Speaking of Psychology - Suicide Science (SOP84)

Episode Date: July 3, 2019

Suicide rates in the U.S. climbed in all but one state from 1999 to 2016, according to a CDC report from June 2018. This alarming report and notable celebrity suicide deaths like Anthony Bourdain and Kate Spade have pushed this topic further into the national spotlight. Psychologist Samuel Knapp, EdD, discusses the factors that cause people to die from suicide, the effects of past trauma on mental health and how psychologists can successfully treat suicidal patients. Suicide is the cover story for the July/August issue of the Monitor on Psychology, APA’s magazine for members. Read the story at apa.org/Monitor. APA is currently seeking proposals for APA 2020 sessions, learn more at http://convention.apa.org/proposals Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to Speaking of Psychology, a biweekly podcast from the American Psychological Association. I'm your host, Caitlin Luna. Suicide rates in the U.S. climbed in all but one state from 1999 to 2016, according to a CDC report issued in June 2018. This alarming report and notable celebrity suicide deaths like Anthony Bourdain and Kate Spade have pushed this topic further into the next. national spotlight. In this episode, we'll be exploring the factors that cause people to die from suicide, the effects of past trauma on mental health, and how psychologists can successfully treat suicidal patients. Our guest is Dr. Samuel Knapp, a licensed psychologist in Pennsylvania who has worked in rural community mental health centers delivering psychotherapy and crisis intervention services.

He's the author of the forthcoming book, Suicide Prevention, an ethically and scientifically informed approach that will be published by APA in August. Suicide is also the cover story for the July-August issue of the Monitor on Psychology, APA's magazine for members that covers science, education, psychology practice, and more. Welcome, Dr. Knapp. Thank you. My first question for you is, why do people die from suicide? Suicide is multi-determined, meaning that many factors can be involved, but we have identified some common factors that reappear over and over again. One of the major ones is a lack of social connections so that people perceive themselves as unwanted or as a burden to others.

In fact, Dr. Thomas Joyner, a noted suicidologist, has used the term perceived burdensomeness to describe that sense of being a burden on others. And as a society, it appears that we are becoming more disconnected from each other, and that may be a factor in the increase in the suicide rates. But the immediate cause might be a disruption of a social relationship, loss of a job, financial distress, some kind of humiliation. But usually there's a loss of social concern. connecting us as well.

You mentioned Dr. Thomas Joyner. He and other psychologists developed the interpersonal theory of suicide. Can you explain what that theory is? It's a very helpful theory and that it on its surface is very simple, but it's actually very useful and that suicide is caused by both a desire to die and the capability of killing oneself. And the desire to die is usually associated with thwarted belongingness, not being part of a valued social group or perceived burdensomeness. And then you have the second step, which is the acquired capability. That means a person has overcome the normal habituation, the normal inhibitions

against harming oneself. We have very strong self-preservation instinct. And it takes a lot for people to overcome that. And it usually occurs when people have become habituated to pain and suffering or they lose their fear of death. There's other, it's called an ideation to action theory. And there's other ideation to action theories. And they overlap a great deal. But all of them look at the unique role that acquired capability has and leading a person to die from suicide. And what do you think the factors are behind that steep rise in suicide deaths around the U.S.

That was noted by the CDC? Well, I think it's the increased lack of social connectedness that we have in society. Now, suicide is also multi-determined, I mentioned. And we have to realize, too, that even though the nation itself is prosperous, there are many areas of the country and many professions where people are, struggling financially. You know, farmers losing their family farms, a great sense of loss, a great sense of anger itself because they weren't able to make it. And so those are, those are factors as well. We have very high incarceration rate in the United States. And incarceration is often a life event that causes some people to attempt suicide.

And that report did note that in some states, especially North Dakota, the suicide rate went up significantly during that time period. And Montana had the highest per capita rate in that, I believe, between 2014 and 2016. Does that speak to some of the issues going on in rural areas, which you've had experience with? Yes. In fact, some people have referred to the, they call the geographical suicide belt, which is, you know, Western states, rural states, having an increased rate to suicide. Now, there's many factors for this one, which is that some of these states have a higher proportion of older adults, and older adults do die from suicide more frequently than younger people.

They have a greater access to guns, because it's very common for the average household to have a gun. they have a lack of adequate health care services in many of those areas. There's longer distances between people, greater risk of social isolation, younger people moving out, family members moving out. So you have all those factors that appear to occur. There's nothing inherent about living in Montana that increases one's risk of suicide. It's just that people in Montana are more likely to have these high risk. risk factors that we know about.

And one very interesting thing in that report was that more than half of people who died by suicide did not have a diagnosed or known mental health condition at the time of death. So what does that tell us? That whole issue is controversial. You know, the relationship between a diagnosed mental illness and a suicide attempt. Now, Thomas Joyner, whom I mentioned before, did a study where he looked, to the medical records of people, and even if they didn't have a diagnosed mental illness, a lot of them appeared to have symptoms that were noted in the medical record, suggesting that

perhaps they really did have a mental illness that was not diagnosed, or maybe they were in great distress, but didn't meet a formal definition of mental illness. So I suspect that the rate of emotional turmoil or mental illness is probably higher, far higher than with the CDC. suggested. There's also been some very useful research from Palo Alto University with Dr. Joyce Chu, who looked at suicide among Asian Americans. And she found that the rate of mental illness, instead of being 90% higher, as most studies find, was about, I think, if I recall correctly, about 66%. So she's suggesting that mental illness is less a factor in Asian American suicides. But then I wonder if some of these Asian-Americans didn't have cultural variations

of distress that aren't picked up in the usual diagnostic nomenclature that based primarily on Western populations. Now, this is just speculation on my part. But the CDC finding of less and half of people with diagnosed mental illness. I think we need to put that in perspective and say that might say more about our diagnostic system than about suicide itself, which is almost always linked to great emotional turmoil, a diagnosable mental illness, or a cultural variation of a mental illness. So there's definitely a lot more involved in this than just simply saying that these people didn't have...

That's right. Yeah. Yeah, far more than that. And going back to what you're talking about about older people, there was an investigation by Kaiser Health News and PBS News Hour that found that older Americans are quietly killing themselves in nursing homes, assisted living centers, and adult care homes. What are your thoughts about that report? Well, there is what we call passive suicidal ideation. Now, going back to the interpersonal theory, remember, there was the desire to die and then the capability. of dying. And some of the people in nursing homes may have a desire to die, but because they're in a

restricted environment, they don't have the capability, or maybe they don't have, maybe they haven't become sufficiently habituated to pain and suffering that they've overcome their inhibitions against actually killing themselves. But there is such a thing as a past of suicidal ideation. People just wish that God would take them away and wish that they didn't have to live anymore even though they can't actively take steps to kill themselves. And people in nursing homes are more likely to have some of the risk factors associated with suicide, such as a comorbid mental illness, a comorbid physical illness, chronic pain,

restriction in their activities of daily living, loss of connection with other people. In fact, one study found that when suicides do occur, nursing homes. It very often occurs when a loved one has been transferred out of a nursing home, and so a big social connection has been lost. Also, a very interesting perspective by psychologist Kim Van Orden talked about the role of the ages of might play in this, which is something I hadn't thought about, which I probably should think about because I'm an old man, but people get put into an age role. You're expected, your expectations people, they can't do this stuff or they're not interested

in things. They just need to sit in a corner. And maybe that's a factor too that I had not thought about before. You've spoken a lot about the importance of social connections. And I think that might apply in this case. I want to get your thoughts on it. But more than a million children and teens in the U.S. were admitted to the emergency room for suicidal thoughts or suicidal attempts, an amount that doubled

between 2007 and 2015, according to JAMA pediatrics. Do you have any insights on why this is happening? Is it related to that social connection that you're talking about for? I think it is. And there's also been some speculation on, not more than speculation, some research on the role of smartphones, social media. And some people are thinking that it isn't the smartphones per se that's leading people to increase the risk of suicide, but that it interferes with normal, healthy, direct interpersonal contact that people have. And so having a smartphone is intrinsically bad for a teenager, but it becomes bad if it keeps them from engaging in experiences that are really healthy.

helpful and good. But yes, disconnectiveness is it's a very serious problem with adolescence. It's a society-wide problem that needs to be addressed. Yeah, I did a recent podcast earlier this year about loneliness, which is very fascinating. I talked a lot about the importance of social connections for our physical and mental well-being. It was very good, very good conversation. And going back, you also mentioned too when we were talking about some of the other rural states, some issues that might come into play there, but I think this is more of a national issue. But the National Bureau of Economic Research released a paper in late April that found that when the minimum wage in a state increased or when the state offered good tax credits

for working families, the suicide rate decreased. What do you think about that? It makes sense. You have the loss of income. You have financial insecurity, males are socialized into a breadwinning role, and if they fail to do that, it's a source of great humiliation. So that makes a lot of sense to me. As income inequality rises, as financial insecurity increases, people who are vulnerable to suicide, that's an added burden. One of the greatest spikes in suicide in the United States was in the early 9th.

1930s during the early years of the Great Depression. And I mean, that's a typical example of the impact of economic insecurity on suicide rates. I want to talk a bit about the lasting impact of trauma, specifically in relation to three recent high-profile suicides. One of those was Jeremy Richmond, whose daughter was killed at Sandy Hook, and then two Parkland school shooting survivors. Can you explain the lasting impact of a traumatic experience on a person's mental health? Yes, well, this relates to the interpersonal theory of suicide.

And as I mentioned, acquired capability is one of the factors that Thomas Joyner has identified as related to a suicide attempt. And the acquired capability occurs when people have had exposure to violence, they become habituated to suffering, and they lose their fear. of death. And this explains why. You look at statistically higher rates of suicide, and they find that they occur among people who are physicians, people who are sex workers, police officers, homicide detectives, and you think, well, what do all these groups have in common? And one thing that they do have in common is exposure to pain and suffering. And so, in the And people have that. Now, losing your fear of violence, fear of suffering isn't necessarily bad because you don't want to have a physician who's so afraid of suffering that says she can't do her job well. Or a police officer who's so afraid of suffering that she becomes paralyzed in a time when action is needed.

but when it's combined with the desire to die, then it becomes a factor in a suicide attempt. So we have people, these people, I mean, I don't know them. I don't, only thing I know is, you know, the very brief thing is that they've been exposed to trauma and violence. But people who are exposed to trauma and violence do have an increased risk of developing that acquired capability to kill themselves. You find this with child abuse victims too. Now, most of the people who are victims of child abuse will go on and despite the great pain involved, they can carve out good lives for themselves. But statistically, there are at a higher rate to die from suicide if they've been a victim of childhood violence. So you do create this

habituation of pain and suffering that does increase the risk to people. And because these, the people I mentioned had to experience these incredibly traumatic events in their lives. Yes. Yeah, I think that one thing that was really, I guess, struck me about those stories was how many years it was later. So, especially for the father of the Sandy Hook victim, and he was very actively involved in research into why people commit violence.

And yet years later, he did die by suicide. What does this tell us about how trauma can last for a long period of time? Does this say anything more about how you might feel fine for several years, but then there could be a point where it gets to be too much and you decide to take this action? Well, it is a factor. and hopefully most people experiencing trauma will be able to get some help, be able to put the trauma in the back of their lives. But, you know, not always, as these cases illustrate.

And I want to talk about, too, about do suicides cluster together? I know this can be a very controversial topic. And there was just an article, a bunch of news stories. released recently about the increase in suicide deaths among teens after the airing of the show 13 reasons why. And many of the articles were cautious on making a link between that, but they did note an increase in suicide deaths after that show aired. And we've seen this before about after a celebrity dies. Sometimes I've heard that the rate of suicide does increase after that. Is there a connection and do they cluster together?

Well, we have two things going on. One is called contagion and the other is called cluster. Yeah, can you explain what each one is? Sure. So after the death of a celebrity by suicide, there's a great deal of publicity to it. And many states have been done on the impact of this death upon suicide rates. And it's very hard to research because there are natural variations in suicide rates. During the spring, during the fall, suicide rates tend to increase.

So if a celebrity dies by suicide in April, well, there's going to be an increase in suicide rates anyways. So you have to figure out how much is the increase due to the increased exposure of the suicide versus the natural increase. There was a review about a year ago that says there's a slight impact of publicity of celebrities on suicide rates, a very small impact. When you look at all these different studies, someone which found it impacts some dent, you look at them all together. There might be a slight contagion effect. But we look at clusters, which is different. Now, clusters is when you know someone personally who's died from suicide.

And so, for example, in some schools, there are all of a sudden several suicides of students in a school who sometimes they knew each other. And is this just a coincidence? I mean, sometimes it might be just a coincidence. But is there some kind of effect to the suicide of one person increase the risk? of suicides for other people. And it appears that there is an impact. You know, knowing someone who's died from suicide does increase a person's risk of dying from suicide themselves.

It depends on how well they knew the person, many other factors, but there is a slight increase in risk. Now, why is that? Now, some people say it might be a modeling effect. it might be habituation to violence. People, knowing someone who died from suicide, might see it as an option. There's also been discussions about how should public schools respond publicly

when a student dies from suicide. How can you honor the student's life without glamorizing it? And so there's guidelines established by the, American Association of Suicidology on how to do that so that it doesn't appear to glamorize it or increase the risk of other students dying from suicide. There's something called social network theory which says that many of our traits are similar to those who are close to us, up to three degrees of separation. So if you know someone who dies from suicide, your risk is going to be higher. If you know someone who knew someone who died from suicide, it's going to be a little bit higher.

Three degrees of separation is going to be a tiny bit higher. And beyond that, there's probably not an effect. But yeah, there does appear to be a cluster effect. Does it seem like suicide, the spotlight is on suicide more now today than it was in the past? Or do you think homicides get more attention? Well, I think there's more attention on suicide. as it should be. It's been neglected a great deal. Now, as part of the attention started because the high suicide rates in the United States military, but now it's a 30% increase in suicide since

1999. And so it deserves to be in the public spotlight. It's a very neglected area of public health. For example, in the Golden Gate Bridge, there has been three. I think 2,000 suicides or something like that since the bridge was constructed. They built a bicycle lane, even though the number of people being injured riding bicycles and the Golden Gate Bridge is minuscule. Spent millions of dollars on a bicycle lane for safety purposes. I'm not opposed to a bicycle lane, but that was a priority over putting a net underneath the bridge which would save people.

from dying from suicide, even though far more people died from suicide than died from bicycle accidents on the Golden Gate Bridge. And that's just one example. You look at funding for research. Suicide is the 10th or 11th leading cause of death in the United States, comparable to lung disease, kidney diseases, even though lung disease and kidney disease each receive about 20 times the amount of federal funding for research. than suicide does. So we are really disadvantaged in terms of research because of the lack of funding. It really is being a very serious neglected area of public health. And I think it has to do with myths and prejudice stigma against people who have mental illnesses and who attempt suicide.

Yeah, that's exactly what's going to ask you. Do you think it's because of the stigma? It does seem in general that the stigma might be lifting a little bit is the more it gets discussed, but, you know, that's the research dollars need to catch up with that with public opinion changing. Absolutely. The Monitor article stated that psychologists who studies suicide are still members of a relatively small group because historically most research was done by psychiatrists who work with patients in psychiatric settings. Why is it critical to have psychologists study suicide? Well, fortunately, psychologists are getting more involved in the study of

suicide and the quality of research is excellent in my opinion. I mean, obviously much more needs to be done. But in the last few years, the research is phenomenal and has very real public health implications. For example, efficacy of treatments. We now know that there are, we've always suspected that mental health treatment is going to save. lives of people who die from suicide, who at risk to die from suicide. But now we have evidence that really shows without a doubt that you have research by Craig Brian and David Rudd on cognitive behavior therapies, David Jobs on collaborative assessment and management of suicidality, Marshall Linnehan dialectical behavioral therapy, and, you know,

Guy Diamond's attachment-based therapy. we have these studies that show, yeah, we really have effective treatments. And research is studying more on the phenomenon of what happens in the suicidal crisis state. You know, some really good research by Raymond Tucker and Megan Rogers and Thomas Joyner and Igor Gellenko on the suicide crisis state, what happens immediately before a person attempts suicide. This is really opening a lot of post-examination. as far as prevention and treatment are concerned. So I'm just so impressed by the psychologists who are working in this area.

I benefited a great deal from the research. That's wonderful to know that there's a lot of great research coming out in this field that will help people moving forward. And I want to talk to some more of the practical tips for people. How do we recognize the signs of someone who might be contemplating suicide? Well, it's not always easy to do. And there's been these lists of warning science that people have developed. And sometimes the lists become very, very long.

And one of the problems is that they come so long, they become useless because there's so many factors that are so marginally related to suicide that, well, well, one list I see. if a teenager is disrespectful to a teacher. You know, that's, well, okay, this is not good that teenagers are disrespectful. But that's not, they're disrespectful for a lot of different reasons, of which suicidal thoughts might be one out of many, many, many. But if you go thinking, oh, this child is disrespectful, they must be suicidal. You're just going to be wrong. So much of the time that these warnings list because, because, you're just going to be wrong. so many much of the time that these warnings

list become meaningless. But one of the best things ways to find out is just ask someone. Or you can take a step back and just how are you doing overall?

How are you doing? If you're concerned about someone, focus on your relationship with them. You know, spend time with them. thinking like in a family, a parent and a child or a child and an older parent. How are you doing? Spend time with them, quality of time. Now, because of some of the research I mentioned,

Raymond Tucker and Megan Rogers and others, we do know more about the immediate psychological states that people have before a suicide attempt. And there are some things that occur, agitation, insomnia, irritability. We mentioned perceivorismness, a sense of entrapment, humiliation. Those are, we know those states are present in a large number of people who eventually go on to die from suicide. So that's one of the practical applications of some of the recent research that we've had. So in terms of intervening, if a loved one is, you're worried about a loved one, it can be something like, as you mentioned, saying something about how are you doing, that sort of thing.

What are other ways you can intervene to keep someone safe? Well, I mean, if they're currently suicidal, you know, right now, you know, yes, someone are you suicidal? Yes, I am. Get them into treatment and work with the treatment provider, be willing to be an accident. asset to the treatment provider and what they're doing. And it's hard to generalize because there's so many different, every case is unique. But doing what you can to promote their overall well-being and going back, once again, to the sense of connection, making sure that you have a good relationship. Now, family members usually are very well-intentioned, and they need to draw a balance between being helpful and being overly paternalistic, overly controlling, which sometimes people do.

When they're afraid someone is suicidal, they'll tend to be bossy and dogmatic and pushy and the motives might be good. but that actually can turn people off as opposed to making them feel closer. And how do psychologists treat suicidal patients? What research-informed interventions do you use in your practice or do you suggest others use? Well, I mentioned some of them. And, you know, cognitive behavior therapy, technological behavioral therapy, collaborative assessment, management, suicide. There's also what we call suicide management strategies.

But looking at the broad question, there's a very good book edited by Louis Kaston Gay and Clara Hill on why some therapists are better than others. And one of the chapters there says, okay, what do really good therapists do? and one of them was like good relationships. They practice hard at what they do. They're humble. And this is really good because humility, ability to look at oneself objectively, because they're not afraid of feedback. They elicit feedback.

If a patient isn't doing better, they want to know about it, and they will go out of their way to get the feedback. And then we look at what is there specific about, suicidal patients other than good therapy in general. And there was a very nice article recently by Craig Bryan on some of the common factors in effective suicide treatments. Now, he was looking at treatments in the military, but I think this applies in other places as well.

One of them was making sure that patients are engaged in treatment and they believe in treatment and follow through with treatment. You can't always assume that. Sometimes people come and so demoralize that they know nothing's going to help me or I'm not worth saving. That getting their buy-in is really important. Teaching specific skills. People are in a great deal of emotional distress and giving them skills. Oh, for example, insomnia has a very strong link with suicide attempts.

It greatly increases the risk that someone is going to take. attempt suicide. If all the other things, they're not sleeping well at all, have chronic insomnia. And knowing that, being able, and there's things that people can do. There's sleep hygiene, there's a magical rehearsal that can be done to reduce nightmares. There's some medications that can be done in the short term to improve sleep. So knowing that stuff, being able to get their emotional arousal down, giving them skills is important. And then another very important one that a naive psychotherapist miss, but it's very crucial, and that is suicide management, as being able to give concrete steps so a person is less

likely to attempt suicide than in the short term. You want to keep them safe in the short term. So the psychotherapy has a chance to work. And that's a very important thing to do. And fortunately, there's been some very good research on suicide management programs, such as Greg Brown and Barbara Stanley on some safety management strategies and some other researchers have done work on that, that really gives very concrete steps on things which have been in parisand. verified to help people reduce the risk of suicide. You know, there's one study that was done when asked veterans, what kept you from killing yourself?

And the number one reason they gave, I mean, they gave many different reasons, but the most common one was my psychotherapist cared about me. Wow. And that certainly does say a lot. It does. You want to build a relationship. you want at the end of the first session, you want the patient to think, this psychotherapist really cares about me.

And you also want them to have a chance to tell their story. Now, one of the advances in treatment, with people who are not experienced working with suicidal patients, there might be a fear, they might be alarmist, they might become over-controlling. Oh, you got to go to the hospital. Or I have to tell you family members. I don't care what you think. I'm going to tell your family members regardless of what you think. Over-controlling, bossy.

And that can turn people off very quickly. But it's much better to listen to them. Instead of arguing with them, you should live. Here's the reasons you should live. For every reason you give, they're going to tell you two reasons why they shouldn't live. You're never going to win that argument. But it's much better to. to give them experience of having someone listen to you.

You have the experience of a human connection. So you're not arguing with them, but you're giving them a meaningful human experience that intrinsically makes life worth living. And that's better than any argument you could ever give. For people who've experienced a loss of a loved one by suicide, how do they best cope in the aftermath? Oh, that's very difficult. The pain of people who suffer afterwards is very great.

There was a study done which looked at families of veterans who had a member die from suicide and those who died from natural causes or from combat. And when a family member died from suicide, the adjustment was far worse. And you think about why is that? Well, one of which is shame, guilt, stigma. And people ask themselves, why didn't I pick up on it? Well, what could I have done differently? What's wrong with me as a spouse? I didn't pick up on this.

And the reaction of others is often worse. And people described where they had friends for years and then they just dropped them. Or they have people who would never bring it up. You know, there you are consumed by grief. the most important thing in your life and people aren't talking about it. If you do bring it up, they change the subject.

So the reaction of others is very important in the post post-death adjustment. So how do you go on? You just go on like you would otherwise you rebuild your life. And if possible,

you connect with other survivors who've gone through a very similar experiences. And the American Association of Suicidology does have survivor groups that, opportunities for people to connect with others when there's been a loved one who died from suicide. Yeah, those are great resources for people. Is there any advice for a long-term impact on the surviving family members and friends? I mean, does it change, you know, right after the event versus a year or two later or five? years later?

You know, I don't know. You know, you, the general trend is after trauma, people move to a baseline, but I don't know the long-term data on that. Now, we do know that statistically, you know, we talked about the cluster effect. You know, statistically when a family member dies from suicide, increases the suicide risk of everyone in the family. Now, it's even more of an effect than with a friend. It may be that there are common biological factors that predispose a person to a mental illness.

It might be a similar stressful environment. We don't know. But obviously, most family members don't go on to die from suicide themselves. Other than that, I don't know much about the long-term adjustment. families. Well, thank you so much for joining us, Dr. Knapp. It's been a really wonderful conversation, very insightful, very informative. Well, thank you. I appreciate it. The Monitor story on suicide published online on July 1st. You can read it by visiting APA's website at APA.org slash monitor. And a reminder to all of our listeners who want to hear from you, you can email me your comments and

ideas at K-Luna at APA.org. That's K-L-U-N-A-A-A-A-R. Also, please consider giving us a rating in iTunes, we'd really appreciate it. Speaking of Psychology is part of the APA podcast network, which includes other great podcasts, such as APA journals, dialogue about new psychological research and progress notes about the practice of psychology. You can find all of our podcasts on iTunes, Stitcher, or wherever you get your podcasts. You can also go to our website speakingof psychology.org to listen to more episodes. I'm Caitlin Luna with the American Psychological Association.