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Suicide-UnderstandingAndResponding

Ultimately, what people want is to know how to respond to loved ones, colleagues, and community who are potentially suicidal in a way that helps them to recognize their value and allows them to make the decision to continue living.  Suicide: Understanding and Responding seeks to create a guide for understanding something that is largely not understandable and responding in ways that reduce the probability of a suicide attempt.

Positive Alternatives

Edward Shneidman in The Suicidal Mind said that “only” was the four-letter word of suicide – as in people believe that suicide is the only option.  Another way to think about the problem is that the positive alternatives to suicide have lost their credence.  Even if they’re able to see that there are options, they believe these options aren’t viable.  Maybe they perceive them as too difficult or too improbable.  In any case, the alternatives lose their salience.

Another problem with decision making and suicide is that people don’t really do rational decision making, as acknowledged by Gary Klein in Sources of Power and Irving Janis in Decision Making.  Instead, we evaluate alternatives until we believe we’ve reached a solution that’s good enough.  Barry Swartz in The Paradox of Choice explains that this is “satisficing” – and it’s often the best way to make decisions for future happiness.  This is obviously not the case with suicide, since there is then no future in which to be happy.

With satisficing, we make sequential evaluation of alternatives until we discover one that we believe is “good enough.”  If the limitations of suicide are sufficiently obscured from consciousness, it’s possible that suicide is perceived to be a valid alternative.  Perhaps this is one of the reasons why it’s important to restrict means of suicide from those who might consider it a valid option.  If you can delay the ability to act for a short time, it’s possible that the suicidal individual will decide that it wasn’t such a great option after all.

They may discover that the pain (physical or psychache) they are feeling is temporary, contextually dependent, and isn’t about them.  In this discovery, they realize that there are other options to end their pain than suicide.  In fact, the solution may just be to be patient.

Helping

One of the challenges in helping others, whether medically or psychologically, is to help at the right time, the right way, and in the right amount.  Many have explained that you shouldn’t do for someone the things that they can do themselves but should do those things they need but are not able to do themselves.  This simple framework allows for decisions based on how they’ll help the other person without enabling them.

There are two embedded challenges.  The first is understanding what they need.  How can you determine what someone needs in a general sense?  The answer may be that subjective experience leads to these decisions.  Of course, that’s not very repeatable.

The second challenge is in the form of what the other person can do for themselves.  Sometimes it takes pushing for people to enter into conflict or exercise in ways that are uncomfortable.  It’s not that people can’t do these things, it’s that they don’t naturally want to do these things, and as a result, they should be nudged or even pushed into doing what they can.  Unfortunately, this is generally uncomfortable for both parties.

Keen Why

Suicide, from the point of view of those left behind, is often a senseless act.  Though the person dying by suicide may have had their reasons and reasoning, this is often not available to the survivors.  The result is confusion on the part of survivors as they try to discover why their loved one could have possibly done such a thing.  Shneidman explains that there is never such a thing as a needless suicide.  In the mind of the suicide, there was a keen need that was withheld.

When assessing the risk of suicide, it’s important to consider what it is that people are missing in terms of their needs.  There are many answers to what people need that they don’t seem to get.  The key is understanding which of those things are the most important to the person, so that they can be given strategies to get what they need.

Four Factors

There are four psychodynamic factors that seem to have an impact on suicide:

  • Acute Perturbation – General upset
  • Heightened Inimicality – Hostility, particularly self-hostility
  • Sudden Cognitive Construction – A failure to recognize alternatives
  • Cessation – The idea that there will be an end to the pain, suffering, or struggle

The perturbation may be the intensification of the ambivalence towards death and suicide.  Specifically, it can be that the considerations for death that had been previously repressed may be coming more to the surface.  (See The Worm at the Core for how we suppress thoughts of death.)  Inimicality might also be described as thwarted or frustrated needs.

Intent

Intent is at the heart of whether something would be considered a suicide or not – and intent is hard to infer when the person isn’t available for questioning.  Intent ranges from the completely intended to predicable outcome and eventually arrives at completely unintended.  At the completely intended end, there are some indicators of that intent,  including a suicide note.  However, the low rate at which these notes are left behind (see The Suicidal Mind) makes it a poor indicator of intent.  Techniques like the psychological autopsy are retrospective reviews of artifacts and interviews with those whom the suicide interacted with and can often convey a sense of intent, but they too are difficult to get precision from, and their cost makes them prohibitive in most cases.

Some of the most difficult situations to infer intent from are those situations where the death appears to be an accident but may have been something different.  Consider the single-car auto accident where the car impacts a tree, an embankment, or hurtles off a cliff.  Who is to say whether the driver lost control, consciousness, or their will to live?  Undoubtedly, some deaths ruled as accidents are in fact suicides disguised as accidents.  In many of these cases, we’ll never know what the true cause is.

Some situations, like death through cancer or through freak acts of nature are safe from the possibility of intent because of their unpredictability.  It’s good that there need not be any serious consideration given to intent yet sorrowful for those who lost a loved one.

Relieve the Pain

There’s no singular approach to working with suicidal patients and friends that ensures they will disavow the idea of suicide.  It’s true that if someone really wants to die by suicide, they’ll eventually accomplish it.  However, conversely, if you’re able to reduce the pain just a little, you may be able to restore hope that their pain and problems will end and therefore life may be worth living.  As prediction machines, we’re quick as humans to project ourselves into the future when the small reductions in pain would continue until there’s no pain left.

Hope itself is an amazing thing, and Rick Snyder explains in The Psychology of Hope that it’s two pieces: waypower (knowing how) and willpower (willingness to try).  Often, the pain will drive a willingness to try, but without any sense for how to escape the current pain, they may be stuck and try nothing.  (See The Hope Circuit for more on learned helplessness.)

Bankruptcy

Suicide is, in essence, declaring bankruptcy on life.  There’s a sense that it will never be possible to be happy and therefore suicide is the only option left.  More than declaring bankruptcy in the present, the survivors can often interpret the suicide as in some way invalidating their memories of the person.  The memories of happiness and the joyful times shared seem as if they may be illusionary – as if, somehow, they weren’t enough to prevent the suicide.

This perspective is certainly understandable, but it simultaneously fails to recognize the cognitive constriction that face those who die by suicide.  It’s probably true that the people who die by suicide couldn’t recall the happy times that they had with the survivors.

Not Today

One of the bits of wisdom in 12-step programs is the decision to live life one day at a time.  You don’t have to make a decision to not suicide forever – it just has to be for today.  Related to this is that, for suicide, you don’t need to suicide today – it can be deferred.  Strangely, knowing that it’s a decision that never will expire as an option makes it less desirable.  (See Influence and Pre-Suasion for more on how this functions.)

Losing Your Mind or Death

What if you had to choose between losing your mind or death?  Which would you choose?  It’s an odd question, since both bring an end to consciousness, but it’s one that, strangely, suicidal people consider.  Some feel as if they’re slowly losing their mind.  They can feel as if crazy is creeping up on them, and they don’t know how long they’ll be able to hold out.  Then they’re left with an impossible choice.

Obviously, losing one’s mind doesn’t exactly work like this unless there’s an underlying physical cause, but at the same time, it’s a real fear that many face in fleeting moments or as a more serious consideration.  Maybe sometimes the solution to preventing a suicide is helping people understand that they’re not going crazy – no matter how much it may seem like that is the case.

Offspring

One of the factors that is sociologically associated with lower suicide rates is marriage.  Consistently, those who are married have a lower risk for suicide.  Many hypotheses for this have been put forth, including the closeness of the relationship, the time-to-discovery for an attempt, and others.  One of the more interesting considerations is sense that the desire to protect one’s offspring and relatives may remain even if it’s been subdued in the protection of oneself.  It appears that people will avoid suicide if they know that others are depending on them.  This may be the source of the marital protective force that’s been seen in the data.

Steven Pinker in The Blank Slate, Jonathan Haidt in The Righteous Mind, and Robert Axelrod in The Evolution of Cooperation all hint at an odd bit of genetic programming that allows us to sacrifice ourselves without violating Darwin’s evolution and survival of the fittest proposal.  The short version is that by saving our children, we’re ensuring the survival of our genes even if in doing so we ensure our own death.  This behavior extends to “like-groups” – presumably cousins and other relatives – who carry some percentage of genes that are the same as ours.  Obviously, genes can’t make you too willing to give your life, or there’d be no one to benefit from the altruistic act.

It seems like the complex web of protecting our genes may be able to be subverted for ourselves without subverting other aspects of the gene protection.  That may be at the heart of why people who are recovering for addiction are encouraged to serve others.  It may be the path back to restoring the protective forces for ourselves.

Loneliness

One of the factors that can drive people towards suicide as an option is the feeling of loneliness.  Loneliness the book makes the point that being alone and loneliness are different.  Loneliness is a feeling that can occur while you’re alone or while you’re in a room filled with people.  In fact, Sherry Turkle in Alone Together puts forth the idea that while we’re objectively less “alone” because of the connectivity that technology brings, we’re equally not connecting in ways that fulfill our needs – and therefore may feel more loneliness.

If you want to reduce the loneliness of someone – whether they’re considering suicide or not – the solution is simply to try to understand them, their perspective, and their situation.  When you feel like someone understands you, loneliness must take a back seat to the feelings of being understood.

Nothing Left to Lose

It’s a problem when someone with nothing left to lose, like a death row felon, is free.  The rules of morality and social convention have no hold over the person who no longer has anything to lose.  (See How Good People Make Tough Choices for more.)  Suicidal individuals no longer fear death and therefore must be approached cautiously.  (See The Worm at the Core for more about the fear of death.) There’s no telling what they might do.

Murder-Suicide or Suicide-Murder

Though murder-suicides are rare, they happen.  An interesting challenge comes from whether the person first considers murder and then acquiesces to suicide, or if they decide that they’re going to die by suicide and they need to take one or more people with them.  There’s obviously no one, simple answer.  However, it seems that though we call it murder-suicide because of the (required) order of events, perhaps it would be more accurate to describe it as suicide-murder if we consider the thinking process that happens.

If you’ve already decided on suicide, you can extract revenge on those who have tormented you through murder without concern for the consequences.  They’re not going to kill a dead person, nor are they going to imprison a corpse.

Worthlessness

Joiner in Why People Die by Suicide frames it in terms of burdensomeness.  That is, people feel as if they’re a burden to others and they’d be better off dead.  Here, the word goes less far and describes feelings of worthlessness leading to a desire for suicide.  Worthless is the sense that you can’t generate value to others or humanity – or perhaps not enough to offset the costs that you bring to the world.  Feelings of worthlessness are often a natural consequence of failure.

For some, they’ve picked up some sense that the love and protection that they get from others is performance-based.  That is, that they will only receive love and support from others as long as they perform.  Because of messages they’ve received from their family of origin (mother, father, siblings, etc.) they’ve come to believe that their worth to others is in what they can do for them.  Without any sense of inherent worth, a failure generates feelings of worthlessness and the fear that they’ll never be loved.

The degree to which this is truth or simply perception isn’t relevant.  What’s important is that the individual has developed a perception that they can’t fail if they want to be loved, cared for, and supported.

On Their Terms

At some level, those who call to a suicide help line are asking for help, and while the saying goes, “beggars can’t be choosers,” it doesn’t apply here.  They want to get help – but only the help they want and in the way that they want it.  In a suicidal person’s constricted vision, they may not be able to accept the communication approach and pattern used by the person on the other end of the line.  As a result, the person answering the phone line may need to deviate a fair amount from the official protocol to first form a connection with the caller and from that start to understand then persuade them.  (This is consistent with Motivational Interviewing.)

This extends into a general sense that if they can’t get life on their terms, then they don’t want it on any terms.  In other words, if they don’t get what they want, they’re taking their ball and going home.  In this case, that means suicide.  It’s an extreme sense of feeling as if you’re not heard and valued as you are and as a result, you’re not longer willing – or able – to bend, adapt, and change for the chance to be heard.

Self-Soothing

One of the learnings from having a child is that sometimes the right answer is to let the child cry.  It sounds cruel and heartless, and it’s clearly not the only strategy that can be used.  Sometimes, it’s important for a parent to establish that the child is okay and safe.  It’s even important to demonstrate warmth, compassion, and caring, so that the child can establish a perspective that the world is helpful not harmful.  However, there are times when the right answer is to allow children to cry.

The experience of resolving a sense of pain ourselves is critical to our development.  We can’t avoid all pain because to do so robs of us our experience with resolving it.  Chicks need to escape their shell on their own and sea turtle babies need to find their way to the sea.  (See The Psychology of Recognizing and Rewarding Children.)  Without a sense of efficacy in self-soothing and resolving problems – some self-efficacy – it becomes impossible for someone to face an adversity and believe that they can overcome it themselves.

Calm the Panic

If someone can’t calm the panic that they feel in themselves about their situation and the resulting psychological pain, then the people around them must find ways to help them calm the panic.  While not totally self-reliant, the ability of others to bring forth, encourage, and enable the capacity to shut down the pain that is being felt is perhaps the most important thing that one human can do for another.

Pain itself is, as was said above, a necessary teacher.  However, as Nassim Taleb explains in Antifragile, we need the right kinds of challenges at the right times and in the right amounts to be able to grow.  When we teach people to self-soothe or calm the panic, we’re enabling them to regulate the amount of pain they feel from the challenges facing them so that they can bring them into a range that encourages growth rather than feeling oppressive and crushing.

Overstrivers

One of the psychic pains that can drive suicide is the idea that you’re not “enough.”  That is, you’re not good enough to be loved and accepted as a human being.  While we all face the challenge of feeling like we’re enough at times, some of us are locked into a more persistent struggle.  The irony of the situation is that those people who are larger than life, who are more than enough by other people’s standards, are sometimes not enough in their own eyes.

Many people who are high performers became high performers because of a sense of drive.  They wanted to be more than they were.  While in the context of a growth mindset, this is good, it can be that the driver itself may cause a different kind of problem.  (See Carol Dweck’s work Mindset for more on a growth mindset and its benefits.)  What may be driving it isn’t necessarily a sense of acceptance of the current state and a striving for more but instead a longing to be something more than today so that they’re finally enough.

Some situations exacerbate these feelings and may even lead to suicidal ideation.  The overstrivers believe that that they’re not good enough – and can never be good enough – so the world is better off without them.  This isn’t true, but to them it feels true.

Somebody to be Loved By

There’s an innate need in people to be understood and even loved.  We long for acceptance in ways that convey that our existence matters.  We’re created as social beings having evolved with the primary advantage being our ability to have a theory of mind.  (See The Righteous Mind and Mindreading for more.)  When deprived of love, we find ourselves seeking it out in ways that may be self-destructive or ultimately harmful but that quench the immediate, burning need.

Sometimes, the suicidal individual can’t find a way to feel loved by others.  Whether they are or are not is immaterial.  Their capacity to accept the love that others are pouring into them is somehow blocked or thwarted.  To help a person who is considering suicide as an option, sometimes all that’s necessary is to be present and allow them to recognize that other people do care and that they love them.

Grass Must Not Be Greener

One of the challenges of the early Christian church was the attractiveness of heaven.  If today’s life is hard and the afterlife is all good, why not end the life part today and move on to the afterlife part immediately?  Unfortunately, more than a few people came to this realization, and suicide became a problem for the church, which was trying to increase its numbers.  (See A Handbook for the Study of Suicide.)  That’s why the church made suicide a sin.  By making suicide a sin, they could simultaneously maintain the psychic benefits of a glorious afterlife and remove suicide from the list of methods that could get you there.

Whenever we’re looking at ways to shape the decisions of others, the ultimate answer is easy.  If you can make the option you don’t want them to pick always undesirable, then few will pick it.  (It’s not all because some people have a rebellious spirit.)

Support Withdraw

A disproportionate number of suicides happen while therapists are on vacation.  This creates a struggle for therapists who need to find ways to recharge themselves and simultaneously don’t want to put their patients at greater risk.  There are solutions that therapists can take advantage of by having others that their patients can talk to in their absence.  However, the greater observation is the fact that the patients react to the perceived withdrawal of support.

It’s not that they believe that the therapist will be gone for good necessarily (though that is a possible thought).  It’s simply that they don’t know how to cope with today given the perceived withdrawal of support.  It’s like they’re literally leaning on the therapist when they suddenly disappear.

Interfering with Freedoms

On the opposite end of the spectrum are those situations where it’s believed to be necessary to interfere with the freedoms of suicidal individuals so that they are deprived of the chance to take their own lives.  There are, undoubtedly, situations where this is the right answer.  However, there are also times when depriving people of their liberties to save their lives may be precisely the wrong thing.

Suicide is driven, at least in part, through a feeling of helplessness and the involuntary loss of freedom encourages that feeling.  You necessarily reduce someone’s internal sense of personal agency when you restrict their freedom.  Thus, the short-term protection can come at a long-term cost.  You cannot hold someone indefinitely.  At some point, you’ll have to return them to their own freedom and sometimes at great peril.

So, it makes sense to involuntarily restrict someone’s freedom if there is no question about their intent to harm themselves, but when there is no clear indication, it may be a bad choice.

Patient Proactive

The ultimate goal of any therapeutic approach should be to empower the individual towards their own life separate from therapy.  It’s not appropriate or effective to keep patients in therapy indefinitely.  That means it’s necessary to continue to enable the patient to solve their own problems and, more specifically, learn to cope with life with progressively less external support.

Therefore, every patient interaction should be structured to enable them to solve their own problems rather than the therapist being seen as the expert to which the patient must always come.  (See A Way of Being and Motivational Interviewing for more.)

Separating Despair and Depression

Despair (hopelessness) is different from depression – and it’s more indicative of a situation that requires immediate care than depression.  While depression is a solid indicator for suicide, it’s less predictive than hopelessness, so it’s important to distinguish between depression and despair – with despair requiring more attention and faster intervention.  Depression, because of the diagnostic criteria, is a more long-term condition.  Despair (lack of hope) covers a person unexpectedly and profoundly.  It’s therefore difficult to detect with much advance warning – and it’s difficult for patients to muster defenses against.  It comes when people least expect it.

When encountering people who are in active despair, we must find ways to help them see that things will change for the better – even if it is difficult for them to see that at the moment.

Acceptance through Presence

Sometimes the things that need to be done are so simple and unremarkable that they’ve overlooked.  Often people believe that no one cares and that no one is listening.  Sometimes the intervention is just being present with people and listening.  By being present and listening you convey acceptance of them as a human being and an interest in who they are.  Sometimes this can help them recognize their own value and personal agency.

Often, the stories of those who have attempted or completed suicide are clear about their feelings that they’re not heard or even more explicit about aborting their plan should so much as a single person give them a hint that they’re not alone in the world – that someone cares and recognizes them as a human being.

Tread Water for Now

Being present is one way of treading water.  While you’re being present and listening, few people will actively attempt suicide.  Instead, they’ll be in the moment with you – and that may be all that’s necessary for the suicidal impulse to subside.

If you can point to the finality of a suicide as a solution and acknowledge that the option will always be available to them, they don’t have to choose it now.  For now, all they have to do is survive today.  They don’t have to solve their long-term happiness and the prevention of future pain.  They just need to make today livable.  (See Stumbling on Happiness for more about our lack of predictive powers for what will make us happy.)

No Control, Lots of Hope

Therapists have relatively little control over patients’ lives.  They may have powerful clinical prowess and amazing techniques, but these all pale in comparison to the other forces in a patients’ lives – the other 160+ hours of their week that they’re not with the therapist.  So, while it’s not possible for therapists to accept complete responsibility for the outcomes of a patient, that isn’t to say that they shouldn’t try to make the situation better.

Just because we don’t have control doesn’t mean that we can’t hope that our degree of influence is enough.  In many cases, it can be that the influence that the therapist has is sufficient to convert a tragedy into a triumph.  There’s no way to know which will be which.

The Liberty and Control Coin

Jonathan Haidt in The Righteous Mind calls one of the foundations of morality the strive towards liberty and away from oppression.  Here, the word used is control – whether it is perceived as oppressive or not.  What we realize is that the more liberty someone has, the less control we have.  Conversely, the more control that we exert over someone else, the less liberty they have.  They’re inseparable because they are opposite sides of the same coin.  This creates challenges when trying to limit access to potentially lethal means for suicide and the need to ensure that the person retains their sense of liberty.

Responsibility and Control

One cannot be responsible for something they don’t control.  That’s a truism that extends beyond the bounds of suicide and is a point of challenge, as we’ve taught parents that they are responsible for their children while fully admitting that parent can’t control their children.  This is particularly true as children get older.

Because parents often feel responsible for their children even if they don’t have control of them, they struggle when children don’t do what the parents expect.  This is particularly true of parents whose children die by suicide.  They have no way of accepting their responsibility for the death of their child – and they shouldn’t.  We collectively need to acknowledge and share that, most of the time, parents are no more responsible for their children’s suicide than a therapist is responsible for the mental illness of a patient.

Both can try to create conditions for better mental health and feelings of love and support, but neither can be responsible.

Things Worse than Suicide

While suicide is a tragedy, we can’t forget that sometimes there are fates worse than death.  Some situations are so laden with pain and suffering that we shouldn’t be so hasty to eliminate suicide as an option.  We show compassion to our animals to euthanize them when they’re in too much pain from which they can’t recover, yet we often are unwilling to allow humans even peaceful deaths due to natural causes.  Instead, we attempt everything we can to extend life – even if the person whose life we’re saving would say it’s not worth living.  Sometimes the best – and most difficult – thing that we can do is to allow someone the grace to decide that suicide is the right answer.  That’s one of the reasons why understanding and responding to suicide is so hard.

There are no clean answers.  No quick fixes.  No magic bullets.  However, there is some wisdom in Suicide: Understanding and Responding.