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


  1. For some people characterising suicidal thoughts as irrational may be helpful, but it's unlikely to be helpful in all cases. Suicidal ideation occurs in fairly predictable psychological and sociological circumstances, which indicates that there is some logic to it. Sometimes it's more effective to characterise suicidal ideation as a logical solution to a problem that can be addressed in other (better) ways.

  2. Disagree completely.

    First off this is not a characterization. It requires discussion with the person and argumentation in the Socratic not the political sense.

    Second it occurs in the context of a well defined relationship. People see me as a psychiatrist for treatment of severe disorders and associated problematic thinking. I am not seeing anyone with terminal illness debating assisted suicide. I am seeing people with reversible disorders and the goal is to restore their functioning.

    I have never encountered suicide as a logical solution in that situation and helping that person depends on me pointing that out. In fact the idea that you bring up was one of my reasons for this post.

    With all of the suicides of healthy young people in the news - nobody seems to be getting this message out.

    1. I know this is incredibly rude, but, for the rest of your career, never work with terminally ill people, this post is just so insensitive...

      Thank God during my residency I had a case working with woman in her mid-70s with horrendous metastatic breast cancer, she taught me a lot how to handle people with terrible terminal disease trying to have quality of life at the end.

      My attending totally agreed with me this was a very painful and difficult case, and we made sure the family was completely involved with the way we tried to direct her care before she was discharged from the oncology service.

      You're the kind of guy who would have demanded I hospitalize her on an inpatient psych unit, and thank God you were not my attending...

    2. Thanks for the advice - but I guess you missed the explanation about the intent and context of this post.

      It has nothing to do with the care of the terminally ill.

      I am the kind of guy who was sent terminally ill people to my inpatient psych unit simply because they had a psychiatric diagnosis and happened to be in the ED.

      It was up to me to treat them including their medical complications and find appropriate hospice care. And it didn't happen overnight.

      So I guess you are wrong about the "kind of guy" I am as well.

      I didn't need an attending. I was the attending.

    3. I think what I'm trying to get at isn't that their suicidal ideation is due to their depression, but that it shouldn't be cast as irrational.

      I remember talking to one person who was finding suicidal ideation very distressing, and through talking with them I mentioned that it might be because they were withdrawing from benzo's. It was like a 10 ton boulder had been lifted from their shoulders. They had a logical reason for why they had suicidal ideation, so it no longer concerned them.

      I know that to you the suicidal ideation is irrational, because you know how to treat it, you've seen people with it before and you've seen them get better. But to them it may not be irrational, because given the information they have at hand it looks logical. And I think that framing it as irrational may not be helpful because you're undermining their confidence in their judgement and they might feel ashamed that they still feel that way. It also discourages them from digging deeper and trying to understand how it all logically connects.

    4. I would have done the exact same thing.

      I don't "cast" their thought process one way or another. That is not how psychotherapy works. I talk with them and help them figure out what is really going on.

      You are saying that it is logical for a person to be suicidal because of benzodiazepine withdrawal. I disagree.

  3. For some reason this did not post through the usual mechanisms so I cut and pasted it here:

    Joel Hassman has left a new comment on your post "The Most Important Fact About Suicidal Thinking":

    I am genuinely insulted by this overgeneralization of yours, there are times where suicidality has basis. The provider needs to help refocus with the patient that they have to consider other people's feelings and impact from a suicide death, but just to dismiss it as always irrational thought is so insensitive!

    Wow, I truly am speechless and have nothing else to write...

    I am insulted every day by the way the media treats suicide as a mystery and a problem that cannot be solved. Or in the case of the NYTimes editorial today inadequate advice about taking care of the problem.

    My "overgeneralization" as you put it is a reality based psychotherapeutic strategy - elaborated slightly more in the paragraph following the first response.

    In case you are wondering, that means I am not telling the patient they are irrational. I am talking with them about their thought patterns and illustrating it.

    I obviously can't put those kind of notes on a blog and the average reader would not understand them anyway. Any interested reader can pick up a text on how to discuss suicidal ideation, but in most psychotherapy texts that chapter is missing.

    You can characterize whatever way you wish, all I know is that people appreciate feedback right in the session and have a clear sense of relief. I see many people who tell me they stopped seeing therapists because they got no feedback or dialogue. It was a never - ending recital of their symptoms and problems.

    I don't understand the silence of professional organizations or the advice to see a professional when it is obvious many people never make it that far. We have a generation of people hearing that people can bully you into suicide or talk you into suicide or that suicide is a mystery.

    It is not. It is a problem to be solved.

    Once again - this post is here to give them hope based on all of the people I have talked with and their response to this discussion.

  4. Assisted suicide related to euthanasia is one of my least favorite subjects and here's why. With sensible guidelines for the terminally ill in pain, it barely goes beyond a DNR order and is probably more humane. However, in actual practice, the government (see Europe) screws up sensible guidelines and it morphs into a killing field for people with reversible disorders such as depression and somatic syndromes. It's something we should be able to do right, without much of a problem, but we can't because someone will push it too far. It doesn't say much about the human capacity for ethical self-government that we can't manage what I think is an ethical and pragmatic lay-up.

    1. Agree - the idea that someone is euthanized for a treatable condition, especially one that predisposes to hopelessness and suicidal thinking is unconscionable as far as I am concerned.

      As far as ethical self government goes - it is a guess what that means on any given day.