Understanding Suicide Can Help Prevent It

Spotlight: Mark Schechter MD

Chair of Psychiatry, Salem Hospital

To better understand suicide and how to mitigate it, we turned to Dr. Schechter, who is regarded as a suicide expert across MGB and in the field.

   Why is there Stigma Associated with Suicide?

Dr. Schechter explains that stigma related to mental health and substance use disorders (SUDs), often associated with suicide, is intertwined with, and exacerbated by perceptions about suicide.
When we don’t fully understand something, we often perceive it as different or bad, and in the case of suicide, repulsive, selfish, and weak.

Last year the EAP posted an article about stigma and mental health. Those with mental health and/or SUDs, may face disparate treatment in and outside of the medical system. For example, some mistakenly believe that SUDs stem from personal choice, rather than from an illness with biological and psychosocial components.

When you add suicide to the mix, there are even more significant stigma-related hurdles.
It’s natural to respond to discomfort with avoidance or judgment, but how can we combat these tendencies as individuals or healthcare delivery systems and help those who are struggling?

Separate Myth from Fact 

Dr. Schechter was the expert on this MGB video about Suicide Facts. Below we address some common questions and misconceptions about suicide.

Why do people attempt suicide?

• For most people, attempted or completed suicide is not about death or wanting to die but rather about feeling unbearably bad
• Researchers refer to “entrapment,” which involves a sense of total desperation and the perception that there’s no way out and no end in sight
• It can feel like there is no beginning, middle, and end to the suffering, and that it is never going to end, even though it may in fact be transient
• Picture a fire getting closer and closer, with an open window as the only way out

Is suicide only about depression or mental health?

• No, although depression or other mental illness may predispose some to suicide, these are not the only precipitants
• Some individuals experience a sudden or unexpected life event (relationship, legal or job issue), that is experienced as so catastrophic that it triggers an extreme loss of hope, shame, and entrapment
  – The usual self-esteem supports are compromised, and it feels like the structure beneath this person is caving in

Are suicidal feelings chronic or permanent?

• Not typically
• Despite how someone feels (an intense belief of “no way out”) when they experience suicidal thoughts, these feelings are usually temporary
• If we can help someone stay safe, including providing support and taking whatever steps are needed to help them get through this period of feeling suicidal, more often than not it passes eventually
• There is a suicidal myth that if you stop someone from killing themselves with one method, they will probably just choose another. This is FALSE!  Making the environment safer, such as by removing a gun from the home, limiting access to toxic medications, or putting up suicide barriers on bridges, does help to save lives.
• Another suicidal myth is that if someone is suicidal they probably will find a way to kill themselves eventually. This is also FALSE!  Studies have found that approximately 90% of people who have survived even the most near lethal suicide attempt do not go on to kill themselves

Are all suicides preventable?

• Suicide is often preventable, but not always
• We can reach out to a troubled individual, connect them with help, treat depression, substance use disorders and other mental illnesses, and even temporarily provide hospitalization if necessary for those who are feeling suicidal -all of the steps can save lives
• However, even the most highly trained therapist or psychiatrist cannot predict every suicide, and what cannot be predicted cannot be prevented
• Suicide is a tragedy, and if we know that someone is feeling suicidal there is much we can do to try to help, but every suicide is not someone else’s fault. This is important for loved ones, friends, and professionals to know
• We should not hold back on reaching out to people who are struggling because of discomfort, fear of doing something “wrong,” or somehow making things worse
• We should all work on feeling comfortable asking questions about how our friends and loved ones are feeling. If someone is clearly depressed and/or suffering, we should ask them about how they are feeling, and even about whether it has ever gotten to the point of thinking about harming themselves or ending their life

   How to Help or Get Help

Many people avoid offering help, even when they suspect that someone may be struggling or presents a safety risk. This is understandable, especially if they are not familiar with how to intervene or approach someone. Helping someone in these cases is no different than offering assistance to someone who has another medical condition, such as heart disease or cancer. Dr. Schechter stresses that with knowledge and practice, you will achieve greater comfort and feel less awkward. Below is some guidance:

Learn about common risk factors

• Mental Health – depression, anxiety, bi-polar disorder, personality disorders
• Substance use disorders
• A devastating health issue
• Sudden life change -marriage, job, financial
• Previous suicide attempt
• Family history of suicide

Know the Warning Signs

The American Foundation for Suicide Prevention (AFSP) offers a full list of warning signs. Here are some to watch out for:

• Talks about:
  – Feeling hopeless
  – Having no reason to live
  – Being a burden to others
  – Feeling trapped
  – Unbearable pain
• Behavior:
  – Increased use of alcohol or drugs
  – Withdrawing from activities
  – Isolating from family and friends
  – Sleeping too much or too little
  – Aggression
  – Fatigue
• Mood:
  – Depression
  – Anxiety
  –  Loss of interest
  – Irritability
  – Humiliation/shame
  – Agitation/anger
  – Relief/sudden Improvement

Don’t hold yourself back because you fear the consequences if you get involved and it’s not successful

• What people need when they are struggling is human connection
• When people feel suicidal, they feel alone
• When someone reaches out, they feel less alone and it less likely they will feel that the only choice is suicide
• In general, reaching out is interpreted as caring rather than being intrusive

Does asking about suicide make people more likely to hurt themselves?

No. It makes a suicide LESS LIKELY because it is often experienced as a relief and opens up a pathway to getting help

What can you say when you are concerned about someone?

As a family member or friend

• Anything that starts and keeps the lines of communication open
• “As your friend, I can’t help but notice that you have been struggling lately. How have you been feeling?”
• “I’ve been concerned about you”
• “I‘ve just been wondering because you seem so hopeless”
• “Has it ever gotten to the point where life is not worth living?”

As a clinician

• Move from general to specific
• Ask about thoughts:
  – “Did it ever get specific?”
  – “When was the last time that happened?”
  – “Have you ever come close or done anything to hurt yourself?”
  – “Taken meds or close to it?”
• “Do you have access to a way to do this?”
  –  “Guns or pills?”

Understand what kind of help is needed

•  If it gets to intent and plan, then seek immediate help from a professional or in the Emergency Department
• If thoughts are less specific or immediate, then find a therapist

If you are struggling with thoughts of suicide

• You are not alone
• There is help at work, home or in the community
• You probably judge yourself more than others judge you
• People who care about you want to know that you need help
  – They will feel honored that you would trust them enough to reach out
  – They are likely to feel relieved, rather than burdened
  – They prefer to help, instead of coping with guilt or regret if you harm yourself
• People who love us don’t care about what society thinks
• You will find new ways to fill the void you feel right now
• It won’t always feel this way. It’s temporary

If someone has lost a loved one to suicide 

• When people have lost someone, they need compassion
• Don’t be afraid to approach them or say something
• What you say will not make it all better or worse; you don’t have that much power
• Human connection is usually helpful and appreciated
• Be willing to overcome your own discomfort and reach out