When someone in crisis starts to see suicide as "logical," seeking help can feel unnecessary

Konrad Michel M.D.

THE BASICS

- Suicide Risk Factors and Signs

- Take our Depression Test

- Find a therapist near me

Key points

- Thousands of people die by suicide each year without seeking help prior to their death.

- For suicidal people, suicide is often experienced as ego-syntonic, or in line with the person's sense of self.

- Because suicide may thus come to seem "normal" or "logical," mental health support can appear unnecessary.

- Therapists can help patients learn why they came to view suicide as an acceptable goal.

Fifty percent or more of people who die by suicide do not seek help before their deadly suicidal action. This phenomenon is found even in countries with high-quality services for suicidal people and a long tradition of national suicide prevention and research, such as Denmark .

This can perhaps be attributed in part to the various barriers to seeking help, such as stigmatisation, the fear of not being understood, and the fear of being admitted to a psychiatric institution and being treated against their will. There are important intrapersonal reasons for not seeking help, too.

Yet in a survey with 8,400 individuals who reported episodes of suicidal ideation in the past year, three-fourths said that they did not feel they needed mental health treatment . And in our own follow-up study of patients who had attempted suicide, 52 percent said that nobody could have helped to prevent their self-harm, and only 10 percent mentioned a health professional .

Why might this be?

How Suicide May Become an Ego-Syntonic Goal

Ego-syntonic is a psychoanalytic term, describing behaviors that are in harmony with a person’s sense of self. In hundreds of narrative interviews with patients who had attempted suicide, we found that in an acute emotional crisis—when the self is experienced as negative, useless, and broken—suicide may emerge as a “normal” solution to end it all, that is, as consistent with a highly negative sense of self.

Psychological pain and tunnel-thinking (dissociation) thus finally act as energizers to an ego-syntonic suicide action. Interestingly, immediately after an act of self-harm, people often switch back from an ego-syntonic experience to a distanced, ego-dystonic experience of their suicidal action.

In Bern, for instance, we have high bridges over the river Aare. People who survive the fall usually say that the moment they jumped, they realized that what they had just done was wrong. This was also the message of Kevin Hines, who survived a jump from the Golden Gate Bridge. The switch back is consistent with the concept of the suicidal mode as a switch-on, switch-off phenomenon .

Ego-syntonicity/dystonicity has conceptual similarities with the dual-processing theory . In our everyday decisions, we usually rely on what the authors call "system 1 thinking," which is intuitive, automatic, with little or no conscious input. However, in out-of-the-ordinary situations, "system 2" will usually be activated to override the decisions offered by system 1 in order to prevent us from making fatal decisions. System 2 is slower, characterized by explicit, conscious processing.

The question is why system 2 in the development toward suicide does not interfere with suicide as a life-threatening goal. The answer is that in a person’s negative self-evaluation related to mental pain, self-hate, and unbearable mental pain, probably with a history of repeated suicidal thoughts, suicide may appear as an acceptable, subjectively normal goal.

How a Video Technique Can Help Address Suicidal Actions

In ASSIP , a three-session, person-centered, highly collaborative therapy for patients with prior suicide attempts, we use the person’s suicide narrative—recorded on video in the first therapy session—for self-confrontation in the second session. Here, patients are put into the observer’s role, watching their suicide narrative—thus setting up system 2 to watch the patient's own ego-syntonic, system 1 suicide narrative.

With the support of the therapist, patients learn how suicide emerged as an acceptable goal in their lives. They gain insight into the danger of being caught in the tunnel vision of the suicidal mode, where suicide may appear as the only solution to end the suffering. They learn to recognize the trigger situations and warning signs, and how to mobilize their safety plans when necessary.

In a randomized controlled trial with 120 patients, ASSIP reduced the risk of suicide reattempts over a two-year follow-up period by 80 percent. We believe that the video-playback procedure is one of the main therapy components leading to a conscious revision of one’s own suicidal development

Here is an example of a patient’s feedback after the video self-confrontation.

Dear doctor

Since I have seen you I have been feeling unburdened. Although about a week ago I experienced again something like beginning thoughts about suicide, I do feel better than three weeks ago, after the suicide attempt. Since then I also talked more with friends, and I tried again and again to explain what happened.

I feel that the interview, and above all, watching together the video afterwards, gave me very much in terms of working through. Today it is clear to me what a “silly” idea such a suicide attempt, or suicide itself, is.

Again, many thanks! With best regards

R.W.

Where the Traditional Suicide-as-Illness Model Falls Short

The medical model assumes that people with health problems seek help. However, the fact is that thousands of people at risk of suicide do not seek help.

Theories of suicide based on a medical model do not match the psychological experience of the suicidal person. When faced with suicidal patients, the typical health professional will do a psychiatric assessment and decide on the indicated management of the patient. This illness-based approach is likely to miss what I call “the person in the patient.”

Suicidal ideation and behavior are always highly personal. People need to understand the dynamics of their own suicidality, to become aware of the warning signs before they enter the suicidal mode. A truly person-centred approach must be collaborative, in that the health professionals and patients work toward a shared understanding of the person’s existential vulnerability, suicide triggers, and warning signs.

#James Donaldson notes:Welcome to the “next chapter” of my life… being a voice and an advocate for #mentalhealthawarenessandsuicideprevention, especially pertaining to our younger generation of students and student-athletes.Getting men to speak up and reach out for help and assistance is one of my passions. Us men need to not suffer in silence or drown our sorrows in alcohol, hang out at bars and strip joints, or get involved with drug use.Having gone through a recent bout of #depression and #suicidalthoughts myself, I realize now, that I can make a huge difference in the lives of so many by sharing my story, and by sharing various resources I come across as I work in this space.  #http://bit.ly/JamesMentalHealthArticleFind out more about the work I do on my 501c3 non-profit foundationwebsite www.yourgiftoflife.org Order your copy of James Donaldson's latest book,#CelebratingYourGiftofLife: From The Verge of Suicide to a Life of Purpose and Joy

Click Here For More Information About James Donaldson

The Answer: Person-Centered Approaches to Suicidal Individuals

We need to move beyond the prevalent, risk-factor-based model of suicide and thus overcome the unfortunate disconnect between suicidal persons and health professionals. We need to promote and disseminate models of suicide that are meaningful to suicidal patients and their therapists.

Fortunately, there is now a growing and promising research interest into the role of a collaborative therapeutic working alliance with the suicidal person and narrative interviewing as moderating factors for therapy outcome .

Summary

Thousands of people die by suicide without prior contact with health professionals. A so far neglected reason is that suicidal individuals experience suicide as an ego-syntonic goal. This psychological phenomenon does not fit into the conceptual frame of medicine. Health professionals who are open to the psychological dynamics of the suicidal individual will be more effective in reducing suicide risk in their patients.

If you or someone you know is at risk of suicide, seek help immediately. In the U.S., call 988 or go to 988lifeline.org. Outside of the U.S., visit the International Resources page for suicide hotlines in your country. https://standingabovethecrowd.com/?p=15105