How can we understand the suicidal mind in the moment of crisis?

She posed them all the same question: How can we understand the suicidal mind in the moment of crisis?

Dr Breanna Banks, Director of Clinical Education – Centerstone Research Institute

About nine years ago I experienced some very intense suicidal ideation and a very intense desire to die. Oddly enough, very serendipitously, many things came together and I was able to take much of what I was learning in order to be a clinician and use it for myself. I was very fortunate and managed to pull myself out of a really, really hard and dark time – so there's some intersectionality there that informs my lens.

I've been doing suicide prevention research for about 10 years and I've spent a lot of my life teaching and training around how to work and research with suicidal people. Within the Centerstone Research Institute a big focus of ours is translational science and how we reduce the science to service gap. The question you ask, how to understand the suicidal mind in the moment of crisis, is one that scientists, clinicians, and people with experience of suicide have been exploring for a long time. We don't know yet, as a science, but there are a handful of theories and some bodies of research that are leading us to an answer.

The first thing that comes to mind in finding that answer is the recent debate over the lack of a diagnosis for suicidality or suicide attempt within the DSM 5. There are two main camps around that conversation which aren't mutually exclusive. One is the notion that suicidality can occur during a crisis – those feelings can come on in a very sudden moment and in that moment risk of death or a suicide attempt is very, very high. The other camp treats suicidality more like a developmental issue or a thing that can evolve and change over the lifespan. I think there's truth to both. But I do think that suicidality, or moving from a place of having an initial desire to die to actually taking the behavioural steps to end your life, takes time and exposure. I am inclined to believe, from what the science says and from what I've learned from working with suicidal clients and in my own experience, that it's more of a process that can be exacerbated in the moment or within a particular moment to lead someone to try to die.

When I first started my training to be a clinician and a provider back in 2003 the approach – and I still see it in some training – is a warning-signs or risk-factors model. If we take a look at what the science says there have been about 4000 risk factors associated with suicide in some way. One of the issues that we see in this model, and within that body of research, is that there's not really been any conclusive evidence that says that this risk factor is more connected or more predictive of an attempt than this other factor. Much of the content of this model is valuable and can point us in the right direction… but through my translational science lens, I want to know how I can give this information to a clinician in a way they can actually use.

Fortunately, Dr Thomas Joiner, a Clinical Psychologist at Florida State University, developed the Interpersonal-Psychological Theory of Suicide and that model is, to date, the theory that's been able to actually predict, or be tied to prediction, of high lethality suicide attempts in death or suicide attempts. Thomas's research landed on three core things that are most predictive of suicide attempts and death – perceived burdensomeness, lost belongingness and acquired capability.

Perceived burdensomeness is a person's belief that their death is worth more than their life. It's like a mathematical equation – if I die I'll have more benefit than if I live. Lost belongingness is a sense of lost connectedness. Think about the very high level of risk among the military – when these folks were in the military there was a very strong sense of camaraderie, brotherhood and kinship that was tested and solidified through very harsh experiences, but when they come back from deployment that has gone.

The third factor, acquired capability, is the one I think is most novel. When I've used it clinically it helps me to identify the folks that I need to hospitalise right now and the people I think are safe to go home. Acquired capability is the notion that dying by suicide is hard and takes two core things – physical pain tolerance and a prepared and practiced fearlessness about death. That fearlessness usually happens through repeated exposure to things that we can link to death in one way or another. So, again, if I'm in the military I've seen death, or I've at least been trained to confront it, and I also know a whole lot about firearms – I've come into contact with death in a way that's psychologically familiar.

The publication of that theory really turned the corner for suicide prevention research. When I'm doing suicide risk assessment screening I use a psychometrically-validated measure called the interpersonal needs questionnaire that Thomas created. It tells me where my client falls on burdensomeness and belongingness. Then I can have a conversation with my client about how burdensomeness manifests for them, what it looks like in their life, how belongingness manifests for them, and talk about the acquired capability component.

It's been revolutionary for me personally. I can create interventions that directly target the core predictors of suicidality. If belonging is an issue, how can I create interventions that increase connectedness? Or, if burdensomeness is a core issue for my client, how can I create interventions to build a sense of contribution to the world or a sense of contribution to those around them? And we create treatment interventions that can start with an antidote to those drivers of suicide.

Evan Kleiman, Assistant Professor (Rutgers University) and Director of the Kleiman Lab

The primary thing I've been studying over the past six or seven years is what suicidal thoughts and behaviours look like in everyday life. About four years ago we measured suicidal thinking every couple of hours. What we found is that suicidal thinking, suicidal behaviours and risk for suicide isn't a slow increase to a peak and then a slow decrease; over just a matter of hours we see a very fast movement between high suicidal thinking and low suicidal thinking. Of course sometimes people stay very high for a while or very low for a while, but the period of time over which suicidal thinking escalates is pretty fast – a magnitude of hours rather than days or weeks. The reason why that's interesting to us is it means we have a very short period of time to do interventions and it helps us understand what this period of time looks like.

The primary method that we use to assess suicidal thoughts and behaviours is ecological momentary assessment. We install an app on people's phones and throughout the day they'll get a set of questions asking them how they're feeling right now at that very moment. We get to explore suicidal thinking as those thoughts occur. That's important because if something fluctuates so incredibly quickly it's hard to ask people to reflect on that period and accurately recall how they were feeling. The other methodology we use is wearable monitoring, which lets us assess things like physiological distress.

Across two different studies we found there were distinct groups of people. There were people who had a low average of suicidal thinking and stayed there, people who had a low average but whose scores moved around, people in the middle, people who had a high average and whose scores move around a lot, and people who had a high average and whose scores didn't move at all. Those people who had a high average and didn't move much from that average were the people who had more recently attempted suicide. What it told us was perhaps it's not different groups of people but rather people exist in different phases – as you get farther away from an attempt you still might have high levels of suicidal thinking but there are more occasions when you don't, and this might increase over time. That's more of a preliminary finding which we're looking to validate.

Other research we've done shows that when people are considering acting on their suicidal thoughts it's a really distressing time period. A person in the midst of a suicidal crisis is likely very agitated, distressed, and in a position where their mental ability to stop and think through different solutions, and see the future in a different way, is pretty compromised. This is something that isn't unique to people who are suicidal: when any of us get really distressed or agitated we are less able to stop and think calmly and clearly and slowly. The newer research we're doing now is developing interventions that work with someone who's feeling that way.

There are a lot of interventions that work really well up until a point, but it hasn't been clear why. One reason may be that these treatments work really well if you're, just for example, a seven on a 10-point scale of agitation… but when people are above that level, they need something else. At that point you need a way to get through that crisis and that's a lot of what we've been doing – taking treatments and boiling them down and making them as effective as possible in that really high-risk period. Then once people are calmer, reverting back to other treatments that work but that aren't particularly useful when you're really agitated.

One of the interventions that we're doing right now is to speak to people while they're on the inpatient unit. People who are on the inpatient unit are at the highest risk for suicide once they leave – that's a paradoxical and scary finding. So while they are there we give them three short therapy sessions where we teach them skills like mindfulness, how to get themselves out of a crisis state, and we show them how to use an app. Once people leave the hospital they have the app which pings them three times per day with a survey and three times per day with a chance to practice these skills… if they want to use the skill they just go on their phone and press a button. We're finding that these skills are helpful in getting people through these crises. One metaphor that's used by Urusla Whiteside, who does a lot of this kind of work, is that if someone is on fire you have to put out that fire before you can do anything else. Putting out the fire involves helping people tolerate their distress, and helping them reduce it, helping them to recognise that they feel very distressed right now but that may not last.

One module from the intervention uses a list, which people create while they're calm, of things they like doing which are easy to do when they're distressed like running, walking, reading, watching TV. Later a reminder pops up on their phone and suggests they try to do some of those things. I ran some analyses for a conference a couple of weeks ago and it actually looks like it works well. Not for everyone and not all the time, which is what we expected, but it works for most people at least a decent amount of the time. Our goal is to refine the treatment, learn from it, and figure out when it works and when it doesn't work… but for an initial attempt at this it's very promising.

Dr Karen Wetherall – Suicidal Behaviour Research Lab (SBRL), Institute of Health and Wellbeing (University of Glasgow)

Myriad factors can trigger and reinforce the development of suicidal thinking in individuals, but arguably, at its core, suicide is a psychological phenomenon. That is certainly not to depreciate the huge influence of social and environmental factors such as social disadvantage, prejudice, trauma and other life stressors, but to say that these adverse events and processes work together to culminate in a psychological state whereby an individual believes that suicide is their best, if not only, option

I believe that 'options' is a critical notion when it comes to understanding the suicidal mind in crisis – as viable options are often the very thing that suicidal people feel they do not have. When options to deal with a crisis, whether psychological or otherwise, are limited then people can feel trapped by their own thoughts and life circumstances. Indeed, many people who are suicidal report feeling entrapment or that there is no way out from their situation, and that is when suicide become a salient option. Suicidal people often feel this is their only means of escape, overriding other protective aspects of their life, such as the love of family and friends.

Feelings of entrapment have been measured within psychological research to better understand the nature of why some mental health states are so overwhelming and damaging. A scale to measure entrapment was developed by Gilbert and Allan (1998), and this scale recognises that feeling trapped may be due to external factors, such as losing a job or domestic abuse, or internal factors that originate in our own minds, for example being very self-critical and ruminating over past failures. This feeling of entrapment may even have its roots in evolutionary psychology, as there is evidence that in the animal kingdom high levels of stress and social withdrawal can occur when an animal is defeated and their escape is blocked (Dixon et al., 1989).

Feelings of entrapment are evident in a number of different mental health conditions, including depression, anxiety, suicidal ideation and post-traumatic stress disorder (Taylor et al., 2011). Indeed, entrapment is a key tenet of the integrated motivational-volitional (IMV) model of suicidal behaviour (O'Connor & Kirtley, 2018), which proposes that feelings of entrapment are the proximal predictor of suicidal thinking and intent. This idea is increasingly backed by the evidence (O'Connor & Portzky, 2018). Internal entrapment seems to be particularly damaging for people (e.g. Owen et al., 2018), which may be reflected in the levels of negative thinking and rumination that are integral to many mental health conditions.

How suicidal individuals get to the point that they feel trapped understandably varies between people – and there will rarely be only one thing that leads to entrapment, and the subsequent perception of a lack of options. Commonly though, as proposed by the IMV model, feeling defeated by life will be a key factor in the development of feelings of entrapment (O'Connor, Cleare, Eschle, Wetherall & Kirtley, 2016). There may be some people who are more vulnerable to feelings of defeat, and as a consequence are more likely to feel trapped and develop suicidal thinking. This could include, for example, those who have experienced trauma, have genetic vulnerability to mental health conditions or have personality traits that may make them more sensitive to experiencing feelings of defeat or humiliation in their lives. In particular, people high on perfectionism, particularly when perceived from others, are more vulnerable (Smith et al., 2018), and those that are low on resilient traits, such as problem-solving, may be less buffered against suicidal thinking (Johnson et al., 2011).  

An important question is how do we help people who experience a suicidal crisis, without being able to influence the environmental and societal forces that can place vulnerable people in the situations that increase the risk of suicidal thinking? Knowing how best to help protect people is challenging, but increasing the options that people in a crisis feel they have could be effective in reducing the likelihood that an individual experiencing suicidal thinking will make a suicide attempt. This could include anything that increases a person's ability to see a way out, for example developing skills to better cope with life events or to manage their distress when traumatic events happen.

Ideally theses preventive capabilities would be taught and developed when young, such as an understanding of emotions and how to regulate them (Domínguez-García & Fernández-Berrocal, 2018), or affective problem-solving (Pollock & Williams, 2018). For a person in a moment of crisis, considering such protective factors may be useful, and there has been evidence that safety planning in advance can assist a suicidal individual through their moment of suicidal crisis (Stanley et al., 2018). The safety plan incorporates a recognition of triggers for suicidal crisis, and importantly options for regulating emotions and dealing with triggers in the moment of crisis.

Ultimately, there is often no way of knowing exactly what a suicidal person is thinking, and what has led them to that moment of crisis. Indeed, that is often what makes it so hard for family and friends to comprehend and process a death by suicide. It is clear that in the moment of a suicide attempt, their feelings of pain overwhelm everything else, and no other option for escape from the pain is evident to that person. Helping those in crisis see that there are other options available could reduce feelings of entrapment and the likelihood that suicide becomes the most salient option.

- See also our interview with Professor Rory O'Connor - 'Even the bleakest moments are not permanent'

Find more in our archive.

If you are affected by suicide or you are worried about someone, Samaritans is available 24/7 on 116 123 or via email [email protected].