The Choice to “End it All.”

Suicide Definition Graphic

Written by Steven Barto, B.S., Psy.

IT WAS FOUR IN the afternoon. I was driving along the river in my home town. It was the fourth decade of my struggle with active addiction. Overwhelmed with thoughts of utter failure, rabid hypocrisy and complete hopelessness, I started ruminating about the idea of suicide. Why not? It made sense. I was in bondage to drugs and had grown tired of living a life so out of touch with my Christian upbringing. Seems I could not stop lying, cheating, stealing. Doing whatever it took to keep getting high. Duplicity was the word that most described my existence. I’d grown weary of living on the down-low. I was defeated, exhausted and tired of failing.

I turned into an area boat launch and stopped about fifty yards from the edge of the water. I closed my eyes and took my foot off the brake. I’d barely touched the accelerator when I heard an audible voice. It filled the cabin of my car: Don’t. I jammed the brake pedal to the floor and gripped the steering wheel in a panic. I must be losing my mind! There was no one else in the car. The radio was off. Yet, somehow, I heard a voice that seemed to fill the interior of my car. I could feel the voice, insistent but not loud. No sense of anger or disappointment. It was simply an audible, gentle, compassionate insistence.

Don’t end your life!

It’s been said that suicide is a permanent solution to a temporary problem. Perhaps if some in-between state existed—some alternative to death—many suicidal people would take it. One question every surviving family member has asked without exception, that they ache to have answered more than any other, is simple: Why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note is left behind, it still never makes sense. Yes, they felt enough despair to want to take their own life, but Why did they feel that way? Alex Lickerman, MD said, “People who’ve survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy, but a valid one nevertheless” (1).

A friend of mine took his own life in 1996. We met a few years earlier as co-workers at a Philadelphia law firm. We were both on staff as litigation  paralegals. He had recently started a new career trading stocks. Apparently, he was under investigation by the SEC for insider trading. His wife kicked him out and filed for divorce. He moved in with his parents and had become quite depressed and withdrawn. He stayed home from work on a Tuesday. After his parents left the house, he took his father’s .357 handgun and drove to his wife’s place. When she answered his knock, he shot himself on the stoop in front of her. I always knew him to be outgoing, hilarious, and always up for a good time. His death made no sense to me.

Unfortunately, suicide without warning is common. Patrick J. Skerrett quoted Dr. Michael Miller, a psychiatrist at Harvard Medical School, in a recent article on suicide: “Many people who commit suicide do so without letting on they are thinking about it or planning it” (2). Currently, suicide is the tenth overall cause of death in the United States. In 2018 there were 48,334 suicide deaths in America. Had I not heard God’s voice that afternoon in 2018, the total would have been 48,335. There were an estimated 1.4 million suicide attempts in the U.S. in 2018. The rate of suicide is highest in middle-age white men in particular. It was the second leading cause of death among individuals between the ages of 10 and 34. On average, there are 132 suicides per day. In 2018, firearms accounted for 50.57% of all suicide deaths in America (3).

America’s suicide rate has increased for 13 years in a row.—The Economist

According to the National Vital Statistics Report, suicide was the second leading cause of death for age groups 10 to 24, or 19.2% of deaths, and 25 to 44, or 10.9%. This report presents final 2017 data on leading causes of death in the United States by age, sex, race, and Hispanic origin. These data accompany the release of final national mortality statistics for 2017 (4). In 2017, the 10 leading causes of death were, in rank order: heart disease; malignant neoplasms; accidents (unintentional injuries); chronic lower respiratory diseases; cerebrovascular diseases; Alzheimer disease; diabetes mellitus; influenza and pneumonia; nephritis, nephrotic syndrome and nephrosis; and intentional self-harm (suicide).

Suicidal Ideation and Social Media

Various social media platforms offer an unprecedented volume, velocity, and variety of social data to researchers. Among these, the most consistently studied is Twitter, a microblogging platform in which participants broadcast 140-character posts directly to one another or to the Twitter community simultaneously. Twitter’s sociological and psychological relevance for researchers and treatment providers is elevated due to ease of accessibility to data, the fact that most data collection activities can be undertaken at no cost to the researcher, and the ease of data management. For example, because Twitter limits individual posts to 140 characters, the information is more easily stored and reviewed than longer Facebook posts.

Facebook Suicide Prevention webpage can be found at www.facebook.com/help/594991777257121/ [use the search term “suicide” or “suicide prevention”].

As with a variety of social media platforms, Twitter has been a boon to suicide researchers, who can observe the behavior of individuals in a non-invasive manner, collecting “live” (time-sensitive) information that might not otherwise be shared because of the stigma of mental illness and suicide. One researcher was able to analyze 125 users who publicly announced they had attempted suicide. Analysis of these individuals’ posting history revealed distinct signals in previous posts that could have been used to predict their upcoming attempts and initiate an intervention (5). This is a relatively large sample that otherwise might have been overlooked.

Strong correlations have been discovered between suicidal expressions on Twitter and state-specified age-adjusted suicide rates. It is believed that posting suicide-related content on social media specifically identifies at-risk individuals. In fact, unique posting patterns have been posthumously discovered for Twitter members who died by suicide when compared to those who died of other causes (6). Such results demonstrate the value of verbal content people post on social media sites—providing unique insight into suicidal behavior.

Twitter’s Best Practices in Dealing With Self-Harm and Suicide at https://support.twitter.com [use the search term “suicide,” “self-harm,” or “suicide prevention”].

Psychologists and sociologists have begun to analyze social media data—correlating the content of social media posts regarding the topic of suicide with eventual suicides or attempts. Analysis has proven most useful in this regard. It must be determined whether suicidal behavior can be correlated to online comments among peers beyond one degree of social separation. Also, it must be determined whether that correlation persists after excluding innocuous commentary regarding mood and attitude. In other words, if mood is held to a constant in the analysis, will the observed association in suicide-related behavior still be higher than chance? Recent research has determined that comments on social media relative to suicidal expressions can be studied and correlated  up to three degrees of separation between peers, but no further. 

N.A. Christakis and J.H. Fowler (7) noted that correlation held between suicidal remarks and suicidal actions even when accounting for the distribution of mood among participants in the social media network. They used the bootstrapping method (employing computer-intensive analysis of  variability within their data samples) to study real-time posting activity on Twitter. Their samples were comprised of two non-consecutive 28-day periods. Mechanical Turk (MTurk; Amazon, 2016) raters have compiled suicide-relatedness ratings for each of the 10,222 most common words in contemporary English for use in evaluating social media posts for occurrence of “suicidal conversation.” These words are correlated with a preexisting list of “sad” words (as they relate to the sad/happy continuum) used to infer the general mood of social media users. Collection and analysis was conducted via double-blind method for accuracy and to allow for detecting statistical variation and spurious correlation.

Some variants of “sad/happy” word expressions that may or may not be associated with suicidal ideation include “I’m so sad! I’m gonna kill myself!” “I’m the worst! LOL!” “My final day on earth…” “Just got in a fight…” “It’s a sad day.” “I love my life!” Analysis included placing “sad,” “happy,” and “suicidal” words into columns on a graph and quantifying the number of uses of such words or phrases. Also, degrees of separation (direct friend versus once, twice, thrice removed) were determined at one through six degrees: friend, friend of friend, friend of friend of friend, and so on. The Sad Column, Happy Column and statistically relevant variables were each plotted along the graph comparing “mood” and “suicide-relatedness” comments. Amazingly, this study may be the first of its kind, and involved collection and analysis of over 64 million post from over 17 million unique social media users in two nonconsecutive 28-day periods. Analysis of this real-time data helped predict (by an algorithm) the information collected, which typically has infinite possibilities of correlative meaning.

You might ask, But why is this important? What does it mean? How can it be utilized? Suppose a counselor is concerned with the suicide risk of students in a high school where a fellow student recently took her own life. To get the best data in the shortest amount of time, the counselor would do the following:

  1. Ask a teacher for a list of the decedent’s closest friends and screen them;
  2. Ask any friends on that list to name their closest friends and screen those friends;
  3. Ask any friends from the new group to name closest friend and screen them, and so on; and
  4. Once there are no more positives in a friend group, screen students at random until a positive is found and begin the procedure again until the resources run out (i.e., there are no more students in the population).

Although the above process will provide an  initial “hint” of an assortativity-informed treatment approach, additional research would be necessary before beginning any efficacious intervention. Researchers warn that no offline behavior was included in their study, and therefore was not available for comparison.

Co-occurring Issues and Suicide

Suicide is a major public health problem and a leading cause of death in the United States. Everyone who chooses to attempt suicide has an underlying reason for wanting to do so. Suicide does not discriminate—people of all genders, ages, religious faiths, and ethnic groups can be at risk. Most people at risk will not follow through. Still, assessing the risk for suicidal behavior is complicated. Researchers tell us that people who attempt suicide may do so in reaction to a particular event, thought, or emotion. These individuals make decisions differently than those who do not attempt suicide. Such factors for increased risk are depression, anxiety, personality disorders, psychosis, severe bullying, rape or trauma, and substance abuse. 

Suicidal acts may be connected to recent events or current conditions in a person’s life. Although such factors may not be the primary motivation for the suicide, they can precipitate it as underlying or co-morbid triggers. A major underlying cause of suicide has been combat stress and other related PTSD issues. People in this at-risk category do not necessarily have to experience the horrors of a war zone. Other types of immediate stress include natural disasters, terrorism at home, or catastrophic loss from such events as a structure fire or a serious motor vehicle accident.

People suffering from chronic pain, severe disability, or a major illness may attempt suicide, believing their suffering is too great or that their death is inevitable. Victims of an abusive or repressive environment from which they have little or no hope of escape sometimes commit suicide. Situations that fit this category may include torture, confinement, sexual assault, or persistent physical abuse. Also, occupational stress has been indicated in some suicides due to extreme tension, anxiety, disillusion or “burnout,” and job-related financial pressures.

Cyberbullying, Substance Use Disorder

In addition to the above precipitating factors, many suicide attempts are preceded by a severe change in mood that do not correlate to an underlying psychiatric diagnosis. Mood changes most likely to lead to suicide often include extreme sadness, unresolved anxiety, frustration, anger, or shame. Unfortunately, the number of teens and young adults who take their own lives has increased due to bullying at school or on social media sites. Nearly 1 in 5 students (21%) report being bullied during the school year, impacting over 5 million youth annually. See National Center for Education Statistics [NCES], 2018. 

There has been a spike in cyberbullying over the last couple of years. This is willful and repeated bullying behavior that takes place using electronic technology, including texting, comments during gaming, Internet sites, social media, emails, blogs, cell phones, and so on. Unlike traditional bullying it can happen anywhere at all hours of the day. Approximately 34% of students report experiencing cyberbullying during their lifetime. See Hinduja & Patchin, 2015. Students who experienced bullying are nearly 2 times more likely to attempt suicide. See Hinduja & Patchin, 2018.

Worldwide, more than 1 million people die by suicide every year. Self-harm deaths have been on the rise in nearly every state in America. In the U.S., suicide deaths (47,173) were almost equivalent to the number of deaths from opioid overdoses (47,600) in 2017. It is essential that suicide prevention practices be implemented and expanded wherever possible (8). Opioid Use Disorder (OUD) has a distinctly strong relationship with suicide as compared with other substance use disorders (9). Pain causes alterations in brain circuitry in the brain’s reward center (involving the ventral tegmental area, nucleus accumbens, and the amygdala), resulting in vulnerability to suicide and a higher risk of opioid addiction. This is supported by epidemiological data that have shown chronic-pain diagnoses are linked to suicide. These associations are only partially explained by co-occurring mental health conditions, which tend to further complicate morbidity.

Tolerance to THC can build quickly in cannabis users. Teens who seek help for cannabis-use problems often report withdrawal symptoms such as anxiety, insomnia, appetite disturbance and depression (Budney & Hughes, 2006). These symptoms are of sufficient severity to impair everyday functioning (Allsop et al., 2012) and they are markedly attenuated by doses of an oral cannabis extract (Sativex) that contains THC (Allsop et al., 2014). Bagge and Borges (2015) conducted a case-crossover study of 363 persons who had recently attempted suicide and were treated in a trauma hospital for a suicide attempt within the previous 24 hours in Mississippi. The researchers compared rates of cannabis use in the 24-hour period leading up to the individual’s suicide (case period) to individuals who used cannabis during the same time period but did not commit suicide (control period). They found that 10.2% of those who attempted suicide had used cannabis within 24 hours of their suicide.

Cannabis was involved in an estimated 6.5% of drug-related suicide attempts, and in 46% of attempts the person had also used alcohol. In the 23% of drug-related suicide attempts with toxicology reports, 16.8% tested positive for cannabis, although this cannabis use could have occurred days or even up to one week earlier. In general, 9.5% of all toxicology reports for deaths by suicide (Borges, Bagge & Orozco, 2016) show the presence of cannabis. There is preliminary evidence of higher detection of cannabis among suicide decedents that do not involve overdose (CDC, 2006) and higher detection among male suicide decedents using non-overdose methods than among females (Darke, Duflou & Torok, 2009; Shields et al., 2006).

So Now What?

The Centers for Disease Control and Prevention (CDC) released data on the ten leading causes of death in the United States recently. Tragically, suicide—too often a consequence of untreated mental illness and substance use disorders, and as such a preventable condition—remains on that list as the 10th leading cause of death for adults and the second-leading cause of death in our youth. Suicide rates increased from 29,199 deaths in 1996 to 47,173 deaths in 2017. Click here for more information.

What are the contributing factors to a state of mind that ends in a person taking his or her life? What can be done to intervene? How can we turn the numbers around? The increased number of suicides year after year say something about the conditions under which people live and die, and about our society at large. Our teens and young adults are deciding in record numbers that killing themselves is the best solution to what is usually a temporary situation. Citizens at the lower end of the socioeconomic scale are significantly more vulnerable due to negative views about life and an increased amount of psychological and social difficulties. Many of these conditions are not diagnosed in time or go untreated. Many are turning to substance abuse to cope, which often increases the risk of self-harm behavior. This speaks to an environment that can promote depression, anxiety, and elevation in substance use disorder. Some sociologists have referred to these suicides as “deaths of despair.”

There are a number of interventions we can apply to these dire circumstances:

  • Safety Planning. Personalized safety planning has been shown to help reduce suicidal thoughts and actions. Patients work with a caregiver to develop a plan that describes ways to limit access to lethal means such as firearms, pills, or poisons. The plan lists coping strategies and people and resources that can help in a crisis.
  • Follow-up phone calls. Research has shown that when at-risk individuals receive proper screening, implementation of a Safety Plan, and a series of supportive phone  calls, their risk of suicide goes down.
  • Cognitive Behavioral Therapy (CBT) can help people learn new ways of dealing with stressful experiences through training. CBT helps individuals recognize their thought pattersn and consider alternative actions when thoughts of suicide arise.
  • Dialectical Behavior Therapy (DBT) has been shown to reduce suicidal behavior in adolescents. DBT has also been effective in reducing the rate of suicide in adults with Borderline Personality Disorder or related personality disorders. These mental illnesses are typically characterized by an ongoing pattern of varying moods, self-image, harmful or risky behavior, and impulsive actions. A therapist trained in DBT helps a person recognize when his or her feelings or actions are disruptive or unhealthy, and teaches the skills needed to deal better with upsetting situations.

If you are struggling with thoughts of suicide, please reach out to someone before the fog of desperation clouds your mind. If you have a friend or loved one who has expressed an intent to take their own life, do not dismiss it as a cry for attention—instead, it is a cry for help. If you are interested in becoming a volunteer or mental health professional and want to be a part of the solution for this national epidemic, please talk to a teacher, professor, mental health professional, pastor, or mentor to find out how to get started.

NATIONAL SUICIDE PREVENTION HOTLINE
1(800) 273-8255

Footnotes

(1) Alex Lickerman, M.D. (April 29, 2010). “The Six Reasons People Attempt Suicide.” Psychology Today. https://www.psychologytoday.com/us/blog/happiness-in-world/201004/the-six-reasons-people-attempt-suicide

(2) Patrick J. Skerrett (Sept. 24, 2012). “Suicide Often Not Preceded by Warnings.” Harvard Health Publishing.

(3) “Suicide Statistics.” American Foundation for Suicide Prevention. https://afsp.org/about-suicide/suicide-statistics/

(4) Melonie Heron, Ph.D., (June 24, 2018). “Deaths: Leading Causes for 2017.” National Vital Statistics Reports, Vol. 68, No. 6. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf

(5) Wood, A., Shiffman, J., Leary, R., and Coppersmith, G. (2016). “Language Signals Preceding Suicide Attempts.” CHI 2016 Computing and Mental Health, San Jose, CA.

(6) Bryan, C.J., Butner, J.E., Sinclair, S., et al. (2018). “Predictors of  Emerging Suicide Death Among Military Personnel on Social Media Networks.” Suicide and Life-Threatening Behavior, 48, 413-430. http://dx.doi.org/10.1111/sltb.12370

(7) Christakis, N.A., and Fowler, J.H. (2013). “Social Contagion Theory: Examining Dynamic Social Networks and Human Behavior.” Statistics in Medicine, 32, 556-577. http://dx.doi.org/10.1002/sim.5408

(8) https://doi.org/10.1016/j.jcjq.2019.10.001

(9) Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Substance use disorders and the risk of suicide mortality among men and women in the U.S. Veterans Health Administration. Addiction 2017; 112:11931201.

 

 

Moral Injury

My uncle served in the United States Army during the Vietnam War. He was boots on the ground in country, getting shot at and exposed to hellish conditions. He was exposed to the horrific compound Agent Orange, which ultimately led to non-cancerous masses on the back of his lungs, diabetes, and kidney failure. He was unable to recover. That, of course, was only the physical aspect of his injuries. Certainly, we are all familiar with psychological injuries. We’re particularly acquainted with post-traumatic stress disorder (PTSD). What you might not be familiar with is the extent to which combat veterans are making the fatal decision to end their own lives.

6,500 former military personnel killed themselves in 2012. In 2013, the United States Department of Veterans Affairs released a study that covered suicides from 1999 to 2010, which showed that roughly 22 veterans were committing suicide per day, or one every 65 minutes. Some sources suggest that this rate may be under-counting suicides. A recent analysis found a suicide rate among veterans of about 30 per 100,000 population per year, compared with the civilian rate of 14 per 100,000. However, the comparison was not adjusted for age and sex.

A study published in the Cleveland Clinic Journal of Medicine found that combat veterans are not only more likely to have suicidal ideation, often associated with PTSD and depression, but they are more likely to act on a suicidal plan. Especially since veterans may be less likely to seek help from a mental health professional, non-mental-health physicians are in a key position to screen for PTSD, depression, and suicidal ideation in these patients. The same study also found that in veterans with PTSD related to combat experience, combat-related guilt may be a significant predictor of suicidal ideation and attempts.

The statistics are grim, to say the least. Veterans commit one-fifth of all suicides in America today, at the rate of about 8,000 suicides per year. In 2012, the United States lost more active-duty soldiers to suicide than to combat in Afghanistan. It was the highest number in a year (349) since the Pentagon began tracking numbers in 2001.

Defined as an anxiety disorder, PTSD is believed to be driven by intense fear, helplessness, or horror, following a traumatic event, resulting in a variety of symptoms. Perhaps the toughest group to treat for PTSD are Vietnam vets. Many complained for decades of insomnia. Many also suffered from nightmares and hypervigilance, avoided crowds, and had marital difficulties. Psychiatrists learned to give a quick PTSD diagnosis to these vets and apply the usual formula for treatment. That is, prescribe medication to blunt the fear response, recommend social support, and refer the patient for talk therapy.

A psychiatrist by the name of Jonathan Shay, also a combat veteran, began treating Vietnam vets in the 1980s. Shay said “psychological and moral injury” sustained in combat destroys trust. He also said that when the capacity for social trust is destroyed, all possibility of a flourishing human life is lost. In Shay’s book Achilles in Vietnam: Combat Trauma and the Undoing of Character, he said he was struck by one veteran’s description of himself as a “typical young American boy,” an eighteen-year-old virgin with “strong religious beliefs.” When he went to Vietnam, “I wasn’t prepared for it all.” He found that it was “all evil…I look back, I look back today, and I’m horrified at what I turned in to. What I was. What I did.”

Treatment personnel noted that they had been trained to focus on the soldier’s fear. But these veterans were not talking about fear. They were talking about right and wrong. For those with severe long-standing PTSD, the problem was often a combination of fear and guilt and shame. Those potent emotions came not only from what they had witnessed, but also from their own actions in the morally confusing situations of modern combat. Michael Yandell, a veteran, wrote for The Christian Century earlier this year. He said, “For me, moral injury describes my disillusionment, the erosion of my sense of place in the world. The spiritual and emotional foundations of the world disappeared and made it impossible to sleep the sleep of the just. Even though I was part of a war that was much bigger than me, I still feel personally responsible for its consequences. I have a feeling of intense betrayal, and the betrayer and the betrayed are the same person: my very self.”

Soldiers face impossible moral situations in combat, of “the real stakes for people having to make these decisions.” Interestingly, a group of psychiatrists at Duke University coined the term “post-Vietnam syndrome” in 1972. The syndrome was marked by alienation, rage, feelings of betrayal by military leadership and the country itself, and an inability to give and accept love. These are all “deeply moral categories.” But their moral resonance had been lost in the systemization of PTSD and the nearly thirty years of research that followed.

Eventually, moral injury became another way of understanding combat trauma. Moral injury occurs when a soldier is exposed to or partakes in acts that transgress deeply held moral beliefs and expectations. While traumatic events and atrocities can cause moral injury, so too can more subtle acts that transgress a moral code.

Here’s the exciting part. At the heart of the Gospel is a narrative of creation, brokenness, redemption and reconciliation, a “new creation.” In Jesus Christ, we have a paradigm of mental health and flourishing. After all, Jesus was once rumored to suffer from mental illness. Mark 3:21 says, “And when his friends heard of it, they went out to lay hold on him: for they said, ‘He is beside himself.’” Christ certainly endured physical and mental anguish. The Church has language and practices to foster healing for veterans, such as lament, confession, and reconciliation. All of these allow us to “listen, reflect, bear, and grieve” with our veterans.

War, even when justified, is always a tragic manifestation of human brokenness. Churches and faith-related organizations have launched programs in recent years to better care for veterans’ mental and spiritual health. It is an important finding that our veterans are suffering from moral injury. Just on its face, it seems such an injury cannot solely be treated with medication and talk therapy. One thing though: moral injury is really a rediscovery of an older set of truths. The Church has a long history of ministry to and by veterans. Now the Church needs to find “creative and faithful ways” to walk with people suffering from a range of mental health issues.

So, in the meantime, what can we do when we encounter a veteran who has returned from combat and is struggling? If there’s one thing combat veterans hate, it’s the question, “Did you kill anyone?” It’s best simply to ask a veteran what their deployments were like, keeping in mind that people feel differently about their time in the service. The most effective approach is to be human and work on friendship. The Church has the opportunity to dress the wounds of each war-torn soul among us. Good mental healthcare is a necessary and valuable part of that work. But if we seek the full flourishing of those who have been impacted by war, the Church has an irreplaceable role to play. It is time to realize that combat veterans suffer not only on an emotional and physical level, but also on a spiritual and moral level. It would seem to me that this is the piece that has been missing from our therapeutic work with soldiers suffering from PTSD.

May God bless the men and women of our armed forces.