Key Points

• In spite of research, suicide remains notoriously difficult to predict.
• Person-oriented, narrative approaches to understanding suicide add to our current understanding and may improve prevention.
• People concerned for their well-being or that of others may seek help from the National Suicide Prevention Lifeline 1-800-273-TALK (8255) or 911.

SAMHSA (the Substance Abuse and Mental Health Services Administration) reports statistics about suicide in the United States, including the recent Centers for Disease Control and Prevention survey on 2017 data finding the following:

• Nearly 47,173 suicide deaths occurred (approximately one death every 12 minutes).
• 9.8 million adults seriously thought about suicide.
• 2.8 million made a plan, and 1.3 million attempted suicide.

Suicide…

• Is the 10th leading cause of death for adults.
• Is the 2nd leading cause of death for youths.
• Increased from 29,199 deaths in 1996 to 47,173 deaths in 2017.

Suicide prediction and prevention are increasingly important. There is growing awareness that we are facing a national and global mental health crisis, spurred on by the pandemic, climate change, and other factors. Cultural shifts including greater openness from celebrities and athletes lead to reduced stigma; celebrity suicides and a host of other emerging factors have raised awareness of the need for resources.

In spite of research, accurate, timely suicide prediction¹ remains elusive. Legislative action has led to the establishment of the 988 mental health crisis number (anticipated in 2022). Ongoing work is needed to improve our ability to predict suicide and address underlying risk factors.

Using Narrative Approaches to Understand the Psychology of Suicide

Researchers Tillman, Stevens, and Lewis (2021) from the Austen Riggs Center in Stockbridge, Massachusetts, which focuses on intensive psychoanalytic treatment of patients with persistent difficulties in living, reported on suicide research,² noting existing research and areas for further study.

They suggest that combined research approaches are needed to overcome limitations of quantitative approaches: “Ideation-to-action” models look at changing processes over time that may related to suicide, shifting the focus from data or “variable-oriented” to “person-oriented” models. Understanding the subjective experience of people at risk for lethal suicide attempts adds valuable and troubling insights.

With this in mind, Tillman and colleagues published their work on near-lethal suicide attempts in the journal Psychoanalytic Psychology. To open a window into the suicidal mind, they conducted detailed interviews with 11 people who survived highly lethal attempts due to chance alone seeking to “reconstruct their state of mind prior to the suicide attempt with as much depth and elaboration as possible.”³

Quantitative Findings Regarding Near-Lethal Suicide Attempts

About 75 percent of the participants were women, with an average age of 29 years, ranging from 19 to 51 years. Few were married or in a long-term relationship, and all had been diagnosed with a personality disorder. On average, they had a history of more than five hospitalizations before their current inpatient treatment, with first treatment around age 13 years, and suicidal thinking starting by age 18.

First suicide attempt averaged around 24 years of age with average prior number of 2.64 attempts. Most distressing moods before suicide attempts were “depressed,” “hopeless,” desperate,” and “empty,” in addition to feeling “resigned.” “Enraged” was ranked low among presuicide emotional states. Most participants said they did not think anyone close to them could have known they were going to harm themselves.

7 Themes From Qualitative Analysis of Detailed Narratives

1. Developmental conflicts and crises: Difficulty navigating a major life transition seemed an impossible developmental challenge. Separation was a common theme—for example, difficulty leaving home to go to college, with suicide as a solution and a way to assert autonomy by outmaneuvering parent and therapist efforts. Older patients drew connections to their own adolescent struggles as their own children reached teenage years.⁴
2. Character traits and vulnerabilities: Patients with rigid personalities and coping styles discussed feeling suicidal despair when unable to achieve goals or when others failed to empathize with their distress. Traits included perfectionism, rigid thinking, and maladaptive ways of making use of resources and support, with difficulty coping with mortality and nihilistic experiences. One patient reported inner conflict due to both wanting to die and staying alive because of what others wanted.
3. Interpersonal and object relations paradigms: Betrayal by others and feelings of having disappointed others were commonly reported. Patients expressed pleasure and empowerment around outsmarting people close to them as well as professionals. Deception around suicidal thinking was a characteristic interpersonal pattern. Participants reported right before suicidal behavior mentally “sever[ing] all ties both in the internal world of objects and the external world of people and relationships.” Some reported feeling that others had failed them in time of greatest need, and one person spoke of using suicide to retaliate against those who had wronged them.
4. Thinking and affect: Resonant with previous research, most described feeling excruciating, unremitting psychological pain with no sense that it would ever get better. Emotions reportedly went back and forth between numbing and flooding, including traumatic flashbacks. Patients reported suicidal logic including the idea that after death one would not be around to deal with problems or consequences, neither having to experience suffering nor missing out on good things by virtue of no longer being alive, and minimizing the effect on others. Thinking around suicidal action included cynicism, nihilism, and feelings of being powerful.
5. Fantasies of death: Ideas about what death would “feel like” were common, as well as what function dying would serve. Some spoke of reunion with a deceased loved one like a parent. Some conceived of death as “nothingness” or as “just falling asleep,” imagining peacefulness. Dissonant ideas about death were expressed—for example, participants saying they didn’t believe in an afterlife and at other times describing thoughts about the afterlife, suggesting an insecure attachment with death.
6. Paradoxical nature of the immediate moment of the suicide attempt: Many participants reported both planned and impulsive aspects to their decision. They seemed of “two minds,” reflecting underlying traumatic and dissociative aspects—for example, feeling like they made the decision on the spur of the moment while also reporting having thought about it for years, with “various types of rehearsal, preparatory acts, planning, and intention to deceive others about their plan.” The decision for suicide was described as the “perfect time,” when “everything was falling into place.”⁵
7. Reactions to survival:Everyone interviewed said they had planned to die, with planned lethal intent and action, often with serious medical consequences. They had survived “by accident.” Many continued to feel suicidal and were often unhappy they’d survived. One reported that they’d “lost their fear of death,” making future suicide more likely. Another participant was hopeful after their suicide attempt, having learned that people did care.⁶ Others felt guilt reflecting on how their actions impact others, notably young children.

While this is a small study, it is also notable for taking an in-depth look at a unique group of people who have nearly died by suicide and survived to tell the tale. Some are glad for a second chance, while others remain at risk. Treatment of underlying depression and other related conditions is important to address the underlying emotional pain and attendant thought patterns, and to rework adaptations to developmental adversity that may lead to ongoing suffering and delayed tragedy years later.

People concerned for their well-being or that of others may seek help from the National Suicide Prevention Lifeline, 1-800-273-TALK (8255), or 911. The 988 dialing code is expected to be active in 2022.

Originally published in Psychology Today on October 25, 2021

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