Health Articles

Stayin’ Alive

by Danielle Kuznetsov, AWO Moscow

Out of sight, out of mind. Isn’t that how much of life works, when the issue is not a quick fix? You will be reading this in October, after National Suicide Prevention Month in the United States has ended. September 10 was Worldwide Suicide Prevention Day, so for a brief moment this year, a topic no one really wants to talk about was dusted off and spotlighted globally. Suicide is such a sticky subject, yet many people have been affected by it. We have very little understanding about it, which makes exploring this issue uncomfortable and perhaps, incomprehensible.

Suicidal thoughts, much like mental health conditions, can affect anyone regardless of age, gender, or background. In fact, suicide is often the result of an untreated mental health condition.^[1] The data suggests it is on the rise, so burying our heads in the sand and pretending won’t make the issue go away.

The goal of this article is to raise awareness, discuss prevention and recovery, speak to someone who might be struggling with suicidal ideation, and provide resources for education and suicide prevention ‒ although not in that order. A wealth of information is available worldwide for self-education and advocacy. Mental health issues affect all of society in some way, shape, or form.^[2] All of humanity is on the spectrum, including you and me. Consider this conversation a drop of hope in a vast sea of pain.

Let’s start with statistics. According to the Centers for Disease Control, in 2017, suicide was the tenth leading cause of death overall in the United States, claiming the lives of over 47,000 people. It was the second leading cause of death among individuals between the ages of 10 and 34, and the fourth leading cause of death among people between the ages of 35 and 54. As of 2017, there were more than twice as many suicides (47,173) in the United States as there were homicides (19,510). ^[3]

Across the globe, suicide statistics vary. Lithuania, Russia, Guyana, South Korea, Belarus, Suriname, and Kazakstan all have over 22 suicides per 100,000 residents, whereas Afghanistan, Iraq, and Syria reported very low numbers.^[4] South Korea is the tenth highest country in the world, with the elderly sometimes choosing suicide rather than burdening their families with their care. Students have higher than average suicide rates due to the pressure put on them to succeed. In Japan, it is the leading cause of death among men aged 20-44 and women 15 to 34. In this culture, suicide is an honorable way out of shameful situations like financial burden and losing a job. Sweden reports only 12 suicides per 100,000 people. Given that physician-assisted suicide is legal in that country, this figure might be higher than what is reported. In China, suicide is the fifth leading cause of death, and women account for the majority of deaths.^[5] I never knew the problem was so vast and culturally diverse. I guess there is no “one size fits all” approach to dealing with this phenomena.

It is ironic that suicide has such stigma around it when so many notable and influential people have died by suicide. There are lists and lists of celebrities, musicians, artists and notables who have chosen this route ‒ so many that counting became overwhelming to me. I gave up. Most recent famous people that you may have heard of who survived a suicide attempt include Johnny Cash, Mickey Dolenz, Elton John, Princess Diana, Billy Joel, Ken Griffey Jr., Eminem, Vanilla Ice, Oprah and Martin Luther King Jr.^[6] When it comes to mental health, we must be our own advocates and we must be ready to help others.

Equal to the lists of those who have died by suicide (Robin Williams, Kate Spade, Anthony Bourdain) and the vast array of reasons for their suffering, there is an even wider range of interventions for preventing mental health problems. Most times, people are embarrassed or worried about reputation and so they don’t reach out for help. The idea that people are without resources and support networks to deal with life’s problems is without merit. What we do lack is ongoing, authentic and open global discourse that mental health disorders are common in all places, at all times, to all people. The choice to die by suicide does not happen overnight. Recovery and resiliency are the skills needed to balance out our physical, spiritual, mental, and emotional needs. These are the 21st-century skills that must be taught at home, in school and on the job.

Because an attempted suicide of a child touched my life directly a few years back, I read and read to understand how a person gets to the place to contemplate ending their life. It feels tragic. I offer Targeted Intervention Empathy (TIE) as a possibility for prevention and a way to avail yourself to others in this situation. TIE is the brainchild of Dr. Mark Goulston, a veteran psychiatrist with over 25 years specializing in suicide. I met him through his book, Get Out Of Your Own Way. It greatly helped me to change my thinking and life. I read all his books and came upon his work on suicide, and have been reflecting on it ever since.

According to Dr. Goulston, none of the factors we think of ‒ like depression, alcoholism, legal problems, relationship problems or money problems ‒cause suicide. They may contribute, but they are not the cause. He has identified the thing that nearly all people who die by suicide feel at the moment they pull the trigger, tie the knot, jump from the building or swallow the pills. Dr. Goulston defined it as DES-pair. As a noun, it is the loss of hope. As a verb, it is the giving up of hope. In this conversation, it refers to the void between a person and her life.

Dr. Goulston defines DES-pair as in feeling unpaired with the reasons to live:

1. Hopeless — unpaired with a future that is worth living because all efforts to lessen pain (medications, therapy, etc.) have not worked
2. Helpless — unpaired with the ability to pull themselves out of it
3. Powerless — more of #2 above

4. Useless — unpaired with any solution or treatment that works, or alternatively feeling that you contribute nothing to anyone and are only a burden (even if those people profess the opposite)
5. Worthless — unpaired with one of the key reasons for men [human beings] to exist
6. Purposeless — unpaired with a mission for you to focus on and one that gives you a source of pride, without which one can feel aimless and ashamed as in, “My life has no purpose.”
7. Meaningless — unpaired with what Victor Frankl* was able to discover in a concentration camp and what people can feel when they have no purpose
8. Pointless — unpaired with any reason to not pull the trigger, put the noose around your neck, jump from that building, take those pills, step onto those train tracks

***Victor Frankl was an Austrian neurologist, psychiatrist and Holocaust survivor. He wrote about finding meaning in life's sufferings and experiences, not by avoiding them, but rather by finding meaning through them. He established the school of "existential therapy" or logotherapy, as it was named, because he proposed that human beings can find meaning in the most difficult of circumstances. 

These eight “-lesses” can collectively result in the pain that can no longer be endured ‒ that when collectively felt, causes people to pair with death as a way to make it go away by their going away. (7)©Dr. Mark Goulston, medium.com; used by express permission

The approach Dr. Goulston used to develop Targeted Intervention Empathy Therapy evolved from applying Design Thinking, an approach to creative problem solving, by David Kelley, founder of the design company, IDEO to the problem of suicide prevention by reaching out through social media.(8)

The following is my brief synopsis:

1. Empathy: Understand where your “client” is coming from, even if they are not aware of it themselves.
2. Problem definition: Empathize with your audience by turning it into a problem to be solved.
3. Ideation: Following the problem definition, create or imagine a solution that will be turned into a prototype.
4. Prototype: Create the prototype to address the problem to be solved.
5. Test: Use the prototype to test and verify that it solves the problem mentioned in step two.

When you enter into a distressed person’s world and are with them in it, they are not alone.

The Practical Application for you and me:

1. Get quiet. Listen to what the person is sharing. Don’t give advice. Ask gentle questions.
2. Repeat. Affirm their experience as real and valid. Identify the issue.
3. Connect by either looking the person in the eye, or if by phone, by using tone of voice. Get into the darkness with them so they are not alone. Wait. Affirm.
4. Allow the suffering to pass. Listen. Build upon what is offered as possibility to deal with the pain. Explore.
5. Repeat the possible resolution or plan. Get input. Connect the person with others. Affirm. Repeat. Reflect.

“When they ‘feel felt’ and less alone, suffering they couldn’t deal with became pain they could. And nearly every time, when that suffering stopped, they began to cry and sob, feel relief, and with that could step back from the impulse to annihilate themselves.”(9)

This is what Dr. Goulston describes as pairing ‒ the very experience which is needed for a person to shake off the “-lesses.” Pairing and empathy are essential elements of all productive communication and human connection. Here Naomi Feil, shows us two stellar examples of pairing and empathy for your consideration: https://youtu.be/TgbbkjtO4-M and https://www.youtube.com/watch?v=ESqfW_kyZq8

In addition to understanding the DES-pair experience, Dr. Goulston proposes that there are seven words that are related to pain. They are hurt, afraid, angry, ashamed, alone, lonely and tired. When those words are offered to a person in crisis, they open up a door to empathetic connection. Targeted Intervention Empathy: creating connection to help to prevent suicide. By offering the words, a person is able to choose the one closest to the emotion they are feeling. “When you give another person the words in a non-judgmental manner you are giving them your understanding as you say it and validating that they’re not wrong to feel any of them.” (10) Offering, rather than telling, creates space, which buys time. Time and connection are what the brain needs to calm down.

“Deep psychic wounds in suicidal individuals are similar to physical wounds in that someone, attempting to intervene, needs to go to the core of that wound, clean it out by helping that person feel less alone, and then leaving in an empathic drain by remaining emotionally connected to them. From there, they will granulate in from that wound in their core and from their inside out with hope.”(11)

Neuroscience is defined by the Oxford Dictionary as, “any or all of the sciences, such as neurochemistry and experimental psychology, which deal with the structure or function of the nervous system and brain.” Understanding how the brain and central nervous system develop and work is essential in unpacking the equally mysterious parts of our humanity, like emotions and behavior. Targeted Intervention Empathy makes a way for brain chemistry to kick in to help the emotions get in check.

Oxytocin is our “hormone friend” in this connection process. When a person feels “felt” and understood, the brain produces this wonderful enzyme. It attacks and lowers cortisol, the stress hormone, which is the fight or flight mechanism. The brain must respond, and blood is moved from the amygdala (the emotional brain) to the frontal lobes (the thinking brain). Notice that human connection, openness, and trust are grounded in neuroscience and offer hope and the first step away from a choice of permanent isolation.

“There is a common misunderstanding among all the human beings who have ever been born on earth that the best way to live is to try to avoid pain and just try to get comfortable. You see this even in insects and animals and birds. All of us are the same. A much more interesting, kind and joyful approach to life is to begin to develop our curiosity, not caring whether the object of our curiosity is bitter or sweet. To lead a life that goes beyond pettiness and prejudice and always wanting to make sure that everything turns out on our own terms, to lead a more passionate, full, and delightful life than that, we must realize that we can endure a lot of pain and pleasure for the sake of finding out who we are and what this world is, how we tick and how our world ticks, how the whole thing just is. If we are committed to comfort at any cost, as soon as we come up against the least edge of pain, we’re going to run; we’ll never know what’s beyond that particular barrier or wall or fearful thing.” (12)

Recovery is a process of healing and restoration. It is the journey of learning and living life abundantly in a world that at times does not make sense. It focuses on building strengths, capacities, resiliencies, talents, and inherent worth.(13) It requires our courage, cooperation, and community. Everyone is connected. And since we are all on the “spectrum” this kind of conversation is a critically important first step.

“Tell me, what is it you plan to do with your one wild and precious life?”

― Mary Oliver

Suicide Prevention in the home:

Common Factors in Suicide Risk:

         A history of self-destructive habits

• Substance abuse
• Changes in relationships
• History of family depression and/or suicide
• Previous attempts at suicide
• Untreated mental health problems (such as depression, anxiety, bipolar disorder, schizophrenia)
• Fear or embarrassment over seeking help for mental health issues
• Feeling lonely, shameful, inadequate or alienated
• Lack of close relationships

Warning Signs:

• A lack of interest in activities that used to be enjoyable, or a sudden disinterest in following through with goals
• Overly emotional outbursts, ranging from frequent crying to becoming easily irritated by many different things
• Shifting from being an engaged, achieving student to one who doesn't seem to care about missing classes or not turning in assignments
• Ignoring existing friends, or not attempting to make new friends in college
• Significant changes in eating habits, weight, appearance or level of self-care and hygiene
• Any attempt to give once-prized possessions away to friends or family
• Behavior that seems impulsive or reckless; a lack of appreciation for safety or the value of life
• Frequent, uncontrollable anger that is often rooted in a lack of self-worth
• Writing about suicide, death or dying – especially when interest in the topic is out of the ordinary
• Not wanting to get out of bed, sleeping far more than usual or experiencing insomnia
• Having suicidal thoughts
• A lack of interest or awareness of future plans, or a loss of interest in upcoming events that would usually promote excitement
• Dark or hopeless posts on social media, especially if these kinds of posts are out of the ordinary
• Any attempts to tell a friend, family member or other loved one goodbye in person, on the phone, over text messages or through social media
• Any expression of feeling trapped or seeking any type of relief and/or escape from a current situation
• Any expression of not having a purpose in life, or questioning if life is worth living

Writers, S. (2019). Parents' Guide to Suicide Prevention: Support & Resources. [online] AccreditedSchoolsOnline.org. Available at: https://www.accreditedschoolsonline.org/resources/suicide-prevention/ [Accessed 26 Sep. 2019].

Steps to help protect your teen

• Address depression or anxiety. Don't wait for your teen to come to you. If your teen is sad, anxious or appears to be struggling ‒ ask what's wrong and offer your help.
• Pay attention. If your teen is thinking about suicide, he or she is likely displaying warning signs. Listen to what your child is saying and watch how he or she is acting. Never shrug off threats of suicide as teen melodrama.
• Discourage isolation. Encourage your teen to spend time with supportive friends and family.
• Encourage a healthy lifestyle. Help your teen eat well, exercise and get regular sleep.
• Support the treatment plan. If your teen is undergoing treatment for suicidal behavior, remind him or her that it might take time to feel better. Help your teen follow his or her doctor’s recommendations. Also, encourage your teen to participate in activities that will help him or her rebuild confidence.
• Safely store firearms, alcohol and medications. Access to means can play a role if a teen is already suicidal.

Mayo Clinic. (2019). Do you know the signs your teen is at risk of suicide?. [online] Available at: https://www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/teen-suicide/art-20044308 [Accessed 26 September 2019]. 

©Dr. Mark Goulston, medium.com; used by express permission

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Suicide Prevention in Schools:

Youth who feel suicidal are not likely to seek help directly; however, parents, school personnel and peers can recognize the warning signs and take immediate action to keep the youth safe. When a youth gives signs that they may be considering suicide, the following actions should be taken:

• Remain calm.
• Ask the youth directly if he or she is thinking about suicide (e.g., “Are you thinking of suicide?”).
• Focus on your concern for their well-being and avoid being accusatory.
• Listen.
• Reassure them that there is help and they will not feel like this forever.
• Do not judge.
• Provide constant supervision. Do not leave the youth alone.
• Remove means for self-harm.
• Get help: No one should ever agree to keep a youth’s suicidal thoughts a secret and instead should tell an appropriate caregiving adult, such as a parent, teacher or school psychologist. Parents should seek help from school or community mental health resources as soon as possible. School staff should take the student to a school-employed mental health professional or administrator.

The Role of the School in Suicide Prevention

Children and adolescents spend a substantial part of their day in school under the supervision of school personnel. Effective suicide and violence prevention is integrated with supportive mental health services, engages the entire school community and is imbedded in a positive school climate through student behavioral expectations and a caring and trusting student/adult relationship. Therefore, it is crucial for all school staff members to be familiar with and watchful for risk factors and warning signs of suicidal behavior. The entire school staff should work to create an environment where students feel safe sharing such information. School psychologists and other crisis response team personnel, including the school counselor and school administrator, are trained to intervene when a student is identified at risk for suicide. These individuals conduct suicide risk assessment, warn/inform parents, provide recommendations and referrals to community services, and often provide follow up counseling and support at school.

National Association of School Psychologists (NASP). (2019). Preventing Youth Suicide: Tips for Parents & Educators. [online] Available at: https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide/preventing-youth-suicide-tips-for-parents-and-educators [Accessed 26 September 2019]. 

©Dr. Mark Goulston, medium.com; used by express permission

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Suicide Prevention at Work:

In researching to find what is done at work to raise awareness and prevention, I found there are no clear-cut approaches, and that human resource departments are just beginning to formulate plans based on individual company policies, environments and funding.

I offer the Comprehensive Blueprint for Workplace Suicide Prevention as a starting point. The National Action Alliance for Suicide Prevention’s site is a solid place to start research.

The blueprint can be found at https://theactionalliance.org/communities/workplace/blueprintforworkplacesuicideprevention

Helpful Resources:

www.suicidology.org

www.afsp.org

www.bbrfoundation.org

www.depression-screening.org

www.nami.org

www.TheNationalCouncil.org

www.nimh.nih.gov

www.sprc.org

Help Lines:

American Psychiatric Association Answer Center 1-855-357-7924

American Psychological Association Public Education Line 1-800-964-2000

National Suicide Prevention Hotline 1-800-273-8255

Self Help:

American Self-Help Group Clearinghouse

www.mentalhelp.net/selfhelp/

Recovery International

www.recoveryinternational.org

http://youtube.com/stayalivevideo

Terminology:

http://www.sprc.org/sites/default/files/migrate/library/glossary.pdf

References:

1. ^[1]Nami.org (2019). Get Involved | NAMI: National Alliance on Mental Illness. [online] Available at: https://www.nami.org/Get-Involved/Awareness-Events/Suicide-Prevention-Awareness-Month [Accessed 25 Sep. 2019].
2. ^[2]Mental Health First Aid USA, 2015 National Council for Behavioral Health and the Missouri Department of Mental Health, p.ii

3. ^[3]Nimh.nih.gov. (2019). NIMH » Suicide. [online] Available at: https://www.nimh.nih.gov/health/statistics/suicide.shtml [Accessed 25 Sep. 2019].

 3.^[3]Suicide Rate By Country Population. (2019-08-28). Retrieved 2019-09-25, from http://worldpopulationreview.com/countries/suicide-rate-by-country/

4. ^[4]Suicide Rate By Country Population. (2019-08-28). Retrieved 2019-09-25, from http://worldpopulationreview.com/countries/suicide-rate-by-country/

  5.^[5]Goulston, M. (2019). Why people kill themselves- Part 2: It’s not depression. [online] Medium. Available at: https://medium.com/@mgoulston/why-people-kill-themselves-part-2-its-not-depression-24183d4bb99f [Accessed 25 Sep. 2019].

6. ^[6]Swift, J. (2019). 10 Famous People Who Attempted Suicide But Lived To Achieve Amazing Success. [online] Thought Catalog. Available at: https://thoughtcatalog.com/james-swift/2017/01/10-famous-people-who-attempted-suicide-but-lived-to-achieve-amazing-success/ [Accessed 26 Sep. 2019].

7. Goulston, M. (2019). Why people kill themselves- Part 2: It’s not depression. [online] Medium. Available at: https://medium.com/@mgoulston/why-people-kill-themselves-part-2-its-not-depression-24183d4bb99f [Accessed 25 Sep. 2019].

8. Goulston, M. (2019). Why people kill themselves — Part 5: Targeted Interventional Empathy for Suicide Hotlines — Seven Words. [online] Medium. Available at: https://medium.com/@mgoulston/why-people-kill-themselves-part-5-interventional-empathy-for-suicide-hotlines-seven-words-9f6419210446 [Accessed 25 Sep. 2019].

9. Goulston, M. (2019). Why people kill themselves — Part 6: Design Thinking Suicide Prevention. [online] Medium. Available at: https://medium.com/@mgoulston/why-people-kill-themselves-part-6-design-thinking-suicide-prevention-3eeaee37ccef [Accessed 25 Sep. 2019].

10. Goulston, M. (2019). Why people kill themselves — Part 5: Targeted Interventional Empathy for Suicide Hotlines — Seven Words. [online] Medium. Available at: https://medium.com/@mgoulston/why-people-kill-themselves-part-5-interventional-empathy-for-suicide-hotlines-seven-words-9f6419210446 [Accessed 25 Sep. 2019].

11. Goulston, M. (2019). Why people kill themselves — Part 6: Design Thinking Suicide Prevention. [online] Medium. Available at: https://medium.com/@mgoulston/why-people-kill-themselves-part-6-design-thinking-suicide-prevention-3eeaee37ccef [Accessed 25 Sep. 2019].

   12.Chodron, P. (2019). A quote by Pema Chödrön. [online] Goodreads.com. Available at: https://www.goodreads.com/quotes/215417-there-is-a-common-misunderstanding-among-all-the-human-beings [Accessed 28 Sep. 2019].

13. Mental Health First Aid USA, 2015 National Council for Behavioral Health and the Missouri Department of Mental Health, p.v

To read Dr. Goulston’s complete article on Why people kill themselves please reference this link://medium.com/@mgoulston/why-people-kill-themselves-and-others-part-1-of-7-im-going-to-kill-myself-312c35599382">