Suicide is in the news these days. Military suicides are off the charts. Bullied teens are in the news this week along with a nationally known pastor’s son. Suicide is an important topic! We need to talk about why, for some, suicidal thoughts (fairly common across the population) become plans and actions. We need to explore what helps reduce suicide as a desirable option. We need to talk about how to care for those left after the horror of suicide.
But here’s a question: Have you ever heard a sermon or a Sunday School lesson on the topic of suicide?
I can’t say that I have.
This week I was sent a survey about graduate theological education and suicide assessment and prevention training. Our counseling students get a bit of education on suicide assessment in a couple different courses. They read an article or two on the topic. Not really enough but our challenge is to know what to cut in order to fit more suicide material into the program.
The result is that most learn in the middle of a crisis. Not really the best plan.
If you are looking for materials, let me point you to a few:
1. National Action Alliance for Suicide Prevention.
2. CCEF. Use their search tool to find their resources in this packed website (some free, some cost a bit). Jeff Black’s article on understanding suicide is helpful. There are several blogs that are free.
3. Al Hsu’s book, “Grieving a Suicide.”
4. American Foundation For Suicide Prevention.
If you google suicide and christian, you will notice that the vast majority of material is about whether or not suicided individuals can still go to heaven. While this is an important question, it appears that we have spent more time on this topic than on that of prevention and intervention.
Maybe we can do a bit better than this? Let’s commit to talking about it rather than being afraid.
Here’s an interesting finding. A research team compared the top ten lithium-enriched regions of Austria (areas with naturally occurring lithium in the water) to the top ten lithium depleted regions of the same country. Those regions with greater naturally occurring lithium levels had statistically fewer suicides than those regions that had low naturally occurring lithium. The research does not prove a causal link between suicide levels and lithium levels in the water. It could be that there are better treatments or facilities in those regions. But, it does give you pause.
Lithium is, you may recall, a salt which is used to treat affective disorders like bipolar disorder. For many years doctors considered it the gold standard treatment. Many still do even though compounds like Wellbutrin and some anti-psychotics are also used to treat bipolar disorder.
While NO ONE is considering prophylactic use of Lithium (like we do now with fluoride in the water), this research does beg the question: at what point would preventative Lithium be appropriate? In other words, how many lives would need to be saved to make it something that we would want to give to everyone? Or, should we only give it to those who are deemed at-risk?
Assume for a moment that the cause for the lower suicide rate is the presence of Lithium in the water. Further assume that the research data is accurate in finding that the suicide rate in the Lithium enriched areas is 11:100,000 while the suicide rate in the depleted area is 16:100,000. I doubt that anyone would promote public distribution in order to save 5:100,000 but I do wonder what the number would need to be before anyone would recommend blanket addition to the water supply.
Counselors need to keep regular watch over the insomnia of their clients. Untreated or unresolved insomnia predicts poor recovery and lesser benefit from therapy. It ought not be treated as a secondary problem. But a recent abstract sent to me via email suggests that insomnia may also be a significant factor in suicidal ideation and action. Some researchers at Wake Forest followed 60 adults with both insomnia and major depression for 9 weeks. All received antidepressants but some received a sleep aid as well. Both were assessed by using the Hamilton Depression Scale and an insomnia severity scale.
Their findings suggest that insomnia is a factor in suicidal ideation independent of depression or lack of pleasure. Insomnia leads to more intense suicidal thoughts. Thus, counselors ought to redouble their efforts to ask about insomnia, to track it and to especially follow-up with questions about suicidal ideation or plans when complaints of insomnia increase.
Interested readers may find the abstract of the research here.
Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…
Here are some of the mistakes (in no particular order):
- Superficial reassurance (“you have so much to live for”
- Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
- Professionalism (cold and distant, possibly seen as uncaring in assessment)
- Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
- Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
- Passivity; failure to be empathic (25% took this stance)
- Insufficient directness. No contract to not harm, no next steps
- Overbearing advice. Counselee needs to be involved in the planning for safety
- Stereotyping response (“She’s just a borderline!”)
- Defensiveness (usually about whether hospitalization is necessary)
Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.
Sunday’s lead story in the Philadelphia Inquirer unfolds the tragic story of two high school girls who committed suicide by stepping in front of a speeding train last winter. The death of a child is always a tragedy. But death by suicide exponentially multiplies the pain. Could anyone see it coming? Could they have prevented it?
The story in the paper details the texts and social networking trail of tears leading up to their final actions. If this event happened when I was a child, the parents might have been left with a note or a journal to pour over looking for clues. But, in this case, there are texts and posts over a long span of time. Even worse, the girls made a number of final texts just before their deaths. It appears that loved ones searched frantically for them while “watching” cyberspace during their final act. I can only imagine that this “real time” aspect multiplies the trauma for the family.
Can we learn anything from this? Yes, I think so.
- Pay attention to your child’s (or friend’s) social networking and texts. Clues to their state of mind may well be evident.
- Act on concerns; take stock of their actions and attitudes. Per this case, it appears there were efforts to help them. Probably not enough. But let us not judge the family here. It is far too easy to become complacent. A child has strong feelings that they express over a period of time, thus making suicidal expressions normal. After the fact the signs seem so obvious. During the stress, it is hard to discern how bad it really is.
- Compounding suffering requires additional interventions, whether the child wants it or not. One girl’s father committed suicide, parents’ divorced requiring a move and change of school, a boyfriend was killed by a car. The more these kinds of experiences happen, the more attention the child needs by mentor or mental health workers.
- Even good schools won’t likely pick up on problems. Don’t assume school counselors have enough time to respond. It is not that they are incapable but the sheer number of students to follow makes their capacities limited.
Know that some people commit suicide and no one could have predicted it. Be wary of judging family members. They will live with enough guilt on their own. And yet, look for this recipe of pain and perceptions (summary of Jeff Black’s booklet):
- Strong powerful experiences of pain
- Perception that the they cannot tolerate the pain
- Hopelessness and inability to see alternatives other than relief via suicide
Other risk factors to consider: previous attempt? Suicidal ideation/plan? Hospitalization (even for non-psychiatric reasons)? Access to lethal means? Depressive anger coupled with impulsive history. These factors aren’t that helpful by themselves but looking over the total may provide *some* clues.
This week we spend time in our psychopathology class considering the biblical literature regarding causes and effects of suffering. We do this because any course on problems in living must help students first understand the depths and complexities of suffering. Otherwise our study of problems will be rather sterile if we can’t deeply feel the pain. Some painful suffering leads to suicidal thoughts and that is where I want us to go today…
The January 2008 issue of American Psychologist (63:1) considers “Cultural Considerations in Adolescent Suicide: Prevention and Psychosocial Treatment.” Suicide is most likely to be considered by those who feel intolerable emotional pain and perceive no way out of that pain–other than death.
Not surprisingly, there are significant racial and cultural differences in rates of suicide across ethnicities (Native Americans have the highest, African Americans have the lowest in both genders). Culture plays a big role in each ethnicity’s perception of suicide behaviors, choice of help-seeking behaviors, and what might help prevent suicidality. A couple of examples from the article:
African American male emphasis on coolness may protect them from giving into suicide at first but may increase the likelihood of individuals trying “to provoke others into killing them as an indirect method of suicide” (p. 19).
High rates of suicide among Native American youth, “occur in the context of high rates of other risk-taking and potentially life-endangering behaviors” (p. 21).
The authors look at issues including acculturative stress, enculturation, different manifestations of distress, and cultural distrust in trying to treat and prevent suicide across various cultures. They contend that few culturally sensitive prevention and treatment models exist at this point. In other words, we cannot assume that generic methods of encouraging youth to seek help when distressed will be helpful. In other words, if given the chance, we must make sure we try to understand their (not our) perception of their situation, their pain, their family/community, and possible avenues of hope. Further, we must try to understand how they may perceive us (the counselor) due to our own ethnicity and position of power. We must counter our tendency to allow fear to draw us into a position where we start exhorting our teen clients–thereby shutting them down.