165: Ask David: Why do shrinks kill themselves? How to find out if your loved one is suicidal.

In today's podcast, David and Rhonda answer two questions about suicide submitted by podcast fans.

Question 1. Why do shrinks kill themselves?

Dear Dr Burns,

Before I get to my question (which I hope you will consider addressing in your 'Ask David' segment of the podcast), I would like to extend my gratitude to you. Your book, Feeling Good, came to me at a time when I was struggling to make sense of my depression and anxiety, and it has been a vital part of my recovery journey. The exercises and the podcast have been such lifelines, and I am grateful to you for the incredible and life-changing work that you do.

I know you have addressed the topic of suicide in a previous episode, but I recently was struck by a piece of news from my alma mater, the University of Pennsylvania, where a senior member of the college's counselling services (CAPS) died by suicide. Here was someone who had spent his life's work on promoting suicide prevention, and had a great deal of knowledge on resilience. How can we process/understand the decisions that someone like this might make to take his life. How can I arrive at the understanding that his decision doesn't necessarily spell doom for the rest of us? What TEAM-CBT exercises can we do to make sense of the world when it might not make much sense at first glance, during situations like these?

Thank you very, very much,

Sindhu

Dr. David's Answer

Thanks, Sindhu, this is a really great question.

I’ll put this in the Ask David folder. Should I use your name?

Here’s the short answer. It’s a lot like saying that an infectious disease expert shouldn’t get pneumonia, or that an orthopedic surgeon shouldn’t have back pain, or a broken leg. I know of at least three mental health professionals who have committed suicide, but my knowledge based is tiny. I’m sure there are thousands of mental health professionals who have committed suicide.

People can commit suicide for many reasons, and I can only mention a few here, as my knowledge, like yours, is limited.

1. Hopelessness is one of the most common causes of suicide in depressed individuals. Hopelessness always results from cognitive distortions, and never from a valid appraisal of one’s circumstances. Depressed people often turn to suicide, thinking (wrongly) that it is the only escape from their suffering.
2. You may have done something that you are profoundly ashamed of, and fear it is about to be made public. Like the fellow in New York arrested for child abuse who hung himself just a few weeks ago.
3. I am convinced that sometimes people commit suicide to get back at someone they are angry with, someone perhaps who rejected them.
4. Physician-assisted suicide. I believe that physician assisted suicide is absolutely indicated and compassionate if someone is in excruciating pain from an irreversible terminal illness.
5. The Achievement Addiction. Feelings of failure and worthlessness. In our culture, we sometimes (wrongly) base our feelings of self-esteem on our success in life, our income, or our achievements. And so, if your achievements are only “ordinary,” you may feel worthless, like “a failure,” and kill yourself.
6. The Love Addiction: Many people (wrongly) tell themselves they must be loved to feel happy and worthwhile, and then kill themselves when they are rejected by someone they thought they loved and “needed.”
7. Drug and alcohol abuse: These habit, when severe, can greatly disrupt a person’s life. They can also make someone more impulsive, and more likely to jump or pull the trigger when intoxicated.

There are likely way more causes than just these common ones. For example, a psychotic process like schizophrenia might sometimes play a role as well.

I suspect you may have a hidden “Should Statement,” telling yourself that a mental health professional “should not” get depressed or have the urge to commit suicide. But to me, that would be a nonsensical claim, and it isn’t even clear to me why you might think that way. In fact, most people are drawn to this profession because of their own unresolved suffering. There is, I suspect, MORE depression and anxiety in mental health professionals, but I have not seen data, so I’m not certain of this. But I’ve trained tens of thousands of mental health professionals, and pretty much ALL of the ones I’ve known personally have struggled at times, and sometimes intensely.

People also ask, “Why did so and so commit suicide? S/he was so famous and loved and wealthy!” Well, famous and loved and wealthy people often suffer and commit suicide, too.

Finally, I would say that suicide is both tragic and devastating—for the patient for sure, for the family and friends who typically suffer for years, and for the therapist as well. Fortunately, the family and friends can be helped, if they ask, but it is too late for the person who was depressed. And the tragedy is needless in most cases, since the patient’s intense negative feelings can be treated effectively in nearly all cases.

David

Question 2. How can you find out if a friend or loved one is suicidal?

Many people are afraid to ask a depressed friend or family member if they are feeling suicidal, fearing this will create conflict or may even cause the person to become suicidal. For the most part, these fears are unfounded, and the biggest mistake could be avoiding the topic.

Most people who are feeling suicidal are willing to discuss their feelings fairly openly. Several types of questions can be useful.

Suicidal thoughts or fantasies. Most people with depression due have suicidal thoughts or fantasies from time to time, and these are not necessarily dangerous.

First, you can ask, “do you sometimes feel hopeless, or have thoughts of death, or wishing you were dead?” If s/he says yes, you can ask him / her to tell you about these thoughts and feelings. You can also ask if s/he thinks of suicide as the only way out of his / her suffering.

Second, you can ask if s/he simply has passive suicidal thoughts, like “Sometimes I feel like I’d be better off if I were dead,” or active suicidal thoughts, like, “Sometimes I have fantasies of killing myself.”

Suicidal urges. You can ask if s/he sometimes has urges to kill himself / herself. Suicidal thoughts or fantasies without suicidal urges are usually not especially dangerous.

Suicidal plans. You can ask if s/he has made any plans to actually commit suicide. If so, what method would s/he use? Jumping? Shooting? Hanging? Cutting?

You can also ask if s/he has been acting on these plans. For example, if shooting is the choice, you can ask if s/he has access to a gun and bullets. If jumping is the choice, you can ask where s/he plans to jump from.

Deterrents. When evaluating suicide, you can also ask if there are any strong deterrents, such as religious beliefs, impact on family and friends, and so forth. If there are no strong deterrents, the situation is more dangerous.

Desire to live, desire to die. You can also ask the person how strong their desire to live is, and how strong is their desire to die?

Past suicide attempts. If the person has made suicide attempts in the past, the risk of a future suicide attempt is greater.

Drugs and alcohol. You can ask if the person drinks or uses drugs, and has ever has a stronger urge to commit suicide when intoxicated. This is a danger sign.

Impulsiveness. Some people make suicide attempts when they’re feeling impulsive, kind of on the spur of the moment. You can ask if they every have these kids of sudden impulses.

Willingness to reach out. You can ask if they’d be willing to reach out and ask for help if they ever have a suicidal urge.

Honesty. You can ask if they were felt reasonably open and honest in asking your questions, or if it was difficult to answer some of the questions.

Once you have explored these types of questions, you can decide whether action is necessary. If the person seems in danger of making a suicide attempt, you can bring him / her to an emergency room for an evaluation.

If s/he refuses, you can dial 911 and ask for help. Generally, the police will come immediately and do a safety check, and bring the person to an emergency room involuntarily if necessary. You can also call his or her therapist and alert that person to the situation.

This may all sound grim and very unpleasant, but these kinds of conversations can sometimes be lifesaving, and can protect you from much greater pain later on.

In a future podcast, we will focus on this question: How do you treat someone who is suicidal using TEAM-CBT?

David D. Burns, M.D. & Rhonda Barovsky, Psy.D.