How to Understand and Talk about Suicide
By Halifax Psychologist Brad Peters
Each year approximately 3,500 Canadians commit suicide – a figure only slightly below the number of deaths due to colon and breast cancer. In 2012, a local survey found that about 1 in 5 students in Nova Scotia seriously considered attempting suicide, with female students being more than twice as likely to attempt suicide. In the same survey, almost 1 in 10 Nova Scotia students aged 15-24 reported having thoughts the previous year about taking their lives – a rate 69% higher than the national average and the highest in the country.
All of this reminds us that suicide is a serious issue and its effects hit close to home. But for all the statistics we’ve accumulated, we seem to be falling short of a general understanding of its causes. In this post, I would like to propose a rough sketch for framing the issue – one that is perhaps oversimplified, but may nonetheless provide a conceptual starting point. I will then offer some suggestions on how to best support someone who is feeling suicidal.
Paths to Suicidal Ideation
The most popular way of understanding suicide seems to attribute its cause to an underlying mental illness. The person who is contemplating suicide is thus regarded as an individual who is suffering from some kind of chemical imbalance or mental disease/disorder – the most common diagnostic label being Major Depressive Disorder.
However, I think this is the wrong way to think about these issues. It is doubtful that suicidal thoughts would be caused by chemical imbalances in the way that an insulin imbalance might be said to cause Type 1 Diabetes. People are seldom passive objects to their thoughts. They are conscious agents actively engaged in subjective mental activity and thought. Suicidal ideation must therefore be understood in the context of the thinking and self-aware person (not just their underlying biology). It is a product of the conscious person and how they experience themselves, the world, and their place within it. In short, the traditional medical model of mental illness is reductive, and too limited to fully explain suicide and its causes.
In my own experience as a psychologist, having worked with many suicidal patients, I tend to envision two general pathways to suicidal ideation. One possible path to suicidal thinking, involves the individual experiencing a prolonged and unbearable emotional pain. In this instance, the individual is primarily motivated by a desire to escape an intractable and intense emotional suffering, and for this reason, we might label it Suicide for Emotional Reprieve (SER).
A common example might involve a person who feels so unbearably unlovable, ashamed, emotionally isolated and lonely, that they seek refuge in the thought of suicide, since it would presumably mean an end to their emotional suffering. It is not uncommon that this kind of individual may even imagine their death being a kind of relief for significant others, who they believe are somehow burdened by their existence.
Another interpretation, one from a traditionally psychodynamic approach (e.g. Lees & Stimpson, 2002), takes suicide to be an act of aggression. In this case the person is believed to harbor considerable anger (often unconsciously) toward some significant other; the feelings of anger and murderous rage are too much to experience and express outward, so the individual copes with these emotions by unleashing them on themselves. In these situations, the individual may even fantasize, sometimes with pleasure, about the emotional pain or guilt their death would inflict on the people with whom they are angry.
There are many different examples of situations where a person may become suicidal as a result of some intolerable emotional pain – the previous two examples are only part of a two-part sketch. It is also important to note in severe cases, however, that these individuals truly believe suicide is the only option to end their suffering – there is very little hope about their life situation changing.
The second path to suicidal thinking is motivated less by the desire for emotional reprieve (SER), than by a perceived lack of meaning in one’s life. Persons who arrive at suicidal ideation by this route are often tormented by such thoughts as: What is this life for? Why am I here? How am I to live? What is the point of it all? In short, they lack a sense of meaning or purpose, and therefore, they give up on the idea of living. Sometimes this is called logical suicide (though it should be noted that some philosophers claim to have shown that this form of suicidal ideation is in fact illogical).
While suicide and life meaning are often neglected in contemporary psychological literature, recent studies have begun to shed light on this topic again, revealing the importance. For example, a study by Kleiman and Beaver (2013) found that the presence of meaning in life predicted decreased suicidal ideation over time, and lower lifetime odds of a suicide attempt. Other studies found that purpose in life (a related concept) was also associated with decreased suicidal thinking (e.g. Heisel & Flett, 2004).
Most of us tend to borrow meaning from our wider culture. In the Western world we might value people who are great basketball players, pianists, or successful real-estate brokers. Note that such abilities would have little value or meaning to persons living in drastically different cultures – for example, in traditional hunter-gatherer societies; these skills would be of no significance to the person or the society to which they belong. Meaning is thus relative, since it is defined by our distinctive cultures.
As an applied example, we can think about Canadian aboriginal people, and how they have the highest rate of suicide in the country (more than 5 times the national average). Chandler and Lalonde (2008) have done some important research in this area. They found that while aboriginal suicide rates were largely unrelated to measures of socioeconomic status or geographical isolation, they were drastically lower among bands that were able to hold onto their language, cultural identity, and a degree of self-determination (Chandler & Lalonde, 2008); cultural sources of significance and meaning appear to be protective factors against suicide.
I can also draw examples illustrating the link between meaning and suicidal ideation from my clinical experience. Sometimes this link will be illuminated when exceptionally talented musicians and athletes, suddenly become suicidal after a serious injury – they become incapable of doing that thing that gave their life meaning. And of course there is the cliché, though not uncommon, example of the suicidal individual undergoing a ‘mid-life crisis,’ where they get a subconscious glimpse of their own mortality, and so begin to question many of the meaning-systems by which they’ve lived.
Though the aforementioned examples will often entail emotional distress, I am separating them here because the primary motivator is a perceived lack of meaning; for discussion purposes, I will label this form of ideation as Suicide for Lack of Meaning (SLM).
Implications for Suicidal Intervention
I should again emphasize that these two pathways are meant to provide an abbreviated sketch to help people think about the subject of suicide, and the factors that might play a dominant role. There will likely be overlap between these two ways of conceptualizing how many people arrive at a place of suicidal ideation. However, I think it can also give us some useful clues as to how we might think about intervening.
If someone is dealing primarily with emotion pain and its escape (SER), the primary form of intervention (past immediate safety concerns), will likely involve working with the person to help them frame, label, and regulate distressing emotions. As psychologists, we often do this by exploring those thoughts and feelings in a safe environment without supposition or judgment. The first aim is to acknowledge and validate emotions based on the individual’s lived experience. We encourage people to utilize attachment relationships for support (e.g. family, friends, & partners), challenge negative thoughts that foster interpersonal isolation (e.g. “I don’t want to burden anyone”), and gradually wean them away from maladaptive ways of coping with distressing emotion (e.g. drug & alcohol abuse, engaging in cutting, etc.). The primary focus is to help ground the person emotionally, so that they begin to feel psychologically stable and are in a better position to explore distressing thoughts related to their life situation.
The second form of suicidal ideation, motivated primarily by a lack of meaning (SLM), may include some of the same kinds of interventions, but will naturally focus more on some of the big questions about how the person attains meaning in their life and personal value (sources of significance). Recent studies have found that interventions targeting meaning in life were effective in reducing suicide risk (Lapierre et al., 2007). In these situations, the psychologist should have some awareness of the existential and philosophical issues that might arise in the therapy discussions. They should also be comfortable questioning the meaning systems on which they themselves rely.
Brief Flirtations with Suicidal Thinking is Sometimes Healthy
Some, including myself, would argue that brief spells of suicidal ideation due to a perceived lack of meaning (SLM), can be more or less expected in those who seriously question life’s purpose. Nobel Prize winning author, Albert Camus, tackles the subject matter of meaning and suicide in his book: The Myth of Sisyphus, claiming that “… it is legitimate and necessary to wonder whether life has a meaning; therefore it is legitimate to meet the problem of suicide.” (Preface to MS, Camus, 1955).
Camus concludes that every fully conscious human being has contemplated suicide. To never question life’s meaning, is to blindly assume it. Conversely, to question the meaning of life is to entertain the possibility of meaninglessness.
Celebrated psychiatrist and master psychotherapist Irvin Yalom takes a similar position, and argues that meaninglessness is one of the ‘givens of existence’ that every lucid human being must confront. Rather than passively supposing life’s meaning, the individual actively questions the reasons for living, and having found them, is choosing to live, which increases one’s awareness of both their freedom and responsibility. There is a lot more that could be said, but I want to stress that in such cases where suicide is ‘entertained,’ this is only a starting point, and should not end in the physical act of suicide.
Tips on Talking to Someone who is Contemplating Suicide
Regardless of the underlying issues that led someone to a place where they are contemplating suicide, it is helpful to know how to talk to a loved one who is feeling or thinking suicidal thoughts. While there is no ‘one size fits all’ approach, here are some suggestions or things to think about:
1. Is the person in immediate danger? If so, encourage them to go to the hospital, call the police, or call the Mental Health Mobile Crisis Team (902-429-8167) if they happen to reside in Halifax, Nova Scotia.
Be aware of factors that increase the risk of suicidal ideation turning into a suicidal act. A person having the vague thought about ‘what it would be like to not exist’ is not something to ignore, but they are unlikely to be at urgent risk. If however, the individual has a plan, and especially the means to follow through on that plan, the stakes raise dramatically; in such cases, friends or family members should attempt to temporarily remove the ‘means’ to prevent a sudden act (e.g. remove access to firearms, unlocked medications in the home, keys to the car, etc.).
Additional risk factors often include: a history of previous attempts, a sense of hopelessness, impulsivity, a lack of interpersonal supports, and drug or alcohol abuse.
2. If the individual is in less than immediate harm, talk with them. Don’t try to immediately fix whatever you think is the issue, but just listen and empathize.
Try your very best to understand where the other person is coming from and what they are thinking. Ask open-ended questions to get a better sense of what is going on, and reflect back what you are hearing, to ensure that you indeed understand what the person is expressing to you. The main goal here is to ensure that whatever the other person is feeling, they need not feel it alone.
“My mind is like a terrible neighborhood – I try not to go there alone.” – unknown author
3. If these issues seem serious (though not immediate), encourage them to seek out the help of a counsellor or psychologist.
References
Camus, A. (1955). The Myth of Sisyphus and Other Essays. New York: Alred A. Knopf [MS].
Chandler, M. & Lalonde, C. (2008). Cultural Continuity as a Protective Factor Against Suicide in First Nations Youth. Horizons, 10 (1), 68-72.
Heisel, M. & Flett, G. (2004). Purpose in life, satisfaction with life, and suicide ideation in a clinical sample. Journal of Psychopathology and Behavioral Assessment, 26, 127-135.
Kleiman, E. & Beaver, J. (2013). A meaningful life is worth living: Meaning in suicide as a resilience factor. Psychiatry Research, 210, 934-939.
Lapierre, S., Dube, M., Bouffard, L. Alain, M., 2007. Addressing suicidal ideations through the realization of meaningful personal goals. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 28, 16-25.
Lees, J. & Stimpson, Q. (2002). A psychodynamic approach to suicide: A critical and selective review. British Journal of Guidance & Counselling, 30(4), 373-382.
O’Dwyer, K. (2012). Camus’s challenge: The question of suicide. Journal of Humanistic Psychology, 52(2), 165-177.
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