My Sister’s Death Shapes How I Think About Suicide

Photo: Zerbor, shisuka, BitsAndSplits | Canva
Suicide awareness

The Western world has largely wrapped suicide in a shroud of shame and silence for centuries, even though remaining quiet hasn’t vanquished this scourge. Rates of suicide in the US are alarmingly high and still growing. A record number of Americans, almost 50,000, killed themselves in 2022.

Undoubtedly, many additional suicides are classified as accidents. Many of the "deaths of despair" from drug and alcohol abuse, or neglect of physical and mental self-care, could also legitimately be reclassified as suicide.

Suicide kills more than twice as many Americans than murder, but garners much less attention.

Shame reduction is a first step in encouraging greater dialogue about suicide. Shame isn’t just an internal feeling. It’s literally a loss of face, causing us to tuck our chins and avert our gaze. Shame muzzles us, rendering it harder to speak. Dialectical behavioral therapists (DBT) know that one way to break the spell of a compelling, negative emotion like shame is to take actions that counter the physical tendencies of that emotion.

To reduce shame about suicide one should look others in the eye, speak loudly and clearly, and explain why this is not a shameful topic.

For years, mental health experts have been urging people to speak more openly about suicide. Some fear that talking about suicide just creates new angst, but it also has the potential to add nuance to the conversation. Through dialogue, we can challenge moral judgments about suicide. We can diminish the misinformation about suicide and mental illness. We can embrace ambivalence to provide a more complete picture of the impact of suicide.

To encourage further thoughtful dialogue about suicide, I’m publicly sharing, for the first time, parts of the story of my sister’s death. Perhaps the termination of her life, 37 years ago, can be less final if we use it to build bridges to save other lives, and to foster understanding of why some choose to die.

RELATED: Everything You’ve Learned About Suicide Being Immoral Is A Lie

Foreshadowing death

Growing up, I often felt overcast by the prospect of an early death. None of the men on either side of my family lived past eighty, and most died far younger. But the death that loomed largest was of my father’s father, who reportedly died in his late 30s from a heart attack. It made sense. My father’s five siblings were morbidly obese decades before that became a popular body shape in America. They all had cardiac disease from early ages, which seemed to flow from both genetics and lifestyle.

I only learned the truth about my grandfather’s death a few years after my father’s death. Dad died at 76, following heart valve surgery and a five-month ICU stay.

My grandfather had owned a fashionable grocery store in a Detroit suburb. His finances collapsed during the Great Depression.

In 1932, at the age of 36, he took his own life.

The coroner wrote: "Carbon monoxide poisoning. Accident. Marking on car and closed garage." In those days, even the medical community colluded in hiding suicide. I’m not even sure which relative, checking into genealogy decades later, brought about the accurate revision of the family story.

In addition to his widow, my grandfather left behind six children between the ages of four and eleven.

Severe financial difficulties increase the risk that an individual will commit suicide. But having children at home, particularly more than two children, typically reduces one’s risk of suicide, although this effect is more pronounced in women than in men.

My mother had no awareness that her father-in-law had died from suicide. I don’t know if my father, who was only seven at the time of his father’s suicide, ever knew the truth. It’s even conceivable that my grandmother, who could be oblivious to large swatches of reality, might have just accepted her husband’s death as an accident, without any desire to look more closely at what had happened. My grandfather died in an era when people didn’t talk openly about suicide in the family.

Learning that my grandfather died from suicide, rather than a heart attack, profoundly shifted my understanding of my heritage. I had to replace the possibility of dying young from cardiac disease with the likelihood that my genes actually increased my risk of dying from suicide.

We’ve known for years that suicides tend to run in families. In recent years, researchers have identified several specific genes that increase the risk of committing suicide.

My sister’s death

My sister Susan was just 22, and a year out of college when she killed herself.

She was living in Vermont, where she had gone to school, and was working as a teacher’s aide with "emotionally disturbed children." She had resisted the advice of our parents, both of them teachers, who had tried to dissuade her from a job in education. They had said that a teacher’s work always consumes more than those classroom hours.

She didn’t leave a suicide note. Much of what we learned was pieced together from years of journals she left behind. No entries covered the last weeks of her life or her final decision to end it, although she had sprinkled thoughts of suicide through a decade of preceding pages.

Susan Kruse

Susan Kruse | Photo by author

Her work was difficult and frustrating, marked by insufficient resources, insufficient investment by the parents of her students, and insufficient emotional and psychological preparation for those entering her role.

Unbeknownst to any family members, she had an abortion the year before her death. She didn’t refer back to this event after the procedure was over. For years she had been good at hiding things, and presenting to the world that her life was okay.

Women who have abortions are more likely to make suicide attempts. However, the high rates of suicide attempts in the year after an abortion match the high rates in the year before an abortion, meaning that abortion does not appear to be driving this increased risk.

Susan bought a gun a few weeks before her death. Having never fired one before, she practiced at a shooting range a few times with her unsuspecting boyfriend. When he was away for a few days over the Columbus Day Weekend, she shot herself in the head.

Gun ownership, and access to firearms, increase the likelihood of suicide.

Susan had been tormented by her work, confused about her career path, and disappointed in her romantic relationship. She had long-term grievances against certain family members. She drank heavily the day she died. She had never been diagnosed with depression, a personality disorder, or a substance abuse problem, all of which increased the risk of suicidal ideation.

Maybe even her name contributed through some macabre neurolinguistic programming. Sue-icide. Sorry for the flippant aside — Sue me for tasteless punning — but I’m throwing that in for a reason.

I want you to stop, and be aware that nobody ever fully knows or understands all of the reasons why someone else chooses to die.

In childhood, I had been closest to Susan, who was the youngest of the family. Neither of my brothers was willing to play dolls or games of make-believe with her. In elementary school, when I had a small gig performing puppet shows at birthday parties and libraries, she was my assistant. But as we got older, we grew in different directions.

Her diaries were full of rage directed against the pain and misery inflicted by my mother and older brother. Out of several volumes, I only merited two mentions in passing, about the same as my younger brother, and father.

One of the sillier reasons I’ve avoided talking about her death is that people almost instantly jump to, "Oh, so that’s why you went into psychiatry!" But I was actually pretty far along that path when she died, having finished two years of medical school and two years of graduate school work in neuroscience. So, no, I didn’t go into psychiatry in response to her death. But yes, my gravitating towards psychiatry was probably part of my response to the same unhappy family interactions that put Susan on the route to suicide.

I still think of her. I cry at the many memories she has missed. She never had her own children, launched her own career, or lived in her own house. I never got to tell her I was gay. She never met my husband. She never got to play with our children, who are now nearing the age Susan was when she died.

RELATED: What It's Like Losing A Loved One To Suicide

Mental illness and suicide

We often equate suicide with depression and despair. Indeed, having depression increases the risk between two to five-fold of either thinking about or planning suicide. But the majority of depressed people don’t kill themselves. Several meta-analyses find that poor impulse control and severe agitation from anxiety outperform depression as a predictor of completed suicide.

We need to step back from the glib assumption that suicide itself is always a sign of mental illness. Often, the very act of suicide is retrospectively used to justify a diagnosis of a mental illness that was not detected in life.

In most cases, it’s not particularly fruitful to ask whether killing oneself is rational. Is living ever really rational? Is it rational to continue living in an overpopulated world rife with climate destruction, widespread inequities and discrimination, and pervasive lying by world leaders and information peddlers? Is it rational to keep living if you face imminent death from violence or illness? If you face interminable pain and misery from a major health problem?

The decision to take one’s life usually doesn’t hinge on whether one is rational or not but rather occurs because of that person’s value judgments. Specifically, whether one cherishes quality of life over life itself and how one defines what quality means.

In so many other areas of medicine, we have stepped back from the paternalistic attitudes of a generation ago, when the doctor always knew best. We no longer hide cancer diagnoses from patients. We’re required to obtain informed consent for treatments and procedures. Is there ever any point at which our medical knowledge and personal biases should yield to the autonomy of a patient who profoundly wants to end their intense and ongoing suffering? Is the suffering individual the best judge of the depth of their own misery?

Mental illness, unconscious desires, and social pressure can all impair rationality and encourage individuals to wish for, and even work to bring about their own death. Mental health professionals should provide therapy, medications, and/or other treatment to identify and free the individual from such coercive forces. For the vast majority of suicidal individuals, these interventions are sufficient to help counter their desire for suicide. But what then if despite such efforts, they still want to die?

Although some religions make different claims, I haven’t seen evidence to indicate that any of us get to choose to be born. If we didn’t choose to be born, wouldn’t the most basic human right be to surrender life when you decide it should be over?

When we look at the widely varying rates of suicide across different countries, it doesn’t appear that any differences in rates of mental illness are driving those different mortality rates. Rather, socioeconomic variables (poverty, inequity, discrimination), and accessibility to easy means of suicide (guns, poisons) seem to have larger effects. So, it’s not that mental illness plays no role in suicide, but that mental illness is just one possible factor among many when sorting out why someone might wish to kill themself.

Overemphasis on endings

Talking more openly about suicide may help us steal away some of its potency and notoriety. Why do we need to give suicide top billing when we talk about the lives of Robin Williams, Sylvia Plath, Sinead O’Connor, or Salvadore Allende? Why do we warp the accomplishments of a lifetime by overemphasizing the brief ending?

We focus too much on how stories end. A great sporting event arises from spectacular performances and close competition, not just the final score. Four decades of a loving, supportive marriage aren’t eradicated if they’re followed by an affair and a divorce. As a therapist, all too often I work with individuals tormented about how a job, a relationship, or a life ended, rather than embracing all of the good living that preceded such outcomes. I’m not advocating for ignoring unhappy endings, but we need to find ways to incorporate them as one element of the complete picture.

If the final chapter of one’s life is closed by suicide, that needn’t negate all the pages that preceded it.

The power or pleasure of this sentence doesn’t depend upon the punctuation at the end!

RELATED: Moments Away From Suicide, What Flashed Before My Eyes

Holding on to ambivalence

Changing our dialogue about suicide means acknowledging that the cloud of my sister’s death had some silver linings. Susan’s suicide served as a stark reminder that we don’t always have tomorrow. It brought that old cliche to life and smashed it in my face. Death is a reality, not just a theoretical threat. I had to engage more actively with my life because there might not be more tomorrows.

For years, my younger brother and I had vowed to run a marathon and to do so together. We finally acted on this pledge six months after Susan died, in direct response to her death. I went on to run 100 marathons. I coached several hundred novices to run their first marathon. For more than a decade I was an officer and newsletter editor for my San Francisco running club. I met my husband through the club. We assembled our chosen family mostly through the friendships formed while running.

I wasn’t consciously aware of it at the time, but now I’m sure that Susan’s death also pushed me, a year and a half after her suicide, to come out as a gay man. I had been a twenty-five-year-old confused virgin when my sister died.

It’s altogether possible that two major strands of my core identity — being a runner, and being an openly gay man — would have remained submerged and latent, but never fully executed, had Susan not killed herself.

In even the worst of situations, there’s almost always at least the germ of something good. And by talking about all this — sharing Susan’s story, and mine — perhaps some goodness can spread to you or to someone you love.

Paradoxically, embracing ambivalence about suicide can be life-sustaining. As a psychiatrist, I’ve worked with individuals, who have spent years in the terrible torment of wanting to end their own lives. For some, this pain has occurred all day for years or even decades. Some have tried several varieties of talking therapy, made lifestyle changes, engaged with medications and brain modification technologies, and still don’t feel that their lives were worth living.

Often in such situations, the therapist gets locked into asserting the importance and value of continuing to fight to live, with the patient fighting back about the misery and futility of remaining alive. Sometimes the patient has such an intense need to prove that they are right, that they do kill themselves.

However, if the therapist can skillfully acknowledge some ambivalence about whether it might be actually cruel, foolish, or naive, to force the person to be alive, that stance can sometimes create an opening for the patient. They may be able to relax their insistence that death is the only solution to their despair, and acknowledge some of their hidden desire and hope to remain alive. But skill is really important here because some individuals will misinterpret such statements as a total agreement that their life isn’t worth living.

I hope that the more we talk about suicide as individuals, and as a society, the more adept we become at such discussions. We need to speak back to the shame, not get mired in arguing over rationality, and stop giving primacy to how a life or story ends. By embracing ambivalence we more fully see and honor each other.

Tens of thousands of lives depend on it every year.

If you or someone you know is thinking about suicide, there is a way to get help. Please call or text the National Suicide & Crisis Lifeline at 988.

RELATED: 3 Warning Signs Someone You Love May Be Thinking About Suicide (Or Is At Risk)

John Kruse is a psychiatrist, neuroscientist, marathon runner, and author living in Hawaii. He writes extensively on Medium and creates videos on his YouTube channel about adult ADHD, sleep, and other mental health and wellbeing topics.

This article was originally published at Medium. Reprinted with permission from the author.