of the scale is complicated, but the questions are simple. Participants are asked if they like themselves, like things about themselves, can deal with rejection, can resist suicidal thoughts when humiliated, and so on. Rutter et al. (2008) found that the SRI-25 is a good predictor of suicide risk. Based on the questionnaire, resiliency appears to be the ability to resist suicide in the face of situations identified as risk factors and being able to find social support when feeling suicidal. In other words, being resilient was a combination of qualities one already possessed and the availability of others in a time of need.

What the scholarly literature that examined the protective factors described and cited here seemed to suggest is that when people confront their stresses, fears, and situations honestly and forthrightly, resilience is something that builds. In the studies in which interviewing the participants was part of the research, the participants’ ability to spend time thinking constructively about their potentially bad situations and talk to other people helped build resilience.

Conclusions

If we want “life supporting” communities, we need to learn from blue zones, but we also need to learn from red zones. We need to construct communities that promote and foster social support systems, healthy lifestyles, and full use of people’s skills and gifts. People need a reason to live, and that often comes from having responsibility—though not at such a level that it is overwhelming. We need to make sure our communities are not unhealthy places or places where health literacy is low. This will take resources, both financial and human, but if the results are that it lengthens life and raises productivity, the benefits will offset the costs.

We cannot assume people have good coping skills, problem-solving abilities, optimism, or sufficient social support and resiliency, and these need to be developed at home and at school, and fostered at places of employment. We also have to be aware of the failure of a person’s coping abilities or cognition, or the development of pessimism and despair, or the loss of social supports. Many communities have resources in place, but those in need do not know where to look. Every university, for example, not only has wellness counselors, but tutors, time management educators, learning centers, and recreation facilities. Every town has community resources, though some have more than others. We cannot make people use resources, but we can encourage it in words and actions. Making life-supporting communities takes time, and people who need help if they are suicidal need it immediately. In Chapter 10, Conclusions and Implications, we examine the idea of a national agenda and spell out proposals to create national responses to the problem of suicide, but we will also look at how people implement intervention and prevention programs at the local level.