Few topics trigger more dread to the human experience than death. Discussing death brings up fears of the unknown and loss of personal control- two of the primary components of anxiety. We know that when anxiety arises, avoidance is one of the more predictable coping mechanisms and as such, death as a human condition is largely dealt with by simply avoiding talking about it. In working with patients that are having suicidal ideation, the therapist is best advised to understand that despite a patient’s best judgement to explore their feelings, doing so can trigger debilitating anxiety which challenges the process. Further, frequently discussing suicide without progress in the treatment can begin to cause numbing around the topic, which will be discussed later as a potentiator for transitioning from suicidal ideation to actual attempt. We know that humans attempt to understand concepts through personal experience (Experiential Learning, J. Piaget) however; death is not an experience that anyone living knows very much about. Having established the physical and psychological response that death brings up in humans, we can begin to appreciate the confusion, helplessness, and, avoidance that is brought about with suicide for clients and families alike. Patients self-managing suicidal ideation without formal treatment can begin to act impulsively (cutting, risk-taking, drug abuse) and desensitize to pain, leading to greater risk of completed suicide. Therapists, friends and family members are well advised to expect resistance and be ready to confront it by linking clients with appropriate services at the first sign to begin harm-reduction efforts.
The will to live or, self-preservation is innate in all humans. Many physiological processes including the release of adrenaline (to facilitate faster response to a threat) or dopamine (to reward pleasurable and health-promoting behavior) are directly linked to our survival as a species. We may not all be keenly aware of the physiology that supports survival, but we are certainly aware of the feelings that drive it. Despite these powerful forces at play, suicide remains a health epidemic considered by the World Health Organization (WHO) as the “second leading cause of death among 15–29-year-olds”.
Suicide as a concept is universally recognized, in fact, 45 million Americans die by suicide each year, and for every 1 suicide, 25 others have attempted (Centers for Disease Control and Prevention (CDC) Data & Statistics Fatal Injury Report for 2016). This brings the total of first-hand experiences to over one billion per year not accounting for the friends and family members affected. The numbers are staggering and despite the large scale of impact, avoidance of the topic continues. This is true for those experiencing the impulses to end their lives and those coping with a friend or family member who succumbed to their plans or continues to struggle with them.
A suicide plan, age, gender and access to weapons have long been considered high risk factors. Impulsivity needs to be considered just as fundamentally a predictor of suicidal behavior but not necessarily for the direct impact of impulsivity itself. Impulsivity has been studied and in fact “may actually be a more significant indicator of suicide attempt than the presence of a specific suicide plan” (Bryan CJ, Rudd MD. Advances in the assessment of suicide risk). While anecdotal experience might lead us to believe that impulsive personality traits are generally strong predictors for suicide attempt, the literature indicates an interesting rationale that is less obvious. To understand the role of impulsivity in suicide, we must take into account the process of transition from suicidal thoughts to suicide attempt. Two predominant barriers to suicide attempt are its inherent provocative nature and fear of pain. In other words, a person forming a suicide plan assumes that they will have to endure some level of pain, which prevents the transition from plan to attempt.
Humans have strong reactions to learning of a loved one’s suicide attempt that range from anger to alienation. The person transitioning from planning to attempting suicide is oftentimes feeling isolated and may fear that a failed attempt would bring about further isolation. In my work as a psychotherapist, fear of abandonment and being deemed as a misfit in society are oftentimes the rationale provided for not attempting. The transition from planning to attempting is more likely in those who are desensitized to pain which can serve as a barrier to taking action on a suicide plan (Anestis MD, Soberay KA, Gutierrez PM, et al. Reconsidering the link between impulsivity and suicidal behavior). In assessing data from 70 different studies, Anestis and colleagues found that impulsivity as a personality trait was more likely to increase a person’s exposure to “painful and provocative events”. Those who have had more exposure to pain or have participated in reckless behavior are also relatively less sensitive to the experience of pain and therefore, less likely to have pain be a deterrent to attempt suicide.
In fact, the CDC reports “a prior history of suicide attempt is considered one of the most robust predictors of eventually completed suicide” www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2013-a.pdf.)
The American Foundation for Suicide Prevention (AFSP) hosts various walking and cycling events in multiple cities each year entitled “Out of The Darkness”. As a participant, I have found the experience to be both deeply rewarding and educational. Considering the tendency to push suicide into “the darkness” out of fear and avoidance, the message of these events and others like it can literally save lives. If you know someone battling with depression, exhibiting impulsive behavior, stockpiling weapons or medications or have talked about ending their lives, your willingness to talk about it can be the difference between life and death. You can offer to source a mental health professional who can assess for risk and determine next steps. Another option for those unwilling to try therapy and do not have an active suicide plan is the National Suicide Prevention Lifeline- (800) 273-8255. Teens might prefer to use the Crisis Textline by texting 741741 from anywhere in The United States. Finally, if you believe someone is in imminent danger, call 911 or urge the patient to accompany you to the nearest emergency room.
Pablo Idez has served the Long Island, New York community over nearly 20 years with expertise in the treatment of Anxiety, Panic Disorder and Marital Counseling. He can be reached at (347)772-8373. For more information, visit www.lipsychotherapy.com