Thursday, March 14, 2019
The Most Important Fact About Suicidal Thinking
I am going to keep this post brief and to the point. This is advice that I routinely discuss with people who tell me that they have suicidal thoughts. In most cases they are surprised about what I tell them. This is a beginning to help people conceptualize suicidal thoughts and frame them in a way that they know what they mean and are confident that they can do something about them. For clinicians, it is also an opportunity to expand the diagnostic interview into a therapeutic intervention. In too many cases, the clinician asks a lengthy series of questions for the diagnostic interview and in some cases and additional set of questions for an assessment of suicide risk or aggression risk. At the end of that process the patient being questioned may be more emotional or feeling drained by the process while they wait for a decision about hospitalization or other treatment recommendations. I have found it is best to have a discussion about suicidal thoughts and attempts right at the time they are being discussed in the diagnostic process. I discuss the following point.
Suicidal thoughts are irrational thoughts and it is a normal reaction to experience emotional distress when thinking about them. The best way to think about them is to see them for what they are and that is either a symptom of depression or an irrational thought process.
When people get suicidal thoughts they often attach other meanings to them that increases their emotional reaction to them and keeps the thoughts going. Over the years some of the meanings that I have encountered include:
"I am in a hopeless situation and I would be better off dead".
"I am worthless to my family and they would be better off without me".
"I am not living up to my potential and I have let people down and it would be easier if I was dead."
"If I wasn't such a chicken I would kill myself"
"My friend who killed himself had the right idea and I should follow in his footsteps."
The general pattern is that the thoughts can get more and more complicated but they always come to the same irrational conclusion.
In order to interrupt them - it is important to recognize that they have no particular meaning and that they must be recognized as an irrational thought or a symptom of depression. They have no meaning past that. In my experience most people have not thought of them that way and that is why the discussion is so important. When people see the point of the discussion and recognize the importance of the discussion it is often very therapeutic for them. They recognize for example that the thoughts are transient and that they do not really want to die. They can say that 99.9% of the time they would never seriously contemplate suicide. They realize that they have gone to bed at night with suicidal thoughts and awakened in the morning without them. In many cases they go to work and while focused on their job never experience a suicidal thought. This discussion is a jumping off point where the clinician can discuss a number of ways to intervene in this thought pattern and reduce the frequency and intensity of the suicidal thoughts to the point that they are likely to fade away.
The clinician seeing the patient can develop a treatment plan based on this important discussion. That includes addressing any associated diagnosis. But the focus on suicidal ideation and safety needs to continue until the thoughts are no longer a problem. In the case where the discussion is not very productive and suicidal thinking is very prominent a more acute intervention may be required to assist the person experiencing these symptoms.
Although the focus of this brief post has been on a typical clinical interaction I hope than anyone reading this post who is experiencing suicidal thoughts can use the advice or access help either through mental health crisis services or their health plan. Remember the main message of this post:
Suicidal thoughts are either a symptom of depression or the product of an irrational thought process.
And that means there is hope. The best starting point is to talk with a clinician who has experience talking with people who have these thoughts and giving them advice on how to get rid of them.
George Dawson, MD, DFAPA