Suicide: When hindsight is 20/20
Jacob Gray
CLP-2140-01M
6 November 2018
Eastern Florida State College
Table of Contents
Abstract 4
Suicide: When hindsight is 20/20 5
Models of Suicide 6
Psychodynamic Model of Suicide 6
Sociocultural Model of Suicide 7
Summing Up the Models, Exclusion of Others 10
Causes of Suicide 11
Environment 11
Modeling 12
Drugs, Thoughts and Mental Disorders 13
Summing Up Causes of Suicide 14
Symptoms of Suicidal Ideations 14
Major Depression 14
Schizophrenia 14
Substance Abuse 15
Treatment for Suicide 15
Talk Therapy, Psychoanalysis and Cognitive Therapy 16
Biological Approaches 16
Preventative Education 16
Prevention Effectiveness 17
Conclusions on Suicide 17
References 19
Abstract
Suicide is a tragic fact of life that many people will have experienced during some point in their lives with the loss of a loved one. As of 2016 (the most recent year for which data was available), the CDC reports that suicide is the 10th leading cause of death among Americans, with a total of 44,965 deaths. This figure is greater than the number of deaths caused by traffic accidents, which was found to be 37,461 per the Department of Transportation's National Highway and Transportation Safety Administration for the same year. Given suicide's current significance within society, both as a cause of death for individuals and a source of grief for those left behind, as well as morbid curiosity amongst the public, it is no wonder that the psychological community has delved into research on the topic since the early days of the field. Today, psychology attempts to understand the root causes of suicide to prevent future suicides of both those who have and have not already attempted suicide. This paper will explore the field's current understanding of the causes of suicide as well as treatment and prevention options available today, using Comer's Fundamentals of Abnormal Psychology 8th Edition as well as contemporary research on effective treatments for those who are suicidal and preventing others from becoming suicidal.
Suicide: When hindsight is 20/20
For any psychological disorder to be identified, labeled, diagnosed and treated, it first must be defined within the common language of psychologists. Many people's actions end their lives, whether intentional or not. A college student who drinks too much at a fraternity event due to peer pressure and dies of alcohol poisoning or an accident due to intoxication does not commit suicide. Instead, suicide is defined as the intentional act of ending one's own life. Within this definition, E.S. Shneidman, one of the first and a leading researcher in the field of suicide up until the years before his death in 2009, was cited in Fundamentals of Abnormal Psychology as identifying four different types of individuals within the general schema of those who take their lives. Death seekers who intend to commit suicide to end their life in absolute terms, death initiators are those who commit suicide to hasten the process of dying which they believe they've already begun. Shneidman states that death ignorers are those who commit suicide to enter a better plane of existence, and death darers are those who engage in life-threatening behaviors with no firm commitment to ending their lives, but no firm commitment to continue living either (Comer). Shneidman, like many other researchers in the field of suicide, must rely on hindsight to study the psychology of suicidal individuals, known as retrospective analysis. This is carried out by determining the psychological state of those who chose to end their lives in the time leading up to their death using clues left behind (such as purchases, internet history, or even their own bodies), the accounts of those who were close to the deceased, or, most critically, those who survived suicide attempts and are receiving psychological treatment as a result. Because of the small source of information to psychological researchers, research on suicide is limited, but the information we do have is crucial to our understanding of why people choose to end their own lives and how we can help to prevent their tragic decisions.
Models of Suicide
As with any other psychological disorder, suicide is understood through the lenses of the different models of abnormal psychology. However, since suicide is a permanent decision when successful, some models either do not have much available to research (such as the behavioral model) and any study must be a compilation of case studies due to the obvious ethical problem of instigating animals and especially humans to become suicidal or attempt suicide. Despite these limitations, research that has been conducted on the underlying causes of suicide has found some solid ground within the confines of three well-established psychological models: the psychodynamic model, the sociocultural model, and the biological model.
Psychodynamic Model of Suicide
The psychodynamic model was initially developed by Freud and other psychologists during the late 19th and early 20th centuries and has endured the test of time as an effective, if somewhat eccentric, model of understanding the human psyche. In the psychoanalytic model of suicide, the two key ideas that exist are the idea of loss and aggression directed towards oneself as the driving forces to lead someone to suicide. Additionally, the concepts of self-anger and a "death instinct," or Thanatos, that was described by Freud (Comer 2016, p.232) were proposed as causes of suicide, although later research contended that anger is not a universal feeling present in those who are suicidal, and if it is present, these feelings of anger are less significant than other emotions. Freud's idea of Thanatos, while dismissed by psychological research, has been supported by sociological research, which has noted an inverse correlation between murder and suicide rates within countries (i.e., higher murder rates and lower suicide rates and vice versa tend to correlate together), as well as lower suicide rates when countries are a war. The idea behind this is that Thanatos is directed outwards to other people in cases of murder or war instead of inwards to oneself. Despite sociological support, Freud became dissatisfied with his model of suicide, and thus, the two supported factors today within the psychoanalytic model are loss (resulting in melancholia or depression) and self-aggression.
Sociocultural Model of Suicide
The sociocultural model of abnormal psychology looks at an individual and their interactions with the social fabric that lies around them. As the name implies, this model looks at the social expectations and pressures on a person as well as how their cultural values affect their decision making and thought processes. The leading sociocultural model for suicide is Durkheim's Sociocultural View. On the simplest level, Durkheim argues that those who are well integrated into society and have good, healthy connections with those around them are the least likely to commit suicide or have suicidal ideations whereas social outliers are more likely to have suicidal thoughts and actions (Comer, 2016). Within this model, Durkheim proposed three types of suicide. The first type is egoistic suicide, which is characterized by an individual who does not fit within society not because society rejects him or her, but because he or she rejects society and society therefore "has little or no control" over these people who "are not concerned with the norms or rules of society" (Comer, 2016, p. 233). These people tend to be isolated with little in the way of support from others and tend to be non-religious. The next type of suicide proposed by Durkheim is altruistic suicide, where one is very well integrated into the fabric of society but chooses to end their life for the betterment of those around them. Popular examples of this are a soldier jumping on a grenade to save his comrades (Comer) as well as the act of Seppuku or Hari Kari, Japanese ritualistic suicide through disembowelment that was believed by dishonored samurai to restore honor to themselves and their family name through death. In either case, the decision to die is made deliberately for the benefit of the greater whole in the eyes of the individual ending their life. Durkheim also pointed out in this mode of suicide that societies that value suicide as a method of bringing honor or praise (such as the example with Seppuku) are far more likely to have higher suicide rates, which remains true today. Japan still has one of the highest suicide rates today and still values the act of suicide as an honorable act. The last act of suicide described in Durkheim's model is anomic suicide where someone living within a society which has failed him/her or the whole society has failed or entered a state of lawlessness chooses to end their life. This kind of suicide is seen to increase in prevalence during times of economic recession, such as the Great Depression, which lends its name from the increased number of suicides because of the 1929 stock market crash. In addition to financial decline, times of demographic shifts and immigration tend to lead to spikes in suicide rates. Recent research supports this with a study coming out of Turkey finding that "the most predisposing factor is migration from a rural area to an urban center" (Karatas, 2015), followed by financial difficulties and other personal conflicts. Anomic suicides do not only cover society changing around a person but a person's status within society changing as well. Prisoners serving life sentences without parole are particularly likely to choose to commit suicide, and even individuals who have inherited great wealth have been known to end their lives (Comer, 2016). As a whole, the sociocultural model looks at suicide as a result of an individual's role within society and the responsibility that it places on them. Whether it is to sacrifice oneself for others, to restore honor, or society fails and suicide is seen as a reasonable means of escape.
Biological Model of Suicide
The biological model of abnormal psychology looks at factors that are innate to our body, such as genetics and neural structures within the brain and identifies what is atypical in the functioning of the brain which leads to the dysfunction of the mind. Previous biological research has relied upon family pedigrees and determined that acts of suicide do run in families, suggesting a genetic component. Scientists have found such a gene to exist, one which when inherited from both parents causes Wolfram Syndrome (WS). Carriers of the WS gene (those with a copy of the gene from only one parent but do not suffer from the condition) are eight times more likely to suffer from mental illness resulting in hospitalization or suicide attempts (Bower, 1991). While this research is antiquated by the standards of science, a study carried out by Swift et al. in 1998 on the WS gene found that carriers were 26 times more likely to have been hospitalized for psychiatric care than non-carriers and further research carried out by Swift et. al. in 2005 specifically mentioned major depression as the cause for hospitalization. Major depression is known to carry with it suicidal thoughts and actions, so it stands that the Wolframin gene, as it has come to be known as, is indirectly responsible for significantly increasing the chances of suicidal thoughts or actions in individuals.
In addition to specific genes related to depression, studies carried out by biologically-minded psychologists have found that those who have attempted or committed suicide have considerably lower levels of serotonin in their bodies. Serotonin is believed to cause depression when it is not found in high enough concentrations within the body, and it has been shown to be a reliable indicator amongst people who have attempted suicide who might try to commit suicide again (Comer, 2016). Because of this, serotonin is thought to be responsible for the melancholia felt by depressed patients and has also been shown to cause aggression in males. These two factors (melancholy and aggression) are also the same two factors which psychoanalytic psychologists believe lead to suicide attempts.
Summing Up the Models, Exclusion of Others
To treat a suicidal individual and to prevent future suicide attempts by the same person or others, it is critical that the thought processes and malfunctioning of the mind and body are thoroughly understood. The psychoanalytic, sociocultural and biological models manage to complement each other and explain each other rather well. Because of this, I find that the three in conjunction with each other are all necessary to understand the mind of a suicidal individual. It is crucial that we know why someone's neurochemistry is unbalanced or not responding to certain antidepressants, and if a history of mental illness and suicide exists within the family, preventative measures can be taken. Biology also seems to complement the psychoanalytic theory which posits that a person's past may be leading them to a suicidal future. With these two theories complementing each other due to the similarities in emotions both are thought to cause (aggression and depression) and explaining what is wrong internally, the sociocultural theory explains the external forces that lead a person to suicide.
Other models of suicide have been omitted, such as cognitive and behavioral models for various reasons. Behavioral models tend to focus on learned and repeated actions, such as Pavlov's salivating dogs. While there are instances of copycat and follower suicides, suicide remains a choice on an individual level that primarily results from depression, PTSD or other psychological disturbances rather than being a condition unto itself. Likewise, suicidal ideation and actions are a result of depression and are but a subset of other thoughts which fall under the cognitive model of functioning, and these thoughts would be more aptly considered a cause of suicide, which is discussed in the next section. The humanistic-existential model provides a framework for allowing someone to live their best life; however, suicide cannot be fixed by finding meaning in life when someone is thinking of or has attempted to end their own life. Because of the limited scope of these models, for the purpose of this paper, they have been omitted.
Causes of Suicide
Suicide is explained very thoroughly by the numerous models of abnormal psychology; however, these models do not directly explain the causes that lead individuals to contemplate and attempt suicide. This section delves into the causes of suicidal ideation and attempts on a more micro scale, looking at events, traits, and qualities of people and their lives that lead them to end their lives
Environment
The environment that people live in can make or break people and their lives. People who live meaningful lives often find they have a sense of purpose at their job, in their home and communities and have strong connections to those around them. However, jobs, families and day to day life can also wreak havoc on the psyche. Fundamentals describes various stressful events and situations that can cause suicidal ideation and attempts, including social isolation, serious or terminal illness, an abusive environment or occupational stress (Comer, 2016, p. 228). Humans are inherently social animals, so isolation is incredibly detrimental to the mental well-being of people. Because of this, some human's rights groups have gone so far as to claim that solitary confinement is a violation of basic human rights (Greene, 2012) and its cause of psychological disturbances is well documented. Without a basic social support net, people are more likely to succumb to suicide. Abusive or repressive environments are equally likely to isolate people, such as members of the LGBTQ+ communities where over 42% of LGB students between grades 9-12 have seriously considered suicide, as compared with just 14.8% of heterosexual students. Since the LGBTQ+ community is largely still isolated and stigmatized, especially at such a young age, this comes as no surprise that these individuals may live in environments which are abusive and isolating. Occupational stress can also cause suicidal thoughts or actions, with high-stress jobs such as law enforcement, physicians, psychology and psychiatry, and unskilled laborers all seeing higher rates of suicide when compared to the general population. In addition to abuse and isolation, terminal illnesses are a leading cause of suicide. Several countries and states have legalized the process of physician-assisted suicide or euthanasia for those with terminal illnesses. In states where assisted suicide is not legal, many choose to take their lives through their own means. Robin Williams, acclaimed actor and comedian committed suicide by hanging himself due to his years-long battle with depression as well as a recent diagnosis with a degenerative neurological condition. Tragically, news breaking of Williams' suicide was found to have caused an uptick in suicides in the following weeks.
Modeling
Another cause for suicide is modeling. When an individual commits suicide, it is more likely that another person close to them (i.e., a family member, coworker, classmate, etc.) will attempt suicide. The Netflix original series Thirteen Reasons Why is often a poor depiction of mental health problems, let alone suicide. However, this is one detail they got correct when at the end of season 1, another student in the school attempts suicide. These modeling suicides are not kept at a local level, however, as shown with Robin Williams, a celebrity's suicide can spark a wave of suicides nationally and has led to media organizations altering the way they cover celebrity suicides. Comer cites specifically, MTV's handling of Kurt Cobain's suicide and how the network started a "Don't Do It" campaign. Meta-analysis of suicides showed no uptick in suicide rates following Cobain's death (Comer, 2016, 231).
Drugs, Thoughts and Mental Disorders
Individuals with drug and alcohol abuse problems, mental disorders or depressed moods with hopeless thoughts are also shown to be more suicidal than most other segments of the population. Alcohol is often turned to as a form of self-medication to alleviate depressive symptoms but only exacerbates the issues as alcohol itself is a depressant. A course of action which was initially supposed to help the problem only makes it worse. Additionally, the use of other depressants, such as opiates (heroin, fentanyl, etc.), have been shown to increase the likelihood of someone attempting suicide. Depression often leads to the risky behavior that results in drug and alcohol dependencies which lead to suicide.
With depression comes a mood of melancholy and, in the case of those attempting suicide, hopelessness and an ideology of dichotomatic thoughts. These individuals feel their future and their lives, as they stand, have no hope of improving and they view their world through an either/or lens (Comer 2016), leading to a sense of entrapment. Shneidman researched this phenomenon and found that many of his subjects who had attempted suicide used the word "only" when describing their troubles and why they felt suicide was their only option for relief.
Many people who seek relief through suicide are also suffering from one or more mental illnesses. While many think of depression when thinking of suicide, individuals suffering from schizophrenia or alcohol dependency also attempt suicide. Comer states in Fundamentals "as many as 70 percent of all suicide attempters had been experiencing severe depression, 20 percent chronic alcoholism, and 10 percent schizophrenia" (p. 229) and also notes that of people suffering from these conditions, 25 percent attempt suicide at some point.
Summing Up Causes of Suicide
Those who attempt suicide need help. These individuals are often on the fringes of society, under immense stress, suffer from addictions and mental illnesses and are exposed to the reality of suicide when their role models choose to take their own lives. These stressors and influencers are very real factors that contribute to the decision to end one's own life.
Symptoms of Suicidal Ideations
Since suicides which are successful result in death, it would be rather pointless to list death as a symptom of suicide, although that is the grim reality of the situation. Unsuccessful suicides can result in maiming, disfigurement and numerous complications which can increase an individual's suffering. Because of the somewhat redundant nature of stating the effects of a suicide attempt, this section will focus on the symptoms of comorbid conditions which often lead to a suicide attempt.
Major Depression
The DSM-V lists several criteria to diagnose depression which is a frequent precursor to suicide. Symptoms include a frequent and relentless feeling of sadness or hopelessness, noticeable reduction in speed of actions and thoughts observable by others, excessive feelings of guilt, worthlessness as well as diminished attention spans and increased indecisiveness. The most significant symptom of identifying if depression will lead to suicide is the eighth, which reads: "Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide." (American Psychiatric Association, 2013)
Schizophrenia
Schizophrenia is a well-known condition which is frequently characterized by delusions, hallucinations, disorganized and chaotic speech and thought patterns, as well as "disorganized or catatonic behavior" (American Psychiatric Association, 2013). These symptoms often manifest in delusions that make the afflicted individual feel they are invincible or being hunted by other individuals or organizations. This manic or paranoid state can be equally destructive if an individual is not properly medicated. Some schizophrenic suicides are not intentional, but those which are, are often carried out by someone who is greatly disturbed by their condition (Comer, 2016).
Substance Abuse
Often comorbid with depression, substance abuse lowers inhibitions and reduces an individual's ability to reason. This is especially true with depressants such as alcohol and opioids, as stated earlier. Because of this high rate of comorbidity amongst individuals attempting suicide, substance abuse coupled with depression is an extremely worrisome combination which is found to be very common among those who attempted suicide. In fact, of individuals who attempt suicide, 70 percent have alcohol in their system at the time of their attempt and that 25 percent of successful suicides were carried out by legally intoxicated individuals (Comer, 2016, p. 229).
Treatment for Suicide
For the same reason that makes suicide incredibly difficult to study, it also makes it impossible to treat. Once a person successfully ends their life, there is no returning. Because of this, suicide treatments focus on prevention, whether preventing a first-time attempt or a repeat attempt. One saving grace of suicide attempts is that very few are successful. As a result, most individuals are hospitalized where they can meet with a licensed mental health professional who can get them on track to end their suicidal ideations and attempts. In addition to preventative measures, postventative treatment, crisis prevention, and early education are also options for treating suicidal ideations.
Talk Therapy, Psychoanalysis and Cognitive Therapy
Whether speaking with a crisis counselor over the phone or a therapist in person, suicide prevention largely bases itself on talk therapy and understanding the implications of one's actions. Talk therapy often centers around identifying the source of one's problems, openly discussing a support network of friends and family and learning to block intrusive, negative thoughts (Comer, 2016, p. 242). While these therapies can be effective, they may not be enough alone should the patient have an underlying biological condition that is causing distress such as schizophrenia.
Biological Approaches
Biological approaches to treating suicidal thoughts and attempts can come in many forms such as emergency medical care necessary after an attempt or pharmaceuticals to treat an underlying disorder. Patients with a history of schizophrenia can be prescribed anti-psychotic medication to treat their condition which causes them extreme distress. Likewise, patients suffering from depression can be given anti-depressants and mood stabilizers to regulate neurotransmitter levels such as serotonin. On their own, these treatments can be effective, but research across all disciplines within psychology show that medication in conjunction with therapy is one of the most effective forms of treatment (Comer, 2016).
Preventative Education
The most effective way to treat suicide is to treat it before it is even attempted. With an alarming uptick in suicide attempts among children and adolescents in recent decades (Comer, 2016, p. 235-236), many educational institutions have begun educating instructors and students as well on how they can prevent their students and peers from attempting suicide. The focus for these programs is to enable educators and parents to identify students at risk for suicide by teaching them the signs and symptoms that are indicative of conditions which may lead to a suicide attempt.
Prevention Effectiveness
While the overall effectiveness of prevention programs is inconclusive, research has shown that those who reach out for assistance are significantly less likely to attempt suicide. One prevention hotline in Los Angeles saw that only "2 percent of [callers] later committed suicide, compared with the 6 percent suicide rate usually found in similar high-risk groups." (Comer, 2016, p. 245). Measuring effectiveness is also difficult, because while a local community with a prevention program in place may see an increased rate of suicides, if their increased rate is less than that of the surrounding society, it could be argued the programs have been effective (Comer, 2016, p. 245). While prevention hotlines help those in crisis, even Shneidman agrees "the primary prevention of suicide lies in education." (Comer, 2016, p. 246)
Conclusions on Suicide
Suicide is tragic, complex, poorly understood and very real. It is more deadly than traffic accidents and effects every demographic from children to elders (Comer, 2016, p. 235-242), every nationality and every socioeconomic background. When people talk about suicide, they often ask the wrong question first: how? That's sadly the way morbid curiosity works. The question we should always be asking is why? Without understanding why people choose to end their own lives, psychologists cannot further their understanding of this tragic reality of our society which so many wish did not exist. The key to preventing suicide attempts from happening in the first place is to break the stigma of discussing suicide and talking candidly about why someone chose to end their life. Gleaning what we can from these tragedies, we can help to prevent others from taking their lives by providing non-judgmental support, adequate mental health resources and a safe environment that lifts the shame that comes with discussing suicidal ideations. Once the stigma is lifted, we can begin to understand suicide better and begin to get ahead of this epidemic.
Word Count: 4,229 (I am so sorry)
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Bower, B. (1991, June 15). Gene Linked to Mental Illness, Suicide. Science News, 139(24).
CDC. (2017, March 17). National Center for Health Statistics. Retrieved November 06, 2018, from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
COMER, R. J. (2016). Chapter 7: Suicide. In FUNDAMENTALS OF ABNORMAL PSYCHOLOGY (8th ed., pp. 221-247). S.l.: WORTH PUB.
Greene, T. (2012, March 05). ACLU to United Nations: Solitary Confinement Violates Human Rights. Retrieved November 04, 2018, from https://www.aclu.org/blog/criminal-law-reform/aclu-united-nations-solitary-confinement-violates-human-rights
Karataş, K. S., Şahin, M. F., & Sevinç, S. (2015). Research of Suicide Determinative Factors in Completed Suicide by Psychological Autopsy. Turkish Journal of Forensic Medicine, 30(2), 128-134. doi:10.5505/adlitip.2016.72692
Mack, A. (2012). Sexual Identity, Sex of Sexual Contacts, and Health-Risk Behaviors Among Students in Grades 9–12 — Youth Risk Behavior Surveillance, Selected Sites, United States, 2001–2009. Yearbook of Psychiatry and Applied Mental Health, 2012, 70-72. doi:10.1016/j.ypsy.2011.08.118
NHTSA. (2018, April 23). USDOT Releases 2016 Fatal Traffic Crash Data. Retrieved November 04, 2018, from https://www.nhtsa.gov/press-releases/usdot-releases-2016-fatal-traffic-crash-data
Swift, R. G., Polymeropoulos, M. H., Torres, R., & Swift, M. (1998). Predisposition of Wolfram syndrome heterozygotes to psychiatric illness. Molecular Psychiatry, 3(1), 86-91. doi:10.1038/sj.mp.4000344