(Part 2 of an occasional series. See Part 1: “Suicide: A Survivor’s Perspective.”)
When I was in the hospital after my suicide attempt, what helped me more than the medication or the refuge was the psychiatrist who treated me. He listened to me and shared his take on my despair and certainty of hopelessness and failure. His calm empathy and care helped me feel that all might not be lost. I had found that teaching our patients to abandon despair and substitute hope was a powerful addition to the cognitive effects of an antidepressant, and I began to think about that more systematically.
In the week after the attempt, I allowed myself to get angry about several mental health professionals I had worked with previously, who saw me as “bad” rather than “mad.” My anger allowed me to stop feeling like a helpless victim, which was vital since I still had to defend myself at a meeting at my place of employment. However, this hard-earned insight of myself was not so easily shaken when that meeting finally occurred.
After leaving the hospital, I had the great good fortune to find an outpatient psychiatrist about my age who understood me, and combined medication and therapy skillfully so that I felt better and learned more about myself, which has been to my benefit.
On the other hand, I was demoted at work, both in position and income. About a year later, I found my current job. I got divorced—not because of my attempt, although it contributed—and I found my sisters a source of strength, more than I knew they could be. Some friends left, others were found, and life went on. All the while I studied myself and my attempt and came up with ways to understand suicide with an eye towards prevention, and this is what I want to share with you.
There are several reasons why people become suicidal. The primary reason is a loss of their sense of self. Psychologically, they feel an acute loss of things such as prestige, worth, or value. Evolutionarily, these feelings are what would be called proximate mechanisms to ultimate worth (to survive and pass on genes). A further discussion of the evolutionary aspects of suicidality is beyond the scope of this piece, but information is available for the interested reader.
This loss leads to a sense of isolation, which is reinforced by hopelessness that it will change. While the literature suggests that these 2 issues in combination with mental illness is a dangerous triad, it is also possible that the cognitive aspects of a hopeless sense of permanent isolation can lead to depression, which in itself tends to “see” things, cognitively, through the glass of negativity. But let’s look at these first 2 issues a bit more closely.
Hopelessness is such an important feature that Aaron Beck made it a primary feature of his scale1 that is used as a predictor for suicide. The scale evaluates pessimistic attitudes about the future, expectations, and motivation.
Being that we are social animals, social connectivity is essential to our health and well-being. It’s not by accident that a member of a society excluded or threatened with exclusion will do what it can to conform to avoid or remediate ostracism. Ostracism can be associated with a real or perceived loss of 4 critical areas of human interpersonal need: belonging, control, self-esteem, and meaningful existence2. Loss of one or more of these areas can lead to a feeling of being useless, a burden, unwanted, and other negative self-assessments—as happened to me. In cultures or individuals where shame and guilt play a role in self-assessment, loss of face from omissions or commissions can be just as devastating. In literature, a loss of honor is so critical that duels have been fought to restore or regain it. People died or went to war to die to do so with honor, and in this way death was a means of regaining a loss of perceived social connectivity.
There is a third point that defines this plane of suicidality—mental illness. There has been a good deal of study in these areas, and cluster B personality disorders3 and substance abuse4 are surprisingly more common than depression in suicidality.
I don’t have a substance use disorder, and I don’t think I have a cluster B personality disorder. My primary risk factor was the depression, the loss of face with shame and guilt, and a sense of hopelessness that it would ever change. And so I proceeded to try to end it myself. My psychiatrist patiently and caringly pointed out the errors of my assumptions—what else things could mean, as a kind of cognitive logotherapy. That worked for me, though over time I began to realize that there is no one-size-fits-all approach to suicidality. I did find a number of commonalities, however, which I will begin to share in the next blog piece.
2. Wesselmann ED, Nairne JS, Williams KD. An evolutionary social psychological approach to studying the effects of ostracism. Journal of Social, Evolutionary, and Cultural Psychology. 2012;6(3):309-328.
4. Ilgen MA, Burnette ML, Conner KR, Czyz E, Murray R, Chermack S. The association between violence and lifetime suicidal thoughts and behaviors in individuals treated for substance use disorders. Addictive Behaviors. 2010;35(2):111-115.
Douglas A. Landy, MD, graduated Hahnemann University School of Medicine (now part of Drexel University) in 1983. He is a board-certified psychiatrist, and practices primarily in an inpatient setting with additional work in the Emergency Room and nursing home consultations. He has had experience in sleep medicine and forensic psychiatry, and has an interest in traumatic brain injury. He lives in Rochester, New York.