The recent high-profile suicides of Kate Spade and Anthony Bourdain, coupled with newly released data from the CDC on the general rise in suicide rates, have me returning to the lessons I learned running a treatment study for individuals who had recently attempted suicide back in the early 2000s.
A.T. Beck, the father of cognitive therapy, had a longstanding interest in suicidal behavior, and shortly after he hired me at the University of Pennsylvania, we received a multi-million-dollar grant from the CDC and NIMH to see if a relatively brief psychotherapy (approximately 10-to-15 sessions) could help reduce suicidal behavior. Being awarded the grant meant that I became project director for what I believe remains the single largest randomized controlled clinical trial designed explicitly to target and reduce suicidal behavior in individuals who had recently attempted suicide.
I am pleased to say that we were successful in cutting the subsequent suicide attempt rate in half, and we reduced a number of related symptoms in the treatment group relative to the controls. [For a commentary about my concerns about how the study was primarily written up, and what it means for the relationship between science and practice in psychology and psychotherapy, see here, pages 200-205.]
Here are the top five lessons I learned about the nature of suicidal behavior:
1. There is a logic to suicidal behavior.
People are often mystified by suicides, especially when individuals appear to have had lots to live for, as seemed to be the case for Bourdain and Spade. My experience is that when you deeply get to know people therapeutically, you see that in fact, suicide is not some crazy, irrational act. Rather it is an act that is acted upon for what seem like good reasons, at least at the time. The key to understanding how this happens is to realize that people have very different “self-states.” Almost everyone can relate to this to some degree. Think about when you are in a great mood. Now think about when you are in a lousy, miserable mood. One’s self, the world, and the future all look very different depending on one’s mood.
2. Suicidal behavior is usually motivated to escape from a deep “psychache,” which usually stems from an intrapsychic depressive loop.
Psychache was a term created by Edwin Shneidman to describe the deep, unbearable pain that many who engage in suicidal behavior experience. What causes this pain? Usually, an intersection of three things: 1) difficult circumstances resulting in major stress or trauma; 2) a neurotic or sensitive temperament; and 3) an internal "narrator" who hates and attacks the negative feelings. Together, these elements result in a horrible spiral or depressive loop. For example, the person loses their job or a loved one. Then they are flooded with negative feelings that they first try to avoid, because they hate the feelings and are afraid they will be overwhelmed by them, and are embarrassed or ashamed by them (thus hiding them from others). So they try to coax and cajole themselves into doing anything that will allow them to not feel the feelings. But eventually, the feelings press upon their psyches, which is experienced as intolerable. This narration that the feelings are horrible and intolerable only feeds back into the negative feelings, jacking them up and creating a vicious, downward depressive loop into a private hell.
3. There are suicidal “modes” that activate a core “negative triad.”
Although it is not a well-known feature of his cognitive theory, Beck characterized the different self-states I described above in terms of “modes.” A mode was a particular mindset that included goals, perceptual schemas, emotional schemas, and narrative scripts. These could be latent much of the time, and then get activated by a trigger. Many individuals I saw would be “fine,” or at least not suicidal, much of the time. And then a stressor would hit, and the mode would become activated. While in a suicidal mode, they would exhibit what I came to call “negative triad fundamentalism.” The negative triad was Beck’s term for negative thoughts about the self, the world, and the future. What I mean by negative triad fundamentalism is that folks in the suicidal mode would have rigid, absolute negative beliefs in these domains that they would not hold at other times.
4. Suicidal modes result in “blinders”; suicidal people can often only see the pain of the present.
The suicidal mode is an intense, brutal emotional place. When individuals are overloaded by psychache, the only thing that is direct and real is the pain itself. The future is both fuzzy and dark. The only memories they have ready access to are other times they were in the mode, and so that becomes their world in total. Because of this, folks are not good problem solvers and do not think in flexible or adaptive ways when in this place. Rather they are often rigid and absolute in their thinking about the pain, and the only solution that seems clear is to escape by suicide.
5. Isolation, shame, and a public-private split are often present. Not only is the pain itself intolerable, but it is also secondarily experienced as shameful. Compounding the problem is that usually folks who have deep wounds that result in psychache are also lonely and isolated and do not have the kind of deep, safe, intimate relationships that allow these kinds of feelings to be processed. So, feeling shame and isolated to begin with, and terrified about burdening others and being judged as “crazy,” “weak,” or “toxic,” they hide their pain from others. This is compounded by the fact that the core experiential pain is usually, at its root, some form of low relational value — that is, not feeling known and valued by self or important others in a nourishing way. All of this means that many folks who deal with suicidal darkness “split” their private pain from their public, outward appearance, and only feel more isolated or alienated in doing so. This feeling will persist even if, from an objective, external perspective, the individual seems like they are valued.
So there is a logic to be followed. Now, let's turn to the top five lessons I learned about treatment to reduce suicidal behavior.
6. Suicidal behavior can be targeted directly.
In direct contrast to former NIMH director Thomas Insel’s 2013 call to think about psychiatric problems as brain diseases, we considered suicidal behavior as a mental behavior that was maladaptive. That is, although it was obviously deeply problematic, there was, in fact, a logic to it based on the fairly standard psychosocial processes described above. Of course, we knew that depressive states shifted the brain function. But so does sleep and falling in love—clearly, these are not brain diseases; they simply represent the logic of the brain as a behavioral investment system. In this light, the depressive shifts were conceived of as states of psychosocial shutdown, which emerged because the individual perceived their situation as hopeless and themselves as helpless and were caught in vicious intrapsychic loops. The key was understanding the psychological logic and adjusting the behavioral patterns and contingencies accordingly. This said, we certainly did at times encourage folks to take anti-depressant medications, as these have been shown to reduce depressive symptoms. But they do not cure a depressive brain disease, rather they take the edge off of intense negative feelings. (Note: I do consider Bipolar I and Schizophrenia to be justifiably conceptualized as mental diseases.)
7. Treatment requires presence and engagement on the part of the therapist.
As therapists, we needed to enter the space of the individual. We had to make contact with their felt sense of isolation and desperation, and we needed to bear witness to their pain in an authentic, empathetic way. The patients needed to know that they were deeply joined by another human being who could see and cared about their pain. Superficial advice without deep empathy was generally pointless and readily dismissed. This makes good sense, as the feeling of patients is that no one can understand their pain. (By the way, this can be brutal and tough on the therapists. I still experience what might be called "vicarious trauma" from entering the world of many hopeless, wounded people, who often, very understandably, see no way out.)
8. A shared understanding of both the suicidal behavior and the situation the person is in is key.
I learned that the keys to starting an effective treatment were a thorough assessment with a focus on understanding the logic of the suicidal behavior that was shared with the patient. If, as was often the case, suicidal behavior was a solution to escape from psychache, well, then we needed to understand where that came from in rich detail. The patient was the expert on the details of their story and the key moments in their history that were defining that pain. I was the expert on the domains of their psyche and the feedback loop between feelings and narration and social isolation, and how their history might be impacting them today. Together we would build a clear picture of both themselves and the function of the suicidal behavior. For a specific assessment of suicidal behavior, I recommend the CAMS developed by David Jobes.
9. People can raise the basement on suffering by learning strategies to short-circuit the depressive loop.
The Buddha realized 2500 years ago that suffering was a function of pain, coupled with an attitude of resistance and a desire to avoid or escape. The hatred of the pain and then the hatred of the self for not being able to handle the pain and then the hatred of not being able to escape the pain drives the individual into the pit of hell. While we cannot control our feelings directly, we can, with training, learn how to control our reactions to feelings. We can learn to be present, we can learn to reach out, we can learn to tolerate distress, we can learn to talk differently to ourselves, we can learn to talk differently to others. All of these things can short-circuit the depressive loop and, as we would say, put a “basement” on the misery that we could then learn to raise. Note, this metaphor means folks will still have a basement of pain and will still find themselves dealing with deep pain some of the time. Psychic pain is not eliminated—indeed, psychic pain, like physical pain, is an inevitable part of life, especially for those who are high in trait neuroticism with long histories of depression. But, with training and effective strategies and techniques that are practiced, it can be contained and reduced.
10. Acceptance, integration, and connection are central to longer-term healing.
Although I did not have the language for it at the time, I was essentially guided in my work with the suicide attempters by what I now call CALM MO principles. That is, I found individuals who had fragmented psyches, whose narrator and coping strategies were generally oriented toward escape, avoidance, and hiding from others. This left them vacillating between acting as though everything was OK and diving into deep bouts of despair. What was needed was a different approach. We needed to help the individual develop a meta-narrative (or meta-cognitive) observer perspective (the MO) that could start to see all the pieces of the individual’s moods and self-states. And we need to attempt to integrate and connect those pieces together, so that they were not nearly as disparate and fragmented. And we needed to connect the individual with others who could help process the feelings of loneliness, isolation, and shame.
(For examples of clinical cases from the study itself in the professional literature, see here. For an example of how I approached treating a highly suicidal college student a few years back, see here.)
Three Other Key Findings
I learned much during my time conducting this study. Here are there other key lessons:
- The population of people attempting suicide had much more intense symptom profiles in 2000 than in the 1970s, and were much more likely to make subsequent attempts.
- A history of multiple suicide attempts is an important marker for psychopathology and subsequent attempts. It is a far easier and better marker than a diagnosis of borderline personality disorder.
- The problems the people who entered the study faced were pervasive, and the DSM Diagnostic System was not up to the task.
Suicidal behavior is underfunded and not discussed nearly enough. If the recent tragedies increase our discussions of this difficult topic in a productive way, then at least these tragic losses can result in some positive consequences for others who are suffering.
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