Then there are microhumiliations, the annoying, daily invasions of privacy that rattle the world of some patients. Examples are online postings of salaries, professional rankings (as in the case of Rigoberto Ruelas), legal judgments, and a variety of postings on public social Web sites. I can think of an instance where a patient in crisis came for treatment. She had discovered a photo of her “significant other” and a new love interest on a social Web site.
Humiliation scenarios abound; however, because of the speed and pervasiveness of technology, a new challenge is introduced: there is no longer anywhere to hide. Walter Kirn6 writes, “As the Internet proves every day, it isn’t some stern and monolithic Big Brother . . . it’s a vast co-hort of prankish Little Brothers equipped with devices that Orwell . . . never dreamed of.” When all is said and done, technology is the greatest social equalizer, with some people more vulnerable than others.
It is our job as medical professionals and therapists to identify whom to worry about and how best to intervene. According to the American Foundation for Suicide Prevention, more than 34,000 Americans die by suicide annually. Of these, 10% have never been given a psychiatric diagnosis. Like the suicide victims in this story, most of the time they seem to be happy, which highlights how truly baffling the suicidal process is and how much still needs to be accomplished in designing effective suicide prevention strategies.
For now, perhaps the best course of action is the old adage, “know thy patient.” Rather than being lulled by the traditional epidemiological risk profile—male, elderly, chronically ill, prior suicide attempts, active substance abuse, and family suicide history—the clinician should look for “near term” warning signs (Table), such as the crisis in the moment, the immediate presentation, the acute agitation/cogitation, and the patient’s behaving differently, rather than listen to what the patient is saying.7 I would perhaps add an inquiry about recent episodes of judgment or embarrassment, particularly if they occurred in cyberspace.
TABLE: Near suicidal signs7,8
• Inability to form a working alliance
• Unwillingness to be known
• Intolerance of being understood
• Detachment and despair
• Social isolation
• Change in treatment compliance patterns
• Suicidal ideation, plan, and intent with preparations
• Discrepancy between verbal self-report and actions
• Perceived environmental humiliation