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Suicide is a tragic ending to life that, in many cases, can be averted. It constitutes a public health problem of considerable magnitude in the United States, occurring at nearly twice the rate as that of homicide. From 1999 to 2016, suicide rates have steadily risen in nearly every state in the union. Understanding this seemingly perverse anti-life behavior as well as other self-destructive actions that often precede the final act is an important concern to practitioners in the mental health field. The prediction and prevention of suicide are complex and challenging; however, these are not impossible goals.
Several years ago, my colleagues and I discovered a unique window into this complicated problem. By eliciting and identifying the internalized negative thought process — which I have termed the “voice” — along with the painful effects that accompanies it, we were able to develop a theoretical framework and methodology that illuminates the psychodynamics of self-destruction.
The Psychodynamics of Self-Destructive Behavior and Suicide
People acquire a sense of self in an interpersonal context. Unfortunately, it is this same social milieu in which this delicate sense of self is fractured. This division of the mind reflects the basic split between forces that represent the self (the self system) and those that oppose or attempt to destroy it (the anti-self system). To varying degrees, all people are both themselves or an intimate enemy to themselves. In the case of suicide, this enmity reaches epic proportions.
Ironically, the child's desperate struggle to preserve intactness and wholeness is what produces this fragmentation. Because of the power and size differential in relation to their parents paired with total dependency on them for survival, children tend to feel vulnerable and powerless. To avoid painful feelings of helplessness and insecurity, they unconsciously identify with their powerful parents and incorporate negative parental attitudes and destructive behaviors that are directed toward them. They come to think of themselves as bad, unlovable and unworthy because the alternative of perceiving the parent as inadequate, hurtful or outright rejecting is too threatening. They internalize these critical, punitive attitudes at times that are particularly stressful or abusive, often when their parents are at their worst. In extreme situations of trauma or abuse, parental aggression and death wishes are incorporated into the self and take the form of a vicious internal dialogue or voice, which later, in adolescence or adulthood, results in a suicidal process.
The Voice in Self-Destructive Behavior and Suicide
There are certain recognizable signs of suicidal risk or intent that can be identified in suicidal ideation, i.e., destructive thoughts toward oneself and/or others. When my colleagues and I interviewed depressed and/or suicidal individuals, we discovered that they were able to identify these harmful ways of thinking about themselves and easily related to the concept of the voice. Similarly, in his interviews with 50 survivors of potentially lethal suicide attempts, Richard Heckler (1994) observed that the pull toward suicide “often comes in the form of a voice…This voice grows in volume with the stress of the suicidal ordeal. It demands increasingly to be heard above everything else, and it begins to occupy a greater part of the person’s psyche until it smothers more reasonable voices altogether” (p. 74).
The Continuum of Self-Destructive Thoughts and Behaviors
The voice process exists along a continuum of intensity, ranging from mild self-criticism to extremely angry, self-abusive thoughts. In suicidal individuals, these thoughts have been observed to change, at some point, from guilty self-recriminations to destructive self-attacks and injunctions to cause harm to the self. Suicide is the ultimate result of acting upon the extreme end of the continuum of this negative thought process.
If we are to more effectively identify potential suicide victims, we need to recognize the profoundly self-destructive intent of the voice that underlies inimical life-styles. Clients who see suicide as the “best solution” are not basing their perception on rational thinking, but instead on irrational, malicious cognitive processes. To summarize, I have developed the following hypotheses regarding the relationship between the voice process and self-destructive behavior and suicide:
(1) A conflict exists within each individual between life-affirming propensities to actively pursue goals in the real world, and self-denying, self-protective, self-destructive tendencies.
(2) Thoughts antithetical to the self vary along a continuum of intensity from mild self-reproach to strong self-attack, and suicidal ideation.
(3) Self-destructive behavior exists on a continuum from self-denial and self-limitation at one end to isolation, drug abuse, and ever more severe self-defeating behaviors, culminating in actual bodily harm.
(4) Both of these processes, cognitive and behavioral, parallel each other.
Clients may remain stabilized for long periods at the mild level of the continuum. However, any movement toward the more extreme level should be taken seriously as a potential indicator that the person is embarking on a regressive trend that could eventuate in harmful acting-out behavior. Therein lies the predictive value of eliciting and identifying the content of clients’ negative voices and evaluating the level of intensity of their aggression toward self.
At the extreme end of the continuum, severely depressed individuals become exhausted and listless in their struggle against self-destructive urges and self-abusive thoughts. They have reached a stage where the balance has shifted to such a degree that the alien point of view represented by the voice has become their own point of view. Consequently, to a large extent, they no longer have contact with their real self and feel hopelessly estranged from others as well. At this point, they are at high risk for suicide. They are almost completely “possessed” by the voice process, which Heckler identified as the suicidal trance.
The Development of the FAST
Most people who seek professional help experience self-defeating and self-destructive thought processes that can be conceptualized as an internal dialogue or voice. I believed that it was logical to use these negative thought patterns to predict increasingly aggressive cognition and affect toward the self. Therefore, Dr. Lisa Firestone and I developed the Firestone Assessment of Self-Destructive Thoughts, the FAST (R. Firestone & L. Firestone, 2006) to help determine the degree of an individual’s suicidal intent.
The FAST is a self-report questionnaire consisting of 84 items drawn from 11 levels of progressively self-destructive thoughts expressed in the second person format, such as, You’re a failure. You’re not very attractive. You just don’t fit in. Just stay in the background. You’re a burden. You don’t deserve to live as well as cynical thoughts about others. Why go out with him(her)? He(She) is cold, unreliable. He(she) will just reject you. The items are made up of actual voice statements that were reported by subjects in clinical studies and by in-patients and out-patients in a variety of settings.
The scale incorporates a unique approach: Instead of being asked to report symptoms, the client is asked to endorse the frequency and severity with which he or she is experiencing various negative thoughts directed toward him or herself. When items are presented in this format, they bring to light elements of a self-destructive process that may have been partially or completely unconscious.
Analysis of the FAST revealed three factors of increasing self-destructiveness.
1. Self-critical thoughts of increasing intensity ranging from statements such as: You’re incompetent, you’re stupid, to thoughts rationalizing self-denial: Why go on this vacation? It’ll be such a hassle; to thoughts that are cynical and hostile toward others: You can’t trust men/women, to thoughts predisposing isolation: Just be by yourself. You’re miserable company anyway; who’d want to be with you? and finally to thoughts expressing self-contempt: You idiot! You creep! You don’t deserve anything; you’re worthless!
2. Thoughts that support the cycle of addiction, first urging an individual to indulge, and then attacking them for the same behavior: Just take a hit; you’ll be more relaxed. Go ahead and have a drink, you deserve it. And then, later: You weak-willed jerk!
3. Thoughts that represent the full spectrum of self-annihilation, from psychological suicide, such as: Thoughts telling the person he or she is a burden to others See how bad you make your family (friends) feel. They’d be better off without you, to thoughts associated with giving up one's priorities and favored activities: What’s the use? Why bother trying? Nothing matters anyway, to thoughts of self-mutilation: Why don’t you just drive across the center divider? Just shove your hand under that power saw! To suicidal plans and injunctions: You have to get hold of some pills. You’ve thought about this long enough. Just get it over with. It’s the only way out!
Reliability and validation studies have shown that the FAST effectively discriminates between suicidal and non-suicidal individuals at a high level of significance. In other words, empirical research clearly demonstrated the predictive power of the concept of the voice in suicide. The process also operates in reverse; when therapists become familiar with a client’s dysfunctional behavior as contrasted with his or her stated goals, they can also deduce the underlying voices. In 1996, the FAST was added to the repertoire of instruments utilized by mental health professionals in both the private and the military sectors for assessing suicide, as well as for identifying the inimical thinking that controls other self-destructive actions and lifestyles.
New Conclusion
The way that defended individuals are damaged and the way they function are closely linked to negative internalized thoughts. The knowledge gained through accessing and identifying the partially unconscious thought processes driving a suicidal person toward death can be used to set potentially lifesaving interventions into motion. Because ambivalence is almost always present within persons who are in a suicidal state, every opportunity must be offered to help them.
In therapy sessions, individuals express their negative thoughts in a dialogue format, analyze their source, and develop corrective experiences to challenge them. Identifying the specific content of negative thinking and releasing the associated emotions of anger and sadness provide them with tools to counter injunctions to harm themselves. This type of awareness is crucial in that it provides clients with a sense of mastery over behaviors they previously perceived as being beyond their control.
References
Firestone, R. W ., & Firestone, L. (2006). Firestone Assessment of Self-Destructive Thoughts (FAST) manual. Lutz, FL: Psychological Assessment Resources.
Heckler, R. A. (1994). Waking up, alive: The descent, the suicide attempt, and the return to life. New York: Ballantine Books.
