Suicide and Suicidal Behavior

Introduction

In the last days we are told there will be signs given to us to forewarn Christ's second coming. Traditionally we have limited these signs to such events as "wars and rumors of wars," "the whole earth shall be in commotion," and "iniquity shall abound." However, there is one sign we may have overlooked that is just as important. In Doctrine and Covenants 45:26 we read "And in that day ... men's hearts shall fail them ..." As a mental health professional I see depression and suicide as a possible interpretation for "men's hearts failing them." Suicide is a leading cause of death. The rate of suicide in young people has increased significantly since the 1950's. Suicide in the elderly has increased also. The elderly, in fact, present the greatest risk for suicide. Suicide is more likely in the elderly than at any other time in the life span, and particularly for males. (The topic of elderly suicide is discussed at greater length in the chapter on Mental Illness in the Elderly Chapter ???.)

Suicidal behavior includes suicidal thoughts, suicidal speech (including threats), suicidal plans, suicide attempts, deliberate self-injuries, and other self destructive behaviors. Suicidal behavior includes self-injury without the intent to die (though this too often happens anyway), and self-injury with intent to die, but without successful suicide completion.

Suicidal behavior is often a serious complication of mental illness. It is clearly a possible lethal complication of mental illness. Research data show that almost all suicide completers have a least one diagnosable mental illness or substance abuse disorder. The majority of suicide completers have more than one of such disorders. Suicide is a potential danger in the mental illnesses of depression, schizophrenia, and bipolar (manic-depressive) disorder. Substance abuse disorders have a significant association with suicide. The combination of any mental illness with a substance abuse disorder can be particularly lethal.

Even the use of alcohol (not abuse) and other mood altering drugs (including prescription medications, both for mental illness and health problems) may increase risk for suicide. Alcohol for example, can make depression more serious. Some medications such as the benzodiazapines, for example, while helpful to individuals with significant problems with anxiety, and sometimes used as a muscle relaxant in medical procedures, increase depressive feelings for some people. Steroid medications prescribed for medical conditions can increase depressive feelings, while at the same time relieving the medical condition. The drug or medication-induced or heightened depression can then become a significant factor leading to suicidal behavior. Street drugs used to produce a high can lead to difficulties in reasoning and judgment, followed by increased impulsivity and/or risk taking, leading to increased suicidal behaviors.

For family and friends, brothers and sisters of members who are mentally ill, the possibility of suicidal behavior is likely to be extremely stressful. This is likely to be compounded or added to in a culture such as our LDS culture. We value life highly, and generally view the taking of human life very negatively.

Awareness of suicide risk factors

How can family, friends, and members of the LDS Church better handle their own stress associated with suicide and at the same time help their loved one who may be at risk for suicide. First we can increase our awareness of suicide risk factors. Here are several to keep in mind:

Is there a family history of suicide?

Is there past or present family violence, including physical and/or sexual abuse?

Has the individual made prior suicide attempts?

Does s/he have easy access to a firearm or other weapon?

Has s/he been exposed to suicidal behavior of others, either personal exposure or to media exposure?

Is there any alcohol or drug use or abuse?

Has s/he a past history of risk-taking behavior?

Is there a past history of impulsivity?

Has the individual recently experienced any adverse life events such as divorce, loss of job, loneliness, financial problems, business failure, or loss of health?

Add to your awareness of these risk factors an awareness of several behaviors that indicate a serious attempt at suicide may be imminent:

Persistent statements that life is hopeless, that there is no help that can make a difference, and that even if there was hope and /or help, "This soul isn't worth it." Your loved one experiencing suicidal thoughts may believe that what s/he does (or has done) is not enough, and that s/he simply makes no difference. There may be statements that nothing s/he can do will change things. S/he may state that s/he gets little, if any, gratification from life, and doesn't expect that will change. At times, misunderstandings about Gospel principles where perfection is the end goal, and imperfection is described and felt by some as immoral, wicked, or as a sign of personal weakness may increase feelings of "worthlessness."

Setting affairs in order. This may include making a will, or checking a will already made, giving away items s/he thinks family members or others would like to have, terminating bank accounts.

Visiting old friends not recently seen; otherwise "closing out" chapters in one's life.

Talking about death or suicide. The individual may give verbal cues of suicidal intent that may include clear statements such as "I'm going to kill myself." Verbal suicidal cues may also be statements which are less clear, such as "I wish I weren't alive," "I wish I were dead," or "I wish the world would go away."

A sudden improvement in mood in an individual who has talked about suicide or death when recently depressed. A person with suicidal thoughts may appear more calm and composed when s/he has made a decision to kill him/herself. Having made such a decision, s/he then may be sufficiently energized to carry out the decision. To family, friends, fellow members of the church, the lifting of a depressed mood likely might be interpreted optimistically, lessening vigilance about self harm. The lessening of vigilance may then be followed by successful suicide completion.

Statements of awareness of having a severe mental illness. Early in the course of the illness, young people with schizophrenia, when they are beginning to recognize the nature of their illness, are particularly vulnerable to suicidality.

Increase in use of abusable substances including alcohol, illicit drugs and some prescription medications.

Any change in circumstances that decreases access to support systems. Examples of this could include: inability to get to church due to transportation problems, other mobility problems, family members or special friends have moved away etc.

The approach of anniversaries of significant, often negative events from the individual's past. This might include the anniversary day of death of a spouse. It may include even the anniversary of the marriage to a departed spouse. This can also include yearly family holidays when the individual feels isolated from family, through geography, estrangement or death; it might also include the anniversary of the date of a business failure.

Awareness of these important indicators of possible suicidal behavior will be helpful in preventing suicidal behavior. The degree to which we follow the counsel given to Aaronic Priesthood holders in Doctrine and Covenants 20:53 to "... watch over the church always and be with and strengthen them" and effectively do our home and visiting teaching may in fact save a life!

What family, friends and fellow members of the church can do

What can family members, friends and fellow members of the church do when concerned about possible self-harm or suicide of a loved one? What can be done when you are concerned about the presence of other risk factors for suicide in your loved one or you've observed any of the "pre suicide behavior indicators" discussed above? The following is suggested:

Seek professional advise. State clearly to a mental health professional what your relative or loved one has said or done or is saying or doing that concerns you. Ask not only for the mental health professional's evaluation, but also ask for help in developing a care plan or intervention, if such is warranted. This will help you know what to do when you see a need to do something to be of help.

Gain control of access to "lethal" objects. Suicide is frequently an "impulse" behavior. By this, we mean suicide is frequently the response to a lethal combination of thoughts, feelings, and opportunity coming together at one moment. Any way that we can disrupt that combination helps decrease the potential for successful suicide. Thus, the more difficult access to a "lethal weapon" is, the greater the likelihood of averting successful suicidal behavior. Don't allow possible suicide weapons to be easily available. Hide, or lock away guns, ammunitions, or other lethal instruments. This may include taking control of your relative or loved one's medications. Many medications, in sufficiently high doses can be fatal. Multiple medications, inappropriately mixed and in sufficiently high doses, can be fatal. During the time when suicide is a danger, in agreement with a treating physician (and preferably a treating psychiatrist), you may need to take responsibility for medication administration to your loved one.

Talk about suicidal thoughts and plans with your loved one if you believe s/he presents a suicide risk. Be clear in your talking with them about the behaviors that concern you. Ask specifically if they have any thoughts about suicide. Ask specifically if they have a suicide plan. What do they intend to do? If suicide thoughts and plans are present, insist that a professional evaluation be done at the "first opportunity". The clearer and more specific the plan, the more the "first opportunity" needs to be "now".

Let your loved one know that he/she is important to you. We all like to feel that who we are and what we do makes a difference. Those considering suicide feel void of this sense of making a difference to others and to this world. They feel that the world would be better off without them. It is better to give specific examples of how the individual is important to you than to give general reassuring statements. As has been noted above, suicide is frequently the product of an impulse in response to feelings of a the moment, and circumstances of the moment. It is helpful that you comment on your loved one's importance to you during the times of possible self harm. It is also important to do so between such moments, when things are going more smoothly. When your loved one is experiencing periods of relative contentment, success, or happiness, provide compliments, show interest and demonstrated appreciation. Pay attention when things are going well, proclaim the value added to your life by their contributions to it.

Consider your needs. Replenish yourself. An empty vessel cannot provide sustenance to anyone. Seek help and support for yourself, even professional support, if necessary. The Dead Sea is said to be dead because it receives only, and doesn't give. The Sea of Galilee is alive because it both receives and gives. A sea which does not receive will be a Dead Sea soon, once it gives all it has.

Rely upon the Lord. Sometimes the only thing we can do is to have faith and pray for the one we love. Involve trusted members of your local LDS Church group. Perhaps a bishop, a home teacher or someone else can be a support to you and/or your loved one. Regardless of what eventually happens to you or your loved one the Lord knows. The Lord understands. It is reassuring what we read in Matthew 10:29-31 "Are not two sparrows sold for a farthing? and one of them shall not fall on the ground without your Father. But the very hairs of your head are all numbered. Fear ye not therefore, ye are of more value than many sparrows." Your loved one's value to the Lord is also "more value than many sparrows." He knows your loved one's name and personal circumstances.

When suicide happens

Relating to and caring about a loved one who has the potential for suicide can be challenging and stressful, even when one does take care of one's own needs, and when one has followed sound professional advice. Added to that stress can sometimes be the added burden of thoughts and feelings experienced when the other person for whom you care, and for whom you've provided care, in spite of all we've done, does kill him/herself. And it does happen that even members of the LDS Church with best of care do commit suicide. When this happens we are likely to experience feelings of grief, feelings of anger, feelings of resentment, and feelings of guilt and self-blame.

Survivors of suicide may have thoughts about their loss, thoughts about how could the other person have done this to them. They may have thoughts about the turmoil and trouble the suicide has brought into their life. And they will probably have thoughts about what they could have or should have done differently or better. These feelings and behaviors are common for those remaining after a suicide. As members of the LDS Church we may have the added experience of despair, as we have thoughts that the individual's progression towards perfection may have been halted by her/her act of suicide. Those surviving suicide may carry the burden of pain that these feelings and thoughts bring for years as they try to make sense out of what may not make sense--the voluntary and intentional taking of one's life. The words of Elder Bruce R. McConkie, formerly of the Quorum of the Twelve, provide us with needed perspective and relief, "Persons subject to great stresses may lose control of themselves and become mentally clouded to the point that they are no longer accountable for their acts. Such are not to be condemned for taking their own lives." (Mormon Doctrine, Salt Lake City: Bookcraft, 1966, p. 771)

However close we were to the person committing suicide, we are yet outsiders who do not know the inner experience of the person who has died at his/her own hands. M. Russell Ballard (October 1987) in his Ensign article Suicide: Some Things We Know, and Some We Do Not reminds us that we do not know the full circumstances associated with a suicide. We do not know of the degree of accountability the individual who has committed suicide had at the time of the act. He suggests that we ask ourselves. "Was the person who took his/her life mentally ill? Was s/he so deeply depressed as to be unbalanced or otherwise emotionally disturbed? Was the suicide a tragic, pitiful call for help that went unheeded too long or progressed faster than the victim intended? Did he or she somehow not understand the seriousness of the act? Was s/he suffering from a chemical imbalance that led to despair and a loss of self control?"(pg. 8) Further reading of the entire text of Elder Ballard's remarks is suggested to those wishing more information. Some of the questions asked by Elder Ballard we can answer in specific cases; in no case can we know the answers to all of these questions. Therefore, as we cannot have knowledge sufficient to judge, "Let not your heart be troubled" (John 14:1).

PERSONAL REFLECTION AND AN LDS PERSPECTIVE

I am saddened by the experience of those I encounter who have more than fleeting thoughts about suicide. There can be much more that is positive for such individuals in their lives, though they can neither see nor experience it during those times. There are medications and psychotherapies that can make a difference to those experiencing the pain associated with suicidal thoughts and feelings that are more than momentary.

I am aware of the sanctity of life, and the import of the taking of life, either of another or oneself. I am also aware, throughout my church experience, of the difficulty of mortals sitting in judgment of others behavior. I am quite content to leave judgment to those whose calling and role it is to render judgment when they are called upon to do so.

I do know that, either in the present, or ultimately, the Gospel will bring a "sweet peace" to all whose hands have grasped the iron rod.

8/17/01/rdh/rt