The Inner Mechanisms of Suicide - Part II

In the first article of this series on the inner mechanisms of Suicide, I covered two rough pathways to understanding suicidal contemplation, which are meant to provide an abbreviated sketch to help people think about the subject. I think it can also give some helpful clues as to how we might choose to intervene if someone is dealing primarily with emotional turmoil, and it's escaped the primary form of intervention. Past immediate safety concerns, interventions will likely involve exploring distressing thoughts and feelings in a safe environment without judgment. 

The first aim is to acknowledge and validate another's first-person experience. It is critical to encourage people to utilize attachment relationships for support, such as family, friends, and partners. We may challenge negative thoughts that foster interpersonal isolation, such as "I don't want to burden anyone," and we encourage them to let go of maladaptive ways of coping with distressing emotions through drug and alcohol abuse, cutting, and so on. The primary focus is to help ground the person emotionally and interpersonally.

The second form of suicidal ideation, motivated primarily by a lack of meaning, may include some of the same interventions, but will naturally focus more on some of the big questions about how the person attains meaning in their life, such as the sources of significance. Recent studies have found that interventions targeting meaning in life were effective in reducing suicide risk in these situations. Psychologists should have some awareness of the existential and philosophical issues that might arise in therapy discussions, and of course, they should be comfortable questioning the meaning systems on which they themselves rely.

Notice that in these general responses, we're not at all concerned with diagnosis. In my opinion, the focus on DSM diagnosis is one of the many things that are wrong with mainstream discussions about suicide and intervention, particularly with teens. Here's what I see happening all too often: first, the professionals tell us that depression is the number one cause of suicide and that mental illnesses like depression are brain disorders that should be treated no differently than physical illnesses. We're told explicitly that it's best to consult with a professional as soon as possible, and it's very important to get the correct diagnosis.

I'm actually paraphrasing almost word-for-word from a very popular website tailored specifically to teens and their parents. From here, a parent might pick up on some subtle or not so subtle signs that something isn't right, but they don't quite know how to talk with their teens. They might even be afraid of making things worse. After all, they're not a mental health professional, and we've suggested to them that they need to consult one. So, the anxious and worried parent takes their kid to their family doctor or to the hospital emergency. The teen tries to tell the doctor or the intake worker what's wrong, but the people they meet are most interested in trying to get a proper diagnosis. They're more interested in that than making a meaningful connection to the person in front of them. They get passed along to a specialist who can take months to get in and see. And, if they can wait that long, they find themselves having to tell their story yet again to someone who is primarily interested in an abstract diagnosis so they can begin the process of treatment.

So many teens have said that they're tired of telling their stories to people who don't understand. Is it possible that these teens have a reason to feel this way? If everyone is focused on assessment and diagnosis, as opposed to making an empathic connection and having a meaningful conversation, doesn't it make sense that they would feel this way?

So, what can we do differently? Well, here are a few of my thoughts or opinions for whatever they're worth. I think we need to get away from our obsessive focus on diagnostic labels. Let's get away from fruitless attempts to turn the experiences of others into generalized categories of abstraction that fool some into thinking that the situation is an object suitable for medical intervention. Instead of depersonalizing and decontextualizing the issue by turning the human experience into some hypothetical object like a biology's depression, let's focus the conversation around supporting the subjective person on their own terms. This means conceptualizing the individual holistically, as opposed to reductively, taking the time to empathically attend to how they experience themselves and their world. We need to ensure that they feel non-judgmentally accepted and understood so they feel some meaningful connection to someone. It's not acceptable that people walk away from these primary care facilities saying how tired they are of telling their stories and that no one understands them.

I'm also concerned that our present way of conceptualizing depression and suicide may have the effect of scaring anxious parents and teens into thinking that they're not equipped to have these deeper conversations, as if they should only be had with professionals. I've lost count of the number of times I've met with a suicidal teen whose parents didn't talk to their teens for fear of being intrusive or because they felt ill-equipped as mental health professionals.

I think there's so much more that we could do to support parents, teachers, and loved ones so that they can feel competent exploring the thoughts and feelings of the people that they care about. I honestly have to wonder how much of the stigma everyone's talking about is not just about mental illness, but rather discussing feelings openly. More than ever, I hear people telling friends that they suffer from major depressive disorder, but they wouldn't dare get into a conversation about what that feels like for them. How many billions of dollars might we save, and how would this impact mental health more generally, if we change the dialogue from one that seems to focus on diagnosis and treatment to the validation of first-person experiences and real human suffering?

I don't want to suggest in any way that a friend or family member should replace a mental health professional, but there are so many things that you can do to get the conversation going and offer support to someone who is feeling suicidal. Here are some things to think about first:

Before anything else, is the person in immediate danger? If so, encourage them to go to the hospital, call the police, or an emergency crisis line. These steps may not feel so great, but they're often necessary in a moment of extreme crisis.

Be aware of factors that may increase the risk of suicidal thoughts and feelings turning into a suicidal act. A person having the vague thought about what it would be like not to exist is not something to ignore; that is, it still needs to be taken seriously, but this person is not necessarily at urgent risk. If the individual has a plan, the means to follow through, and a more immediate timeline for acting, then the stakes raised dramatically. You want to talk directly with a person to try to assess if there is an imminent risk. Instead of asking, "Have you had thoughts of hurting yourself?" ask, "Are you having thoughts of killing yourself or ending your life?"

Some people feel uncomfortable asking direct questions like this, but you need to overcome it. Someone you care about could be seriously thinking about killing themselves, and they need to feel like an honest conversation is possible. This is sometimes a first step toward them feeling a little less alone. It's also important that you get an accurate assessment of how dangerous the situation might be. Depending on how imminent the risk is, a friend or family member might ask if they can remove, if only temporarily, the means to follow through, including access to firearms, unlocked medications, keys to the car, and so on. If they refuse and the risk is high, you might need to force the issue in whatever way you can.

It can also be helpful to ask what has prevented them from following through. This might be a scary question for some people, but it's important. Knowing the reasons for living can give you a sense of where the individual gets their sense of strength, support, and meaning. It can also give you another sense of how risky the situation is. For example, if someone says, "I would never do that because I know it would devastate my best friend and/or my parents," then the importance of those relationships might be protective factors against following through. On the other hand, if someone says, "I haven't tried because I haven't worked up the courage, or I freeze when I'm about to," then that might be a dangerous situation. In the right circumstances, such as when the person is able to overcome those feelings while under the influence of drugs or alcohol.

I should stress that suicide risk assessment is notoriously difficult, even for professionals who have decades of experience. There are plenty of examples where someone goes into an emergency room one evening, is assessed as low risk by a social worker or psychiatrist or psychologist, and they're allowed to go home and then they're found dead within 24 hours. 

Part of the problem is that if someone wants to get out of the hospital setting, all they have to do is tell the doctors what they think they want to hear. Risk assessments are far from perfect, and it has a lot more to do with the truthfulness of the answers, which are sometimes better assessed by people who are emotionally close to the individual contemplating suicide. Now, if you think that someone is in less than immediate harm, that doesn't mean that the conversation can wait days, weeks, or months. It means that there's time to have a discussion. 

Here are some suggestions that can help you open up that important dialogue:

  • Stay away from giving advice or opinions or trying to fix whatever you think the issue is, unless the person is explicitly looking for this kind of feedback.
  • Listen and empathize. Trust that this is, in fact, doing something.
  • Check out authentic resources on helping your child regulate feelings. The ideas that I discuss in it apply equally well to teens and even to adults.
  • Try your very best to understand where the other person is coming from and what they're thinking and feeling. Imagine what that would be like. Put yourself in their shoes. People who have serious thoughts of suicide are often in agonizing hell. As much as you're able to, enter it with them.
  • Try to help them put words to their experience. Ask open-ended questions to get a better sense of what's going on, and reflect back what you're hearing to ensure that you understand what the person is trying to express to you. If someone says, "Sometimes I feel like I just want to die. I feel so alone, like no one cares," don't say, "But you aren't alone. I'm here, and so are your friends." These kinds of responses are more trying to convince someone that they might not have reason to feel the way that they do. There might be a time and a place for these kinds of responses, but stay away from them initially. Instead, try to understand the reality of the person making the utterance. A better response might be to say, "That sounds horrible. How long have you felt this way? What's that like for you? Do you sometimes feel like I don't care?"
  • Validate the other person and their experience. This is a way to just acknowledge their reality. By validating, I don't mean that you have to agree with the reason that frames their experience, but rather acknowledge the experience in itself and its mattering to you. For example, you might say, "That must be so hard for you, feeling like no one gets it," or you might even ask questions like, "Is that why you spend so much time in your room alone?" It's okay to share your feelings for them as well. For example, "You know, it makes me feel sad to imagine you feeling like no one cares." When you do this, the focus is on your feelings for them, not your feelings about the situation.
  • Take, for example, a parent who discovers a note suggesting that their teen may be feeling suicidal. The parent may panic and feel overwhelmed. They may even say something like, "You know, how could you think about doing that to me?" These kinds of responses are not usually helpful. If anything, the other person may feel ashamed for having these feelings at all and will be less likely to talk about what's going on for fear of upsetting the other person again.

The whole focus here is to explore feelings by going deeper into them. There's a highly relevant quote by an unknown author that reads, "My mind is like a terrible neighborhood. I try not to go there alone." The main goal here is to ensure that whatever the other person is feeling, they need not feel it alone. I think one of the most significant protective factors against suicide or almost any mental health-related issue is feeling emotionally connected with another human being - that is, experiencing yourself being felt by another person or feeling yourself mattering to someone else. Don't underestimate how important that is. If your attempts to engage are going nowhere, that is, if you get one-word answers or they keep trying to tell you that they don't want to talk about it, or that everything's fine when you know that it's not, then you may want to say something about how you're feeling about the situation. If you feel helpless, then tell them that. If you feel shut out, then tell them that. This shouldn't come from a guilt-inducing place but rather a place of concern and care. If the person can't seem to risk sharing a vulnerability with you, then maybe you can take the first step in sharing your feelings for them and their situation. Just be sure they don't take your comments to mean that you are burdened by any of this. I talked about this in another place. As long as an open and honest conversation is happening, there's usually no reason to panic.

This goes the other way as well. For example, I had a reader of a previous writeup ask a really good question from the perspective of someone who's feeling suicidal. They wanted to know how they could safely talk about their suicidal thoughts and feelings with their therapist without having to worry about their therapist panicking and calling a family member or the police or even, in some places, having them admitted to a hospital against their will. For me, it's all about trust. If therapists are hyper-reactive to client disclosures, then they're not going to be honest about what's going on, what they're experiencing, and how bad it is. So, as long as I feel like there's a good rapport and degree of communication with someone, and as long as the patients can trust to reach out for help when they take a bad turn or need to talk outside of therapy hours, it becomes more comfortable working through the issues as go along. A client needs to trust that the therapist is not going to overreact to their disclosures, and the therapist needs to trust that the client is going to utilize the supports that are there.

Before I wrap up this, I want to say that if you're reading this and if you happen to be struggling with suicidal thoughts and feelings, please consider the possibility that the situation that you find yourself in may only be temporary, and that you can still get help. This may seem absurd to many people. You may have been feeling this way for months, years, perhaps even your entire life, but things can change. And it may be the case that as you look back years from now, you'll be amazed and thankful that you survived it. Take it one day at a time. Hang in there and know that there are people you can turn to for help. I hope this content was useful and stimulated some discussion. If so, please add your comments below and remember to share your own thoughts about the topic. Remember that each input and opinion shared enriches our understanding. You can also subscribe to our youtube channel and social media handles for future mental health-related resources. Thanks.


The section is being updated.


Pritam Chakraborty

As I was moving through life, I occasionally saw brief glimpses of beauty.

Post a Comment

Share your thoughts! We're eager to hear you out

Previous Post Next Post