Suicide Prevention

One of the most baffling experiences for many of us to accept is the purposeful taking of one’s own life. For those who have never been suicidal, it is difficult to comprehend such an act. In reality, analyses show that there are many different reasons for suicide. Ernest Hemmingway took his life after becoming increasingly depressed about overwhelming medical problems. The noted psychiatrist Bruno Bettelheim did not want his family to be encumbered by his chronic and debilitating illness. Still others grow weary of their feelings of depression, hopelessness, drug/alcohol abuse, and/or other practical or psychological problems leading to suicidal behavior. Clearly, this is a very personal act decided upon for varied reasons.

It is estimated that well over 30,000 people commit suicide yearly (Centers for Disease Control and Prevention 2007). However, experts believe that this is a gross underestimate of the actual number, because so many ambiguous deaths are ruled accidental. Moreover, it is estimated that at least 10 persons attempt suicide for every 1 who completes the act.

Some have argued that an individual would have to be psychotic or insane to perform such an act. However, psychological autopsies that involve case study analyses of the histories of those who commit suicide do not support such a contention. Although it is clear that most suicidal individuals usually have one or more psychological disorders, this is not always the case. Moreover, most individuals who commit suicide do not appear to be out of touch with reality (i.e., psychotic). Along these lines, it should be noted that suicide is not classified as a psychological disorder in the most recent diagnostic manual (the American Psychiatry Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th ed., or DSM-IV) used by mental health professionals.

Outline

I. Correlates

II. Suicide Statistics

III. Common Characteristics of Suicide

IV. Theoretical Orientations

V. Children, Adolescents, and College Students

VI. Assessment

VII. Suicide Prevention

Correlates

Obviously, we cannot perform experiments to delineate factors that cause suicide. Therefore, we are left with correlational analyses of these acts. Interestingly, studies have shown that those who attempt suicide are different than those who “succeed.” Attempters are likely to be white housewives between 20 and 40 years of age who are experiencing marital or relationship problems and who overdose with pills. Those who actually end their lives tend to be white men over 40 years of age who are suffering from ill health and /or depression, and they shoot or hang themselves (Diekstra, Kienhorts, and de Wilde 1995: Lester 1994; Fremouw, Perczel, and Ellis 1990).

Suicide Statistics

Suicide is the eighth leading cause of death in U.S. men.
Married people are less likely to kill themselves than those who are divorced.
Suicide rates are highest during the spring and summer months.
The suicide rate among college students is twice as high as those who are not in college, and one in five students admits to suicidal thoughts sometime during college.
Men commit suicide about three times more often than women, although women attempt it about three times more frequently.
Physicians, lawyers, law enforcement personnel, and dentists have the highest rates of suicide.
Socioeconomic status is unrelated to suicide, although a marked drop in socioeconomic status is associated with greater potential for suicide.
Suicide rates are lower in countries where Catholicism and Islam are a strong influence.
Native Americans have very high rates of suicide compared with Japanese Americans and Chinese Americans.
Suicide rates tend to be low during times of war and natural disasters, which tend to create cohesiveness and purpose in a greater percentage of people.
The majority of people who commit suicide communicated their intent prior to the act.
Men over 65 years of age are the most likely group to commit suicide.
Men are more likely to use violent means to kill themselves than women (e.g., firearms versus pills, respectively), although women are increasing their use of methods more likely to be successful.
About 60 percent of suicide attempters are under the influence of alcohol, and about 25 percent are legally intoxicated.
The majority of suicide victims show a primary mood disorder.
Childhood and adolescent rates of suicide are increasing rapidly, and suicide is the third leading cause of death among teens.
Although depression is correlated with suicide, hopelessness is more predictive of the act. (For information on this and the other items in the above list, see Berman 2006; Centers for Disease Control 2007; Leach 2006; and Shneidman 1993.)

Common Characteristics of Suicide

Suicide victims almost always show ambivalence caused by the built-in desire to survive and avoid death. Still, the goal is to end psychological pain that they see as permanent. They have reached a point of seeing the future as hopeless. Tunnel vision is a common state for the suicidal, wherein they are unable to see the “big picture.” Death is viewed as the only way out. Other options and the impact of suicide on significant others are minimally considered, if at all. Th us, the act undertaken is one of escape—an act, moreover, that is often typical of their lifelong coping styles.

Theoretical Orientations

Theories of suicide generally focus on sociological, psychodynamic, and biological causes. Sociocultural explanations were originally advanced by the French sociologist Emile Durkheim (1951). He postulated three types of suicide: egoistic, altruistic, and anomic. Egoistic suicide results from an individual’s inability to integrate one’s self with society. Lack of close ties to the community leaves the individual without support systems during times of stress and strain. Durkheim argues that highly industrialized and technological societies tend to deemphasize connection with community and family life, thereby increasing vulnerability to suicide. Altruistic suicide involves the taking of one’s life in order to advance group goals or achieve some higher value or cause. Examples include some terrorist and religious acts. Anomic suicide occurs when dramatic societal events cause an individual’s relationship with society to become imbalanced in significant fashion. Higher suicide rates during the Great Depression and among those who were freed from concentration camps after World War II serve as examples.

Psychodynamic explanations were derived from Freudian theory, which says that suicide is anger turned inward. Presumably, the hostility directed toward self is, in actuality, against the love object with whom the person has identified (e.g., the mother, the father, or some other significant relation). Interestingly, research analysis of 165 suicide notes over a 25-year period showed that about one-quarter expressed self-anger. However, the majority either expressed positive self-attitudes or neither. Thus, although some suicides may involve anger turned toward oneself, it appears other emotions and factors are also relevant (Tuckman, Kleiner, and Lavell 1959).

Biological explanations have focused on the fact that suicide, like many other psychological phenomena, can run in families. That is, there is evidence that suicide and suicide attempts are higher among parents and close relatives than with nonsuicidal people. Additionally, patients with low levels of the metabolite 5-HIAA (which is involved in the production of serotonin, a brain neurotransmitter) are more likely to commit suicide (Asberg, Traskman, and Th oren 1976; Van Praag 1983). Such persons are more likely to possess histories of impulsive and violent behavior patterns (Edman, Adberg, Levander, and Schalling 1986; Roy 1992). Of course, this evidence is correlational in nature and does not indicate whether low levels of 5-HIAA are the cause or the effect of certain moods and emotions or whether they are directly related.

Children, Adolescents, and College Students

Although suicide almost always leaves one with a deep sense of loss, it is particularly tragic when it occurs with a young person. In many ways, those belonging to the youth population are the most vulnerable to making irreversible decisions (their last) without receiving much, if any, support or help and without fully understanding the ramifications of the suicidal act, including how it will affect others.

There is evidence that family instability and stress is correlated with suicide attempts (Cosand, Bouraqe, and Kraus 1982). Many suicidal children have experienced traumatic events and the loss of a parental figure before age 12. Their parents have frequently been abusers of drugs and /or alcohol. Their families have been found to be under greater economic stress than matched (control group) families. The families of suicide attempters also showed a higher number of medical problems, psychiatric illnesses, and suicides than the control group families.

Carson and Johnson (1985) say that 20 percent of college students have experienced suicidal ideation during their college years. Research has shown that students who commit suicide tend to be men, older than the average student by about four years, more likely to be a graduate as opposed to undergraduate student, more often a foreign or language/literature student, and to have performed better academically as an undergraduate than as a graduate student (Seiden 1966, 1984). Further analyses have shown that, despite excellent academic records, most college undergraduates who commit suicide are dissatisfied with their performances and pessimistic about their abilities to succeed. Along these lines, they tend to show unrealistically high expectations for themselves and perfectionist standards and often feel shame over their perceived failings. Additionally, a frequent stressor is the failure to reach expectations or loss of a close interpersonal relationship. A precipitating factor is often the breakup of a romantic relationship. Also, suicide attempts and suicides are more likely to occur with students who have experienced the separation or divorce of their parents or the death of a parent.

Assessment

Clinical psychologists use various tests, such as the Beck Depression Inventory, Beck Hopelessness Scale (BHS), and Beck Scale for Suicide Ideation, to help assess suicide probability. These and other types of psychological tests can be used to supplement clinical interviews, patient histories, and other information as data that can help determine suicidal risk. These measures depend on the honesty of the respondent because they do not have validity scales that can determine people who are deliberately denying their true feelings and intentions. Interestingly, Exner’s Rorschach system can be used to predict suicide risk. The test includes a suicide constellation score that allows for prediction of those who possess heightened potential for such. Because the Rorschach is comprised of ambiguous stimuli, it is very difficult to fake. Although all of these measures can be used to complement other inputs, the BHS has been found to be particularly helpful in predicting eventual suicide (Beck, Steer, Kovacs, and Garrison 1985).

Most suicidal victims display signs of their intent. Families, coworkers, primary care doctors, mental health professionals, and others need to be aware of these signs and then act appropriately in terms of the specific context. Of course, laypeople are not expected to be able to predict the likelihood of a suicide attempt with the accuracy of a trained professional. However, friends, coworkers, and family members are certainly in a better position to see day-to-day changes in potential suicide victims’ moods and earlier behaviors in ways a professional cannot. As a result, family members and acquaintances may be able to intervene effectively or get the sufferer needed professional help. For example, knowing that men, particularly the depressed elderly, are more likely to commit suicide than other demographic groups can alert us to warning signs in that group. Suppose we know such a man who lives alone and recently lost his wife after a sustained illness. Add to this information the fact that he seldom sees his family or friends and possesses a gun. Certainly, risk factors are present in that case. Obviously, such factors do not mean that the man will attempt to take his life. However, we should be alert to the higher risk of such an act taking place in this situation.

Both laypeople and professionals should be aware that people who have thought out a plan for their suicide are more likely than those without a plan to try it. Generally, the more detail they can provide about their plan, the more serious they are about carrying it out. Also, they often communicate their intent to others and provide indirect behavioral clues. For example, they may make out a will or change insurance policies, give away prized possessions, or go on a lengthy trip. At any rate, their presuicidal behavior in retrospect is often seen as somewhat unusual or peculiar. Of course, previous suicide attempts are often a precursor to a “successful” one and are a major risk factor. Still, we need to keep in mind that some suicide victims have neither tried suicide before nor communicated their intent to anyone.

With respect to suicide prevention, the phenomenon of subtle suicide (Church and Brooks 2009) is relevant. Subtle suicide typically involves a long-term pattern of self-destructive behaviors, thoughts, and feelings that ultimately drag a person down in a self-defeating fashion. As with overt suicide, subtle suicide involves deep ambivalence about living. Sufferers have a desire to live, while, at the same time, there is an equal or greater wish that their life will end. Although not actively suicidal, the subtly suicidal engage in neglectful, self-defeating, risky and self-destructive behaviors that inevitably lower the quality and sometimes length of their lives. A downward spiraling effect occurs that can eventually lead the subtly suicidal to become overtly suicidal. In other words, some people pass through an extended period of being uncommitted to living before ending their lives. Professional and family interventions may be effective in getting these individuals committed to living more fully and out of a “subtle suicide zone,” where they compromise their own physical, psychological, and social well-being.

The main point to emphasize here is that many people take a long, slow slide downhill that may or may not be apparent to those close to them. We need to keep in mind that over half of those who commit suicide have made no previous attempt (Zhal and Hawton 2004b; Stolberg, Clark, and Bongar 2002). Over time, some people who have been subtly suicidal become overtly so, particularly as their lives deteriorate and they become more hopeless in their outlook. Interventions as early in the process as possible stand to save lives and enhance the quality of life for the potential victim and significant others. Thus, early detection of people who are becoming or have become suicidal— regardless of whether they suffer from serious psychological disorders—is a first line of defense in the effort to prevent suicide. Many people can avoid the process of dealing with active suicidal ideation and behavior altogether if they get the prerequisite support and help.

A second form of prevention involves crisis intervention. The objective here is to intervene appropriately when an individual calls for help with suicidal ideation, gesture, or attempt. The focus is on maintaining contact with the potential victim. The contact could be on the telephone or in person in a hospital, mental health clinic, or other location. In all instances, the objective is to give helpful support and feedback. Constructive feedback can help in a number of ways, including (but not limited to):

Bringing calm to the situation.
Minimizing loneliness and alienation.
Reducing the tunnel vision that many suicidal people have in this state.
Combating hopelessness.
Giving empathy.
Offering practical options and choices.
Making referrals to other professionals.
Initiating an involuntary or voluntary psychiatric hospitalization.

Follow-up treatments can be crucial in preventing future attempts. Even with treatments, there is an increased risk, as those who have a previous attempt are at a five times greater risk to die by suicide (Stolberg, Clark, and Bongar 2002).

Some successful prevention studies have been done with particular high-risk groups. One program placed older men in roles where they are involved with social and interpersonal activities that help others. These activities have been found to help them cope with feelings of isolation and meaninglessness (Maris, Berman, and Silverman 2000). A similar program involved adolescents with suicidal ideation and behavior and/ or mood or substance abuse history (Zhal and Hawton 2004a). Finally, working with adults who had made previous attempts, Brown and colleagues (2005) found that 10 cognitive therapy sessions targeted at suicide prevention reduced subsequent suicide attempts by 50 percent over an 18-month period. The same subjects’ feelings of depression and hopelessness, moreover, were lower than the comparison group (Brown et al. 2005). These are just a few of the studies that have shown clear evidence of how suicide prevention can be used effectively.

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