Department of Psychiatry
Penn Behavioral Health

PAH Outpatient Behavioral Health Clinic

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Newsletter: September 2010

Suicide: Three things to keep in mind

Hallie Kushner, MA


Although a rare tragedy, suicide leaves behind a long trail of grief, guilt, and pain. Surviving family and friends ask what they might have done differently to prevent a loved one’s suicide. There will always be limits to how much one can do, but having information about suicide can go a long way toward knowing what to look for—and how to help. In the September 2009 issue of this newsletter, Karin Sofer provided common risk factors and warning signs of a person who is considering suicide (http://www.med.upenn.edu/psychotherapy/SuicidePrevention.html). This issue will add to that important topic by focusing on three things to keep in mind about people who may become suicidal.


The interpersonal theory of suicide

Thomas Joiner and his colleagues have theorized a model of suicide that respects the complexity of people’s suffering, yet is easy to understand and remember (Joiner, 2005; Van Orden et al., 2010). According to this model, people are at most risk for suicide when three things occur: 1) the person feels disconnected from other people; 2) the person feels that he or she is a burden on other people; 3) the person has the capacity to act on suicidal thoughts. I will review each of these factors in more detail.


“I am alone”

There are many ways to be alone, and not all of them are unpleasant. But feeling lonely or disconnected is different. For example, somebody might live in an apartment by herself because she likes to play music at odd hours and cook dinner at 2:00 a.m. That person probably will not feel bad about living alone. A woman whose husband has died and whose children live in another state would probably feel very differently. A man who enjoys going out by himself would probably not mind going to a movie alone, whereas others would. But even though people have different levels of comfort with being alone, most of us need to feel connected to at least a few people in our lives.  An absence of feeling connected to others is what Joiner and colleagues call “thwarted belongingness.

We all feel lonely sometimes. Or we might get busy at work for a while and lose track of what our friends and family are up to. People suffering from clinical depression may isolate themselves for a while. Loneliness is a part of life. It becomes dangerous when the person who feels a thwarted belongingness is also hopeless that the situation will change. 


“I am a burden”

People who feel that others would be better off without them are at increased risk for wanting to commit suicide. Joiner and colleagues call this belief “perceived burdensomeness.” Unemployment and illness are two sadly common life circumstances that might lead to the belief that one is a burden on others. For example, a father who is having trouble finding a new job might feel so much shame and worry that he forgets that his family needs him for other things, too. A mother suffering from a physical or psychiatric illness might think that committing suicide will relieve her loved ones of caring for her.  She forgets that they love the person she is more than they hate the illness. Teenagers experience this feeling, too. For example, a teen might feel his family would be better off without him if his parents are having money problems or there are other siblings who need a lot of attention. Like with loneliness, temporary feelings of uselessness or being a burden will not drive someone to suicide. But feeling hopeless about the situation changing can lead to stronger thoughts or wishes for suicide.


“I could do this to myself”

It might seem surprising, but not everybody who thinks about suicide or wants to die could actually bring himself or herself to do it. The instinct to live is strong, even for people who are suffering a great deal. Thus, “capability for suicide” is an important risk factor. Can the person get over a natural fear of death? Can the person act violently toward him or herself?

Unfortunately, there are many ways that people develop this capability. Sometimes people who have been abused get used to being hurt, and might even hurt themselves. Sometimes people witness violence, in the home, the community, or even at work, and violence begins to seem normal. Sometimes people get into a lot of accidents, especially while under the influence of alcohol and drugs, and the injuries start to seem like no big deal. Even talking about suicide can increase the capability to act, because the more a person talks about or thinks about suicide, the less scary those thoughts become. Very few of us start out with an ability to bear the thought of death or physical pain, but almost anyone can develop it over time.


How you might use this model

If you think someone close to you has the desire for suicide and the capability to act on that desire, you should not feel like you have to handle it alone. It will be good for you, as well as your loved one, to seek the help of a mental health professional. You may want to encourage that your friend or family member visit a psychotherapist or psychiatrist. But there is still a lot you can do. You can keep an ear out for comments about loneliness and try to make that person feel more connected. For example, something as small as sending a note or greeting card might help a person feel less alone. You can also pay attention if somebody says something like, “people will be better off without me.” Often people who feel like they are burdens to others do not notice the ways in which they contribute to their family or their community. You can make them feel needed by pointing out how they are important—as a parent, as a child, as an employee, or any number of things. The best way to prevent a suicide may be to prevent someone from wanting to die. You cannot do it alone, but you can help.