Each year, around 800,000 people die by suicide according to World Health Organization (WHO). Which equates to one suicide every 40 seconds. These suicide rates also vary greatly between countries, different cultures and genders.
In 2012, a local survey conducted in Nova Scotia, Canada found that about one in five students aged 15 to 24 had considered attempting suicide, and almost 1 in 10 had thought about taking their own lives in the previous year. These statistics indicate that suicidal contemplation is common, yet many people have a hard time imagining how someone could even consider it, let alone feel like they could safely explore these very difficult conversations with others. This is part one of a two-part discussion series on suicide. The first part, this one, will attempt to look at ways that we can try to understand or make sense of suicide, including circumstances and vulnerabilities that could make suicide a viable option for some people. The latter part will tie some of these things together, discuss risk factors, and offer suggestions for what we can do, either as the one who is suffering or as someone trying to provide support.
The first question can be summarized like this: How does a person get to a point where they might willfully kill themselves?
Now, I don't mean to suggest that we could ever fully understand or explain a suicidal act by peeling back to some prior event or a clear-cut cause. I don't think that's possible, but that shouldn't prevent us from developing a rough sketch that will help us consider suicide from the perspective of the individual who's suffering. But first, let's address some common areas of confusion.
Many people seem to think that suicide is caused, at least in part, by an underlying illness or a disorder like depression, for example. The website suicide.org states that over 90% of people who die by suicide have a mental illness, the most common of which is depression. They claim that untreated depression is the number one cause of suicide. If depression is the leading cause of suicide, it makes sense that we should try to understand what causes depression. Unfortunately, mental health professionals are largely divided on that question, or on whether there could even be a straightforward answer that generalizes across individuals and their very different life circumstances. Some people claim genes or biology cause depression, some say that it's the environment or external stimuli, and some say it might have more to do with how the individual deals with emotions and the quality of their social relationships, or even how they make sense of themselves, others, and the world as they encounter it. My own position involves an integrative or a biopsychosocial understanding, as opposed to a medical or a disease model of depression.
I also believe that to fully understand depression, it is important to consider the subjective experiences of the person at the core of the discussion. However, many professionals insist upon a disease model that takes depression to be a chemical imbalance or a brain dysfunction. If this were true, and if suicide were largely caused by depression, then it would seem to suggest that suicide is ultimately caused by a dysfunction in neurophysiology.
There are many problems with this line of argument. First, many people attempt suicide without being depressed, and the overwhelming majority of people who suffer from depression don't attempt suicide, which tells us that there is no strict causal relation between depression and suicide. Recent studies also suggest that while depression may often have an indirect link with suicidality, it is perhaps better explained by psychosocial factors, including emotional anguish related to psychological or interpersonal needs that have gone unmet.
Secondly, it doesn't seem right to say that suicidal thoughts, feelings, or impulses are caused by dysfunctional neurobiology or chemical imbalances in the same way that insulin imbalances cause type 1 diabetes. People are not passive, but rather actively engaged in their first-person experiences such as thinking and feeling, doing, even the sort involved in what we call depression.
For example, compare the fact that a person can have cancer without ever knowing it with depression, which by definition must involve experiencing something that you're not only aware of, but also something over which you typically have some voluntary control. So, as much as a person may feel sadness and despair to the extent that the psychological distress makes them unwilling to get out of bed in the morning, the fact of the matter is they're still physically capable of doing so.
Now, I'm not suggesting for a moment that depression is something that can be easily overcome, or that it's simply a matter of willpower or anything like that. My point is that having cancer is not like being depressed, no matter how much people try to force the comparison. I think they do so out of a concern that if depression can't be objectified as a physical thing observable in third person, it risks being dismissed as not real. Our first-person experiences are real, human suffering is real, and we don't need to engage in unnecessary biological reductionism in order to justify their validation.
That's not to say that there aren't more objective ways of trying to understand aspects of depression or suicidal thinking. For instance, those labeled as depressed and suicidal often exhibit predictable general patterns of thought, such as catastrophic all-or-none thinking, negative self-attributions, or a sense of hopelessness. But the existence of such patterns isn't to be explained by some yet-to-be-found biological cause. They're expressions of people who may find themselves in situations that for them involve a kind of psychological suffering that often feels unbearable. And although distorted thoughts and overwhelming feelings may strongly compel a person to construe the situation in a way that restricts the range of possibilities that feel open to them or that intensify feelings of helplessness, suicide is still closer to a voluntary act, such as raising one's hand, than it is a causal event driven by biological mechanisms in the brain or antecedent conditions out there in the environment.
It's interesting to consider how our use of language can have unintentional consequences for how we think about suicide. In recent years, we prefer to avoid saying that someone "committed" suicide. Understandably, people want to avoid judgment or blame, such as when we talk about committing murder or a serious crime. But notice what has been replaced: now we say that someone "died by suicide," which may take it from a personal act to a passive event, such as when we say that someone "died by food poisoning" or "died by heart attack. This makes it sound like the cause of suicide might be discovered in some neurophysiological event or succession of environmental happenings. The human being is no longer within focus. In my opinion, suicide needs to be understood in the context of the thinking and self-aware person. It is the product of the conscious individual and how they experience themselves and their world. It has to do with relationships with meaning, a felt sense of significance, and so on. In other words, suicide is deeply personal, and any sensible explanation of what brings a person to consider suicide needs to be understood in the context of the individual for whom the suicidal act is a contemplated possibility.
In my own experience, I tend to envision two very rough pathways to contemplating suicide. These two ways of understanding suicide are far from inclusive. For example, in this article, I won't have a thing to say about suicidal acts in the name of religion or ideology, nor will I say anything about doctor-assisted suicide related to terminal illness or as a means to end further physical suffering. This brief sketch will only explore what, in my opinion, are the most common ways that people come to consider suicide.
One path involves the person experiencing or anticipating having to experience some prolonged and unbearable psychological or emotional pain. And so, the individual is strongly motivated by a desire to escape an intractable situation involving excruciatingly intense psychological pain and suffering. For example, a person may feel unbearably ashamed, unlovable, inadequate, lonely, misunderstood. Maybe they've been cheated on, habitually lied to, betrayed, or hurt beyond words. They might have felt rejected by others and by society such that they feel estranged from the world. The list goes on and on. These individuals may seek refuge in the thought of suicide since it would mean an end to their emotional pain. This person may even imagine their death as a kind of relief, not only for themselves but also for significant others whom they suspect are somehow burdened by their existence.
Now, it's important to note that this kind of thinking is almost certainly based on distorted assumptions. The reality is that suicide survivors, such as friends and family members, are devastated when a loved one takes their own life. It causes psychological wounds that never fully heal. For others, it's the opposite of what I'm describing. They know that their death would cause their loved ones to suffer, and the guilt that they feel for inflicting that kind of pain is pretty much the only thing stopping them from acting.
Keeping with this theme of suicide as a way to deal with psychological pain, there are various psychodynamic interpretations, one of which takes suicide to be, in some cases, an act of aggression. In this situation, the person is thought to harbor considerable anger, often unconsciously, towards some significant other or others. The feelings of anger and rage are, for various reasons, just too much for this person to experience or express outward. So, these feelings are instead turned inward and effectively unleashed on themselves.
In these situations, we often discover that someone may have good reason to feel hurt and angry toward people who've caused them to feel neglected, mistreated, betrayed, and so on, but the feelings of anger are curiously absent. This is important to note because anger is a mobilizing force, whereas its absence can lead to extreme passivity or compliance in relationships, as well as a person feeling an unjustified sense of shame about who they are and feeling hopeless about their situation.
These individuals often feel victimized by the world and by relationships and feel just powerless to do anything about it. Also, note that anger can sometimes be expressed indirectly, such as in the case when suicidal patients often fantasize, sometimes with pleasure, about the emotional pain or guilt that their death would inflict on the people with whom they're angry.
If someone is struggling with these sorts of internal dynamics, in therapy, mental health professionals would work with the client to discourage either the internalization or the indirect expression of anger and to promote the healthy experience and communication of such feelings. Not to encourage aggression or violence, but to mobilize and empower the person to challenge or change unhealthy relationships, some aspect of their life situation, or even a way of looking at life and one's problems. Now, this is just one example of a psychological conflict or difficulty that could be relevant to the experience of prolonged sadness, despair, and thoughts of suicide. It's certainly not the case for everyone, but it suggests that we need to have an understanding of how a particular individual deals with feelings and how they relate to others.
The second, very rough path to suicidal thinking is motivated less by a desire for emotional reprieve than by a perceived lack of meaning in one's life. These people are often tormented by thoughts such as, "What is this life for? Why am I here? What is the point of it all?" In short, they lack a sense of meaning or purpose and, as a result, give up on the idea of living. Sometimes this is called logical suicide, though many philosophers have claimed that it's illogical, at least insofar as the problem of meaning is concerned. This is a position that I would defend, and I may address in a future blog if there's some interest.
Although suicide and life meaning are often neglected in the psychological literature, there's growing research shedding light on their importance. For example, a 2013 study 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 a purpose in life, which is a related concept, was also associated with decreased suicidal thinking.
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 real estate brokers. Such abilities would have little benefit or value or meaning to people living in drastically different cultures. For example, in traditional hunter-gatherer societies, meaning is, in many ways, relative since it's defined by our distinctive cultures or by us as individuals.
As an applied example, we might consider Canadian Aboriginal people who have the highest rate of suicide in the country, more than five times the national average. There's been some insightful research on this issue. A 2008 study found that while Aboriginal suicide rates were largely unrelated to measures of socioeconomic status or geographic location, they were drastically lower among bands that were able to hold on to their language and cultural identity and a degree of self-determination. Cultural sources of significance appear to be protective factors against suicide, at least in some cases.
We can also look at some clinical examples illustrating this link between meaning and suicidal thinking. For instance, exceptionally talented musicians and athletes sometimes become suicidal after a serious injury. They become incapable of doing the thing that gave their life meaning. And of course, there's the cliché, though not uncommon, example of the middle-aged individual undergoing a midlife crisis where they become suicidal. They get a subconscious glimpse of their own mortality and begin to question many of the meaning systems by which they lived. Finding no point or purpose in it, they begin to see suicide as a viable option. Though these examples will often involve emotional distress, I'm separating them here because the crucial motivator is a perceived lack of meaning. Some, including myself, would argue that brief spells of suicidal thought due to a perceived lack of meaning can be more or less expected in those who seriously question life's purpose.
Nobel prize-winning author Albert Camus tackles the subject of meaning and suicide in his book, The Myth of Sisyphus, claiming that it is legitimate and necessary to wonder whether life has meaning. Therefore, it is legitimate to meet the problem of suicide. He concludes that every fully conscious human being has, at some point, contemplated suicide. To never question life's meaning is to blindly assume it. Conversely, to question the meaning in life is to entertain the possibility of meaninglessness and to assume responsibility for creating a kind of relative meaning that will sustain one's life.
The well-respected psychiatrist and therapist, 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 by either finding or creating them, is choosing to live, which increases one's awareness of their freedom and responsibility.
There's so much more that could be said, but I want to stress that even in such cases where suicide is entertained, this is only a starting point and arguably shouldn't end in the physical act of suicide. It's interesting when we go from this link between suicide and socio-cultural sources of meaning back to the common conception of suicide as something tied to a mental illness. Mental illnesses are often regarded as comprising clusters of symptoms arising from within the person, but we could perhaps make a case that it's not always the person who is sick, but the larger society or culture in the sense that they're unable to provide rich and viable sources of meaning. Or to the extent that they don't permit the open expression and validation of real human emotion. Such factors may partly contribute to the emergence of suicidal thought as a seriously entertained possibility.
For example, a culture that suggests that money buys happiness insists on the need to be constantly smiling, or suggests that there's something wrong with being sad or vulnerable. In our culture, men are particularly discouraged from expressing vulnerable feelings or else they're labeled as weak. Whereas women are discouraged from asserting themselves or expressing anger or else they risk being labeled as crazy or difficult to work with. Assumptions such as these are everywhere in mainstream culture, and they no doubt play a significant role in our mental health that we largely ignore them.
Sometimes, it's society's cultures and communities that are in need of change. If we don't recognize this, and if the individual is labeled as pathological, they're only going to feel more ostracized, stigmatized, and so on, which can lead to a place where suicide becomes a contemplated option. As suggested at the start of the article, many teens and young adults contemplate suicide. So before wrapping up, I'd like to take a moment to explore some of the reasons why they might be particularly vulnerable.
When we're small children, our whole world is typically defined by our relationships within the family. Experiences with parents and siblings teach us about ourselves and about the world, and our parents are ideally, though not always, our primary place of psychological support. But during adolescence, most teens find themselves spending less time with family and more time with their peers. They care deeply about how their friends perceive them and maybe a little bit less about what their parents think or how they might feel about them. For example, some teens will dismiss the opinions of their parents based on the intuitive thought that they wouldn't understand or get what they're going through. Perhaps they have reason to suspect this based on experience. Then again, I think it's just as often an unfortunate assumption that's seldom put to the test.
Another issue arises when a teen can't seem to accept positive comments from their parents. For example, some teens, especially those prone to depression, might dismiss a loving comment from a parent as "you know, stuff parents are supposed to say." This is really unfortunate because genuine comments or gestures from loved ones can be validating reminders of who we are. If it's true that we often learn about ourselves through the eyes of others, then adolescents are increasingly doing so through interactions with peers. But many teens are simultaneously afraid to be who they are for fear that this would lead to possible rejection. Many teens then engage in some kind of conformity in an effort to find acceptance, but this only creates a schism between how we present ourselves on the outside and who we feel ourselves to be on the inside. This will often have the effect of others seeing us as generally happy or content while feeling internally sad, lonely, anxious, or misunderstood.
Overall, teens put a lot of stock in relationships that can be extremely difficult to navigate emotionally, intellectually, and socially. They're often under anxiety and pressures to fit within social groups, and they have to traverse potential landmines related to implicit hierarchies and pecking orders. And of course, teens frequently experience all the intense sensations and feelings related to puberty and the exploration of romantic relationships. They also have unprecedented freedom, but with it comes the burden of responsibility for their choices and anxieties about potential failure. Discovering these new capacities is often a lucid and exhilarating time in one's life, but it can also be very strange, alienating, and frightening.
Adolescents have an increased capacity for self-reflection. From an existential perspective, many teens are questioning meaning and purpose, with executive functioning skills that give them a new way of considering their place within the larger world. They have a unique experience of themselves in time; they are young enough that their experiences are novel, vivid, and teeming with raw sensation. Many will never feel so alive again. It's like repetition seems to dull the senses, yet they're not quite old enough in years to know that they can survive some of the painful experiences that they're presently dealing with. A great number of those who have made it to adulthood have experienced extreme pain and suffering, but have lived long enough to see the other side of it. They have a kind of hope that comes from living, that things sometimes do get better, or at least, you know, they feel less bad.
There are all kinds of issues to discuss in relation to teens and suicide, but I'll leave it at that for now and come back to it maybe later. Okay, so that's gonna be it for this part. We explored some ways to make sense of suicide as an act as opposed to a causal event and two very broad and often overlapping pathways, including the problem of overwhelming emotional distress and that of meaning. In the next part of this series, we'll look at how this translates into treatment and make some suggestions as to how we can support someone who is feeling suicidal. If you found this article helpful, please let me know your thoughts via comments, and share it with people who may be interested. Thanks.
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