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The beeper next to my bed went off at 1:30 a.m. When I called the number, my supervisor said my client was attempting suicide. She was on the Canadian side of the Niagara Falls where she climbed over a railing, walked a few feet and stood 100 feet above the Niagara River. Police cars, firefighters, ambulances, and a crowd of people stood in the dark, waiting to see what happens. Does somebody save her? Is she willing to jump? Will she climb back up? She was a librarian, intelligent, with a dark sense of humor colored by an unremitting, depressive episode lasting over a decade. Before starting my car, I received a call that first line responders talked her off the ledge. She would attempt suicide two other times before I left the clinic, moving to a medical center in another state. Every once in awhile those of us who worked at the clinic run into each other and when her name is mentioned, everyone suspects she's probably dead.
Suicide is newsworthy because life is precious. In 1993, a 6-year old girl living in Florida stepped in front of a train. She left a note saying that she "wanted to be with her mother" who recently died from a terminal illness. This is the power of the human mind. A girl in Kindergarten thinks of the past and imagines a future so bleak, so devoid of meaningful moments without her mom, that she takes her own life. The same mental tools that distinguish us from other animals, the same mental tools that allow us to solve problems and produce creative works that give us symbolic immortality are the same tools that allow a 6-year-old to contemplate a future that is terrible enough to leap into an oncoming train. If a 6-year-old has the cognitive capacity to kill herself, then we need to step up our efforts to understand and prevent it from happening.
There are a few instrumental studies that have helped make a dent in this problem.
1. Researchers dissected 20 suicide notes written by people who attempted suicide with 20 notes written by people who completed suicide. The notes were evaluated on five criteria: sense of burden (would my loved ones be better off without me?), emotional pain (how much suffering is in my life?), desire to escape negative feelings (is death the answer to ending this pain?), problematic social world (is death the answer to my troublesome social relationships?), and hopelessness (is there a sign that life is going to get better?).
What they found deserves your undivided attention: The biggest difference was that the notes of suicide completers included more detail about how they were a burden on other people and society at large compared to the attempters. In fact, this sense of burden was the only dimension that distinguished the letters of these two groups. You might be as surprised as me that hopelessness, amount of pain, and the belief that death will end the pain were common themes in the letters of both groups. Other studies have replicated these findings.
In general, people do not attempt suicide solely because of pain, it's because they don't believe there is a reason to live and the world would be better off without them.
2. But there is another piece of the puzzle that takes us back to the opening story. What is it that enables a person to be tenacious enough to swallow an entire bottle of pills, ingest poison, or push the chair away to dangle from a rope tied to the ceiling? It might be controversial to use the word courage, grit, or strength in this context. Nevertheless, a suicidal person often must overcome intense emotional distress to complete the final act. Leading suicide researchers speculated that a sense of burden is necessary but insufficient to understand who dies by suicide. A person also requires the capacity to harm themselves. A person must be highly tolerant of pain and conflict to make room for the uncomfortable thoughts and feelings that arise when working toward the goal of ending life. This tolerance of distress must be acquired somewhere along the way. Researchers suggest that the greatest suicidal risk exists for people that believe they are a burden on society AND possess a history where they acquired the capacity to harm themselves. This acquired capability can arise in unusual ways such as:
- playing violent and extreme sports.
- getting multiple body piercings and tattoos.
- shooting guns.
- getting in physical fights.
These types of painful and provocative events offer a sense of fearlessness about lethal self-injury. A person might respond positively to items such as “Things that scare most people don’t scare me” and “I can tolerate more pain than most people.”
If you remain unconvinced about the importance of an acquired capacity to tolerate pain and distress, consider sobering statistics. One in 25 people seeking health care services at a hospital because of self-harm or self-injurious behavior will kill themselves in the next 5 years. Dealing with emotional pain by cutting, burning, sticking objects in your skin, or intentionally preventing wounds from healing increases your capacity to kill yourself.
One of the odd things about this line of research is that in any other context, high pain tolerance is a strength, a gift, emotional agility that opens a portal to greater life success and fulfillment. This is why I bring up this research. Search for the motives behind people's actions because what is an admirable strength in one context, is a fatal risk factor in another.
Do not grow weary from the endless news stories of war veterans and emotionally distressed kids, teenagers, and adults who commit suicide. Let these stories be a call to action. And we have some valuable science to guide us in the right direction.
3. And then there is a comprehensive analysis of 50 years of research on risk factors and their ability to predict who has suicidal thoughts and engages in suicidal behaviors over long periods of time. This is not a single study, this is an analysis of 365 studies with 3,923 people who at the minimum, seriously contemplated killing themselves. In general, here are the strongest risk factors that emerged in their work:
- The top 5 for predicting suicidal thoughts—prior history of suicidal thoughts, a sense of hopelessness, a diagnosis of depression, a history of being abused by someone else, and an anxiety disorder diagnosis.
- The top 5 for predicting a suicide attempt—prior self-harm activity, prior suicide attempt, any personality disorder diagnosis, and a prior psychiatric hospitalization.
- The top 5 for predicting a completed suicide—a prior psychiatric hospitalization, prior suicide attempt, prior history of suicidal thoughts, low socioeconomic status, and the presence of stressful life events.
The lead author of this work, Dr. Joseph Franklin, states, “As most suicide prevention] guidelines were produced by expert consensus, there is reason to believe that they may be useful and effective. We recommend that these guidelines remain in use but emphasize that there is an urgent need to evaluate these guidelines within longitudinal studies...few scientists believe that a single factor, such as hopelessness, measured at one point in time will accurately predict suicide over the next 10 years. Instead, most would propose something like the following: a rapid elevation in hopelessness in an elderly man who just lost his wife, owns guns, has a history of suicidal behavior and has multiple physical health problems may increase risk for suicidal behaviors for a few hours, days or weeks. But the studies have not been testing these kinds of ideas.”
There are few single markers, in isolation, that predict who will kill themselves. Pay attention to the totality of the people you know. While it is difficult to talk about death, know that an unwillingness to notice, listen, and gently ask questions only helps to perpetuate the stigma concerning mental health problems. Click here for more resources on how to open conversations on these topics.
For more details on the science described above:
- Carroll, R., Metcalfe, C., Gunnell, D. (2014). Hospital Presenting Self-Harm and Risk of Fatal and Non-Fatal Repetition: Systematic Review and Meta-Analysis. PLoS ONE 9(2): e89944. doi:10.1371/journal.pone.0089944
- Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., ... & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187-232.
- Joiner, T. E., Pettit, J. W., Walker, R. L., Voelz, Z. R., Cruz, J., Rudd, M. D., & Lester, D. (2002). Perceived burdensomeness and suicidality: Two studies on the suicide notes of those attempting and those completing suicide. Journal of Social and Clinical Psychology, 21(5), 531-545.
- Van Orden, K. A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner Jr, T. E. (2008). Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76(1), 72-83.
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