September is Suicide Prevention Month in the United States. The Nassau County School Board passed an initiative last week to address suicide prevention in the school district through educational initiatives for school employees. This move highlights a progressive stance by the district to combat the 2nd leading cause of death for 15–24-year-olds in this country.
Suicide is an incredibly complex behavior that is rarely predicted by healthcare professionals, much less by the public. The complexity of the issue, compounded by social stigma, often leads us away from addressing concerns and ignoring the problem all together. Reducing the number of suicides in our community requires us to increase suicide education, to examine our own feelings about suicide, and to evaluate the greater cultural narratives around the topic.
Suicidal ideation is common
Suicidal ideation is the clinical term used to describe thoughts of suicide. It is difficult to measure the prevalence of suicidal ideation rates, but estimates are just under 10% of the global population seriously considers suicide during their lifetime. Less specific are the numbers of people who do not actively wish to kill themselves but think things like, “I’d like to go to sleep and not wake up,” or, “I wish I wasn’t here.” Despite some uncertainty on how to classify suicidal thoughts, the statistics indicate probably every one of us knows someone who has seriously contemplated suicide. The only thing that might mitigate the heart-breaking prevalence of suicidal desperation in our society is the much slimmer number of individuals who go on to die by suicide. For people who sought out psychiatric care for self-harming/suicidal behaviors in the last 30 years, 1.6% later went on to complete suicide within a year. These statistics don’t account for the large number of people who never seek out help for suicidality, but the numbers do indicate there remains a significant gap between thought/desire and action.
The impact of stigma
Just last week, a person asked me what I did for a living, and I said, “I’m a psychotherapist.” The person retorted, “It must be fun to work with psychos.” Stigma surrounding mental health is still alive and well. Almost nothing in the mental health field seems to elicit more stigma than suicide. As a result, people having suicidal thoughts are prone to keep them to themselves for fear of judgment. Family members of suicidal individuals often feel helpless and don’t know where to get support. Even many mental health professionals are loathe to work with suicidal individuals for personal fears and concerns of litigation if their patient dies. A 2017 study evaluated the public’s opinions of suicidal individuals and the most common descriptors were, “weak, crazy, and distressed.” The way people admittedly act towards suicidal individuals was to view them with disdain, to attempt to control them, or to avoid them altogether. For an issue plaguing 1 in 10 people, the scope of stigma is staggering.
Understanding suicide from a clinical perspective
Extensive research has been done to determine the factors that lead a person to suicide. Behavioral and mental health researchers have identified several internal (biological and emotional) and external (environmental and social) markers present in individuals that report high levels of suicidality. Behavior scientists have attempted to understand these factors to reverse-engineer the suicidal process by flagging individuals who are considered high risk and working to mitigate threats before suicide occurs. Researchers have then handed this information to clinicians to utilize on the frontlines of treatment in the form of risk assessments. Unfortunately, centering the conversation around risk has not reduced the number of suicides. Research concepts don’t always easily translate in complex human systems. The application of conceptual information almost always requires an emotional intelligence and a dexterity in the implementation of protocol. The bi-directional factors, both external and internal, impacting suicidality are most valuable when applied in human terms.
The external factors leading to desperation are often easy to measure, both for individuals experiencing them and to observers. Despite the many flavors of difficulty humans face in a lifetime, these suicide-inducing situations almost always involve incredibly complex problems for the individual facing them. The death of a loved one, divorce, abuse, financial ruin, addiction, infidelity, or the immediate end of a career are all easily identifiable triggers to suicidal thoughts. These situations are emotionally heavy and have no simple resolutions.
There is another external component often present in suicidal individuals besides a complex, pervasive problem. Suicidal tendencies thrive in the absence of robust social connectivity. This can be the result of acute loss (death, relocation, relationship rupture), an inability to connect emotionally or be vulnerable with others, or a lack of greater social purpose. It’s easy to see how a complex life problem and social isolation often overlap with each other, which exponentially compounds the weight of the situation.
The internal factors impacting suicidality are nebulous and much harder to decipher. Mental health professionals are trained to evaluate a few specific categories of feeling and thought to determine if suicide is an immanent threat: hopelessness, burdensomeness, impulsivity, familiarity with violence, and depression.
Depression describes a constellation of symptoms with various modes of treatment. Most people associate suicide with depression because the Venn Diagram of depression and suicide have significant overlap. Ironically, the deepest forms of depression can be a protective factor against suicide. Avolition, a lack of motivation common in depression, often prevents a person from going through with killing themselves. (See a previous discussion about depression here.)
Other isolated feelings can be harder to pinpoint. Hopelessness is one. Very few people step into a therapy session and say, “I’m suffering from a lack of hope.” The more common reports of hopelessness involve feelings of being overwhelmed or stuck. The inability to imagine a future reality, or a lack of desire for anything to come, are often indicators of hopelessness. Hopelessness can also present as pessimism or negativity. Sandwiched in between an impossible situation and a lack of social support, it’s not hard to see how hopelessness can be the defining straw that breaks a back.
Perceived Burdensomeness is another psychological term clinicians have inherited from research. Burdensomeness is an indicator of a mental division in the mind of an individual and one’s social group. This division hints at emotional isolation and can be expressed in statements like, “I’m around people all the time, but I feel completely alone.” Individuals can believe they are a burden if they don’t feel valued by those around them, if they have lost a sense of purpose, or if they are overwhelmed by feelings of guilt or shame. For those who are constantly judging themselves, burdensomeness can be utilized as a personal resolution to maintain social distance. When the thought, “If people really knew what I’d done/how I feel/who I am, they wouldn’t like me,” is too difficult to articulate, being a burden allows someone to maintain a safe distance from others without the impetus for change. Burdensomeness is closely related to the external factor of social isolation, but it’s a concept, which means it’s real in the mind of the beholder but may not be reflected in the person’s life.
Another common trait suicide research identifies is Impulsivity. When questioned in therapy, “Are you impulsive?” people rarely have a simple answer to that question. And how could they? I know someone who has hitchhiked across the country, had sex with strangers, held public office, and completed graduate school. Impulsivity is not a pervasive trait; it is subjectively measured and can change over time. Impulsivity involves two specific components. The first is a tendency to experience immediate emotions with a blinding intensity. The individual trapped in this perspective warp is taking a metaphorical photograph of their present experience and copying and pasting it across the entire timeline of their lives. Classic language patterns indicating this distorted evaluation include plethora’s of absolute statements. “If something can go wrong, it always goes wrong for me.” “Everyone leaves. No one stays.” “I never get the benefit of the doubt.” The second component of impulsivity is action. Instead of experiencing the intensity of present emotions and shutting down, impulsivity responds by acting on the emotional intensity as a way to mitigate it.
The last component that leads to suicidality is a familiarity with violence. Killing oneself, despite the means, is psychologically, and often physically, violent. Individuals who practice any form of self-harm are accustomed to violence and are at a higher risk for suicide. When a person is unmoved by violence, it indicates the individual has a reduced fear and/or greater tolerance for pain. Both a lack of fear and a familiarity with violence, make teenagers and soldiers particularly at risk for suicide.
Suicide is a human problem
How many of us have felt like the problems we were facing couldn’t be solved? Who hasn’t wondered whether another person in the world understands how you feel? Without hope, without belonging, without perspective, without peace, in the face of overwhelming problems, with no one to turn to, suicide might seem like a reasonable solution for many. The burgeoning stigma facing individuals who are suicidal is an environmental poison we have the power to change. Suicide education is a way for our community to bring understanding to those who are hurting. Compassion is a conscious choice to override our own reactive tendencies to dismiss, coerce, or judge suicidal individuals. Offering belonging and safety for a hurting person might save a life. You might be a hero.