Suicide prevention is hard. Let’s start there.

There are too many factors to count. So many warning signs. Infinite risk factors. Global, specific, cross-cutting, intersectional, and multi-layered statistics. There are general, wide-ranging, broad suicide prevention efforts designed to increase awareness of the problem of suicide and the solutions that exist. There are specific clinical interventions that work more often than they don’t—but they don’t always work. There are public-health approaches that address upstream social determinants of health (racism, sexism, employment problems, housing, food insecurity, justice-involvement, and many more). There are postvention strategies focused on individuals and communities impacted by suicide loss.

We even have several theories of why people think of suicide and then turn towards action; many of these theories and their specific components have held up under the scrutiny of academic research. To summarize the field’s thinking, if I may be so bold: a person feels some form of psychological pain (emotional, cognitive, physical, cultural, or any combination thereof) and they desire to be free from that pain. A wish for the pain to diminish can become a decision to take action, and the action following a decision can happen very, very quickly. Generally speaking, this is the nature of a suicide crisis.

As such, some suicide prevention efforts focus on strategies to put time and distance between a person and a method of suicide during a suicide crisis. These efforts can indeed prevent suicide attempts and death. But—and here we go back to the beginning—the efforts do not themselves address the life, experience, culture, beliefs, previous harm, or values of the person who may be in crisis. Suicide prevention is incomplete without lethal means safety strategies, and yet these solutions aren’t nearly enough to change a culture of suicide.

Each effort is imperative. Also, with the complex combination of upstream and downstream efforts weaving through the myriad individual, social, and cultural risk factors, it is more than a challenge to identify any one element or formula that has the greatest direct effect on preventing suicide.

Those with lived experience of suicide are telling us clearly and directly that much is missing from our collective efforts. Suicide prevention is incomplete without those with lived experience at the center. We are challenged to create focused, specific efforts that are connected holistically with the depth of the experience of the person who thinks about suicide. To be successful, suicide prevention must be, simultaneously: specific, accurate, culturally attuned, lived-experience centered, evidence-based, flexible, and adaptable. Suicide prevention must be social and supportive. It needs resources.It needs clinical interventions. It needs to be accessible and equitable. It needs to be culturally relevant, free of stigma, and inclusive. If we succeed in all of these ways, our efforts may land effectively with their intended audience: the individual who thinks of suicide.

But what does “succeed” mean? How do we measure success? Suicide prevention efforts are measured over time, through statistics that fluctuate, waver, meander, dip, and spike. While we have more public awareness and specific, effective interventions than at any time in our history, over time, the national suicide rate and rates of specific demographic groups have essentially trended up.

Does this mean we are failing? We know that some specific interventions and approaches work. We have crisis and clinical interventions shown to prevent suicide attempts. We have decades of public policy interventions around lethal means safety that have reduced suicide attempts. We are learning from those with lived experience how to better understand, support, and communicate with people in a way that values their full lives rather than reduces them to a diagnosis or a problem to be solved.

We have the science that indicates we know how to prevent some suicides. In other words, the upward trending statistics don’t necessarily mean that we aren’t preventing suicides. I think we are. What the rising suicide rates might mean is that the culture of suicide is growing. The number of deaths by suicide might be outpacing our effective prevention efforts. I’m not sure we know this statistically…but I’m not sure we don’t. Our science – and those with lived experience – seem to say so.

I have now used the phrase twice, and I’m honestly not sure where I’ve heard it previously: a culture of suicide. It’s a stark, jarring phrase. It’s frightening. Good. It should be. At first thought, the phrase suggests that losing people to death by suicide is an intractable part of who we are and who we’ve become. Culture, however, is larger than one piece of its own puzzle. A culture of suicide should also include the perseverance, dedication, and lifelong commitment of those who do the good work of suicide prevention. To attend to those thinking of suicide. To address cultural and systemic inequities. To center the lived experience of attempt or loss survivors (there are so many of us) in our efforts. To improve, enhance, and make more accessible any clinical intervention that works. To stick with public health approaches that may take time to become effective. To make support and resources accessible to all. Culture does change, though the direction towards despair or hope is not always clear in the moment. Despair is all too visible; but hope is also here, and it is everywhere.

Suicide prevention is hard. It should be. And we shall not waiver.