It’s an uncomfortable topic yet significant enough to talk about despite the uncomfortable feelings and awkwardness a frank discussion may elicit. Suicide. It’s in the news. People reading this blog may know personally someone who has attempted suicide or died by suicide. It’s such a significant issue throughout the world that public service campaigns have taken to multimedia formats to educate the public and to raise awareness that family, friends, acquaintances, and even strangers can help prevent an untimely death due to suicide. September has been designated as the time of year to draw attention to the growing tragedy of death by suicide. Aside from the readily recognized tragic elements is perhaps the greatest tragedy correlated with suicide – many people do not realize suicidality is treatable and often preventable.
Those left to take care of the aftermath of an attempt or completion are exposed to the devastation left in the wake of the act. Feelings of anger, sadness, grief, shame, and guilt are common among family, friends, and caregivers. Sometimes this leads to the perception that suicide is about manipulation and spite. Looking at the larger picture, however, may provide additional insight into motives associated with suicide.
Some suicidal behaviors clearly indicate an individual is feeling overwhelmed and in deep emotional pain. Others are more subtle and usually noticeable to those informed in suicidology. Fortunately, specialized training is not a prerequisite to help someone who is thinking about suicide although knowing a few basic facts and tips can help.
Signs, Symptoms, and Risk Factors
Most people who are contemplating suicide provide clues about what they are thinking and feeling (American Foundation for Suicide Prevention, 2015). Knowing how to listen and what to listen for may help save someone’s life. Know what to listen and look for, and think about the best way to respond based on your capabilities and local resources.
· Listen for what in being said and for what is omitted.
· Pay attention to words and phrases that indicate someone no longer wants or has reason to live, or whether there is a preoccupation with death or dying. Are they reading about suicide?
· Is there a sense of being in the way, being a problem, or the perception of being a burden to family or others? Even something like “Why was I even born” can be an indicator.
· Feeling “the world would be better off without me” may be a reflection of pain deeper than self-pity. This is not the time to advise, “Get over it,” or “Cry me a river, build a bridge, and walk over it” or “Put on your big girl panties and deal with it.” Pain is the experience being communicated. Never underestimate the power of pain or the cry for help.
· Is there a sense the person feels trapped, like there is no way out, or is feeling hopeless/what’s the use/powerless (nothing will ever change)?
· Listen for indictors of unbearable pain, physical and/or emotional. Guilt, shame, humiliation, worthlessness, and invisibility are some of the most excruciating emotions people experience. Some people do not know how to ask for help and will struggle against overwhelming odds alone rather than ask for help. It isn’t a matter of pride but of inability.
· Consider changes in the individual’s behavior or in the frequency of usual behavior. Have they stopped taking medications, prescribed medical treatments, or are engaging in self-destructive behaviors such as starving themselves or eating foods they have been advised not to eat? This is often associated with elderly suicides.
· Is there an increase in risk taking, reckless driving, aggressiveness, or fighting?
· Has the individual become more withdrawn from others or socially distant?
· Are they giving away their belongings, especially items they treasure or that are significant to them? Have they rushed to make out a will?
· Are they gathering or locating things with which they might kill themselves? Have items gone missing that could be used to carry out a suicide plan? Have they suddenly developed an interest in firearms?
· Have they contacted people to say goodbye or to make arrangements for care of family members or pets?
· Have their sleeping habits changed (sleeping a lot more or a lot less)? Are they not maintaining personal care and hygiene?
· Have their alcohol or drug patterns increased?
· Are they able to carry out their daily activities, meet their needs, or problem solve daily issues and stresses?
Be aware of mood changes. It is not uncommon for a person who is contemplating suicide to exhibit moods like
· Anger or rage
· Apathy, depression, loss of interest in life and former interests
· Anxiety, worry, fearfulness
· Humiliation, shame, embarrassment
· Sudden change in mood from depressed or agitated to seemingly calm or happy
· Teens may also exhibit rebelliousness, withdrawal, boredom, increased physical complaints like headaches, stomachaches, nausea, or tiredness, and difficulty receiving praise, recognition, or rewards.
It is possible a person who is thinking about suicide will exhibit only a few warning signs. Some people exhibit many. For this reason, and especially when there is a known mental health diagnosis such as depression, all warning signs of suicide need to be taken seriously – even those that seem melodramatic. People who are depressed may have difficulty making accurate assessments about their due to the distorted thought processes associated with the disorder. This is one reason why suicide is a serious risk when someone is clinically depressed, especially when feelings of hopelessness are also involved. Even passing thoughts about suicide can eventually become more robust and serious when not addressed in treatment.
Risk factors correlated with suicide include health factors, environmental factors, and historical factors. Health factors include mental health disorders, substance abuse and use, chronic pain, and serious or chronic health conditions including the dementias, cancers, autoimmune disorders like lupus, diabetes, arthritis, Parkinson’s Disease, etc.
Environmental factors include sensationalized media coverage or exposure to another person’s suicide such as that noted when celebrities or well-known public figures die by suicide. Yip et al (2012) noted that when the method by which the suicide occurred was disclosed through the media, there was an increase in suicides via that means shortly thereafter. Additionally, repeated victimization, death, loss of one’s job, failing at school, chronic stress such as unemployment and poverty can contribute to consideration of death by suicide as can having easy access to lethal weapons, drugs, and alcohol for those with poor impulse control.
Histories of previous suicide attempts, exposure to suicide through family history, intergenerational mental health disorders, and a history of childhood abuse are factors included in heightened risk for suicide. Researchers are looking at whether there is a genetic factor related to suicide (Juel-Nielsen & Videbech, 1970; Roy, et al., 1991; Lester, 2002). Even though some mental disorders such as depression have been observed to run in families, there is thought that suicide may have a hereditary factor apart from depression that may be inherited. Professionals caution, however, that like any other heritable mental health disorder there is no indication that heritability or any factor in and of itself means that a person will commit suicide. It is an indicator, however, that a person may be more vulnerable towards dynamics that contribute to suicidality and a wise course of action is to be proactive towards early treatment when warning signs are noted.
Commonly held assumptions about suicide
While there is some validity to the thought that someone who wants to commit suicide will do so no matter what, such is not always the case. Most people who experience suicidal thoughts even to the point of having a plan they intend to carry out, may be trying to relieve psychic pain through the only means they think will work. Assuming the person feeling suicidal has a death wish is simplistic. Sometimes the pain of life exceeds the fear of death and, if there was some assurance or hope for a less painful future, suicide would not be the preferred choice. Understanding the potency of psychic pain, such as what some people experience with major depression, bipolar disorder, posttraumatic stress disorder, crippling anxiety, schizophrenia, or some of the personality disorders, opens a broader understanding of suicide. For many, having a mental disorder diagnosis seems like a neon sign everyone they meet can see. It has the potential to further isolate the bearer socially and result in deeper loneliness and shamefulness. The antidote is a person who cares enough to invest of themselves into the life another by empathetically listening, being open and objective enough to not personalize unacceptable behavior, and can encourage rather than lecture or give advice. Just being available and listening can be the greatest salve one can apply to psychic wounds. Michael Dye (2007), author of The Genesis Process, wrote that people were designed for relationships, can develop heart wounds through their relationships, and can find healing through healthy relationships. The investment of self into another is a relationship.
Suicidal people are not de facto “crazy.” The American Foundation for Suicide Prevention states that the majority of people who think about suicide do meet criteria for a mental health disorder but only about ten percent are delusional or psychotic (http://www.afsp.org). Most are the walking wounded who hold jobs, have families, and participate in social clubs. They are first and foremost human beings who often fear disclosing their painful inner world for fear of being judged discounted, invalidated, rejected, or written up for instability in personnel records. To alleviate the problem, the focus needs to be on what can be done to alleviate creating more pain for the person who already is feeling overwhelmed with pain.
Preparation is Key
Know what to do when interacting with someone who may be thinking about suicide. If there is concern for the person’s immediate safety, dial 911 and ensure the person is not left alone. The safety of everyone involved is essential and requires professional involvement.
When the situation permits, such as noticing a person exhibiting some of the warning signs they may be considering suicide but they have not acted on their thoughts,
· Consider talking with the person about your concerns encouraging their seeking help from their physician of a professional counselor.
· Encourage the person to get a physical checkup to diagnose or rule out organic causes of depression since depression is a serious mental health condition and a risk factor correlated with suicide.
· Give forethought to personal feelings, thoughts, and beliefs about suicide. Keeping judgments, criticism, blaming, and strong emotions in check is an important part of being able to listen empathetically and accurately to someone who is thinking about suicide.
· Withhold giving unsolicited advice, lecturing, judging, and criticizing. They are more likely to result in the other person feeling more alone, misunderstood, isolated, and rejected. Chances are that any good that would have come out of the interchange will be nullified when the perceived loss of emotional safety triggers the person’s defense mechanisms.
· Recognize that the caring presence of another human being and the simple act of truly listening are among the most cathartic means of interaction.
· Remember, this person probably feels depressed, alone, and without much hope.
· Encouragement and understanding will long be remembered – as will comments like “What have you got to be sad about? You have so much in your life to be happy about.” Or, “Everyone feels that way, just snap out of it.”
· Taunting a person who is contemplating suicide only deepens the despair and intense internal anger. Avoid statements like, “Just go ahead and do it.”
· Recognize personal limits. Helpers are not responsible for effecting the cure. Healing is a personal matter and requires personal responsibility and accountability.
· Helping is encouraged – enabling is discouraged.
· Avoid arguing. Avoid theological debates about morals.
· Safeguarding lethal weapons, medications, knives, razors, and scissors is recommended.
· Ongoing support is helpful as is encouraging healthy behaviors and healthy relationships.
· Contact a reputable professional or organization to learn more about suicide prevention.
Just the simple act of talking and relieving some of the internal pressure often helps the person thinking about suicide realize there are alternatives. The problem is usually one of inadequate coping skills to manage stressful situations, and feeling isolated and stuck. As internal pressures normalize, thinking skills improve allowing more effectual problem solving skills to engage.
Suicide is a serious public health issue requiring the involvement of all people. No one is completely immune from the effects of suicide given its social, filial, and economic damage. To address the problem of people dying by suicide, public service awareness campaigns have been organized on local, governmental, and global levels to help people recognize the warning signs of suicide and to know how to respond to someone who may be thinking about suicide. Suicide is treatable and in many instances preventable when appropriate action is taken on a timely basis. Know the signs and know what to do if someone needs help. Reliable information about suicide may be found at American Foundation for Suicide Prevention, American Association of Suicidology, National Institute for Mental Health, Substance Abuse and Mental Health Services Administration, Centers for Disease Control, Suicide Prevention Resource Center, and the American Psychological Association to name a few. One person really can make a difference.
Dye, M. & Fancher, P. (2007). The genesis process: A relapse prevention workbook for addictive/compulsive behaviors (3d ed.). Double Eagle Industries: 888-824-4344.
Juel-Nielsen, N. & Videbech T. (1970). A twin study of suicide. Acta Geneticae Medicae et Gemellologiae. 19(1): 307-10.
Lester, D. (2002). Twin studies of suicidal behavior. Archives of Suicide Research, 6: 338-389.
Roy, A., Segal, N., Centerwall, B., & Robinette, C. (1991) Suicide in twins. Archives of General Psychiatry, 48(1):29-32.
Yip, P., Caine, E., Yousuf, S., Chang, S., Wu, K., & Chen, Y. (2012). Means restriction for suicide prevention. Lancet, 379)9834): 2393-9.