Suicide's Most Dangerous Cognitive Distortion

The Gulf Stream, Winslow Homer (1899)

Source: Public domain

"“I will find myself in an airport, for instance, and I'll order an airport hamburger... it's an insignificant thing, it's a small thing, it's a hamburger, but it's not a good one. Suddenly I look at the hamburger and I find myself in a spiral of depression that can last for days.""

— Anthony Bourdain

“It can’t rain all the time.”

— Jane Siberry

The preeminent suicidologist Dr. Edwin Shneidman, whose research was based on access to over 700 suicide notes from completed suicides, concluded that “perturbation and lethality are the bad parents of human self-destruction.”¹

By this he meant that people who kill themselves do so because they’re in pain, most commonly a kind of mental pain that he called “psychache” and believed was the result of thwarted psychological needs. Perturbation, he explained was “felt pain,” whereas lethality “relates to the idea of death (nothingness, cessation) as the solution.” “Lethality,” he wrote, “the idea that ‘I can stop this pain; I can kill myself’ — is the unique essence of suicide.”

In that sense, suicide is, at its heart, a rational act. Although much has been written about “rational suicide” through the years, often what’s been debated is the question of what circumstances might make suicide “justifiable.” But justification isn’t the same as rationality — whether suicide is justified is a matter of cultural sanctioning that is subject to moral relativism (see my previous blogpost “When Is Suicide Acceptable?” for a discussion and reference 2 below). To say that suicide is usually rational merely points to the fact that there is typically an internal, and often very simple, logic to it. As Shneidman suggested, the person who ends their life does so because life is intolerable.

This view has guided my assessment of suicidality through the years in my own clinical practice that typically involves treating those admitted to the hospital with “suicidal ideation.” In contrast to Shneidman’s database of completed suicides, the vast majority of patients that I see have been thinking about ending their lives, but have actually done just the opposite — they’ve come in for help. It’s important to first acknowledge that. The next step then involves trying to change the mental calculus of suicide.

One way to do that is to address the psychosocial stressors that might be contributing to the feeling that life is intolerable. In my clinical work, getting a homeless patient off the streets and into housing is often half the battle. Treating mental illness including drug addiction is another key component, with both medications and psychotherapy — often in conjunction — potentially offering great relief.

But not everyone who contemplates or completes suicide has a significant life stressor or is mentally ill. A report from the Centers for Disease Control (CDC) this week states that the rate of suicide in the US has been increased significantly from 1999 to 2016 with 54% of suicides occurring in the absence of a known mental health condition.³ Of course, it may very well be that mental illness is going undetected or undiagnosed in these cases, but it’s also quite possible that many who contemplate and complete suicide aren’t mentally ill, but aren’t mentally healthy either.

Exploring the grey area between mental illness and mental health is the central theme of Psych Unseen and it’s in this space that we can unpack the rationality of suicide in greater detail. Although I’ve argued that suicide is a rational act, based on simple — and often overly simple — logic, this claim must be juxtaposed with the fact that the rationality of normal thinking is often flawed in some way. In other words, the logic that underlies our thinking and beliefs is often a flawed logic, led astray by misbeliefs, cognitive distortions, and unconscious cognitive biases.

The type of cognitive distortions that are most relevant to suicide are often the same that are seen in depression including all-or-none thinking, overgeneralization, jumping to conclusions, emotional reasoning, magnification/minimization, and discounting the positive.⁴ For example, a recent research study examined the content of online mental health forums and found that that the presence of “absolutist words” conveying absolute magnitudes or probability such as “always,” nothing,” or “completely” were 80% more prevalent within suicide forums.⁵ This new finding supports the idea that all-or-none thinking is often a critical category of cognitive distortion when one is contemplating suicide.

Hopelessness, defined as the belief that things will never get better, is one of the strongest predictors of future suicide attempts and completed suicide, especially among those with depression.^6,7 It involves multiple cognitive distortions (e.g. all-or-none thinking, overgeneralization, and discounting the positive) and is rooted in the cognitive illusion that the “self” is a permanent, unebbing thing and that the way you feel in the moment is that way you'll always feel. This illusion could not be less reflective of the true nature of the self, which is constantly changing, but it can feel particularly real when in the throes of depression.

Suicide Essential Reads

The SCOTUS Decision on Homelessness May Increase Suicides

Gun Control vs. Gun Safety as Suicide Prevention

Of course, depression can sometimes persist for months or even years and platitudes like “Cheer up!” or “This too shall pass” can be counter-therapeutic. But the reality is that whatever you’re feeling now, whether good or bad, it isn’t going to last. And the most hopeless situation could change in an instant. In The Bridge, a 2006 documentary about suicide attempts at the Golden Gate Bridge in San Francisco, one of the jumpers talked about changing his mind about wanting to kill himself moments after he jumped. In psychotherapy, changing the internal logic of suicide can often take more time, but the about-face can eventually be just as dramatic.

Suicide may have its own internal rationality, but more often than not, it's based on beliefs that don’t match reality. Shneidman wrote, “the single most dangerous word in all of suicidology is the four-letter word only.” Whatever the secret inner suffering one holds when contemplating suicide, the most dangerous cognitive distortion is the belief that things will never change and that suicide is the only way to escape that suffering. In most cases, nothing could be further from the truth.

If, like many people, you or someone you know is thinking about suicide, let me leave you with something my own therapist used to say which I found enormously helpful:

Hang in there.

And if you're not already in treatment, get help. The National Suicide Hotline number is 1-800-273-8255 (TALK).