Saying‘Yes’toLife:

Theore5calandClinicalConsidera5onsConcerningtheExisten5alandSpiritualCrisisof

Suicide

PaulaHamm,LPCgraduatepsychoanalystCynthiaB.Stevens,MD,graduatepsychoanalyst

CAPS,April,2015Denver,CO

OBJECTIVES

•  Todescribethenatureofsuicidalthoughtsinthecontextofaggression,selfconcept,objectloss,depression,andspirituality

•  Totracethedevelopmentofatheoryofsuicidalthoughtsandac5onsfromFreud’sdualins5ncttheorythroughcontemporaryrela5onaltheory

•  ToexplaintheimpactofacompletedsuicideonaclinicianandoutlinetheresourcesfordealingwiththeaTermathofsuchanevent

TheScopeoftheProblem

•  Suicidewasthetenthleadingcauseofdeathforallagesin2010.

•  Therewere38,364suicidesin2010intheUnitedStates--anaverageof105eachday.

•  Basedondataaboutsuicidesin16NaEonalViolentDeathReporEngSystemstatesin2009,33.3%ofsuicidedecedentstestedposiEveforalcohol,23%foranEdepressants,and20.8%foropiates,includingheroinandprescripEonpainkillers.

•  SuicideresultsinanesEmated$34.6billionincombinedmedicalandworklosscosts.

from“SuicideFactSheet,”CDC,www.cdc.gov/violenceprevenEon

ScopeoftheProblem(con’t)

•  Thereisonecompletedsuicideforevery25aTemptedsuicides.

•  Amongyoungadultsages15to24yearsold,thereareapproximately100-200aTemptsforeverycompletedsuicide.

ThisiswherewealltakeadeepbreathbeforeweconEnue…..

SomeAddi5onalSta5s5cs

•  Amongadultsaged≥18yearsintheUnitedStatesduring2008-2009:3– AnesEmated8.3millionadults(3.7%oftheadultU.S.populaEon)reportedhavingsuicidalthoughtsinthepastyear.

– AnesEmated2.2millionadults(1.0%oftheadultU.S.populaEon)reportedhavingmadesuicideplansinthepastyear.

– AnesEmated1millionadults(0.5%oftheU.S.adultpopulaEon)reportedmakingasuicideaTemptinthepastyear.

Froma2011na5onally-representa5vesample

ofyouthingrades9-12:

Ø  15.8%ofstudentsreportedthattheyhadseriouslyconsideredaTempEngsuicideduringthe12monthsprecedingthesurvey

Ø  2.8%ofstudentsreportedthattheymadeaplanabouthowtheywouldaTemptsuicideduringthe12monthsprecedingthesurvey

Ø  7.8%ofstudentsreportedthattheyhadaTemptedsuicideoneormoreEmesduringthe12monthsprecedingthesurvey

Ø  2.4%ofstudentsreportedthattheyhadmadeasuicideaTemptthatresultedinaninjury,poisoning,oranoverdosethatrequiredmedicalaTenEon.

AgeGroupDifferences•  Suicideisthethirdleadingcauseofdeathamongpersonsaged15-24years,thesecondamongpersonsaged25-34years,thefourthamongpersonaged35-54years,andtheeighthamongperson55-64years.

•  Among15-to24-yearolds,suicideaccountsfor20%ofalldeathsannually.

•  Suicideratesforfemalesarehighestamongthoseaged45-54(9per100,000populaEon)

•  Suicideforadultsaged75yearsandolderwas16.3per100,000.

EthnicDifferences

•  SuicideisthesecondleadingcauseofdeathamongAmericanIndians/AlaskaNaEvesaged15-to34-yearsandis2.5EmeshigherthanthenaEonalaverageforthatagegroup(12.2per100,000).

•  In2011,HispanicfemalehighschoolstudentsreportedmoresuicideaTempts(13.5%)thanAfricanAmerican(8.8%)orCaucasianfemalestudents(7.9%)

LGBTPopula5on

•  SuicideaTemptsbyLGByouthandquesEoningyouthare4to6Emesmorelikelytoresultininjury,poisoning,oroverdosethatrequirestreatmentfromadoctorornurse,comparedtotheirstraightpeers[1]

•  Nearlyhalfofyoungtransgenderpeoplehaveseriouslythoughtabouttakingtheirlives,andonequarterreporthavingmadeasuicideaTempt[2]

[1]CDC.(2011).SexualIden5ty,SexofSexualContacts,andHealth-RiskBehaviorsAmongStudentsinGrades9-12:YouthRiskBehaviorSurveillance.Atlanta,GA:U.S.DepartmentofHealthandHumanServices.[2]Grossman,A.H.&D'Augelli,A.R.(2007).TransgenderYouthandLife-ThreateningBehaviors.SuicideandLife-ThreateningBehaviors.37(5),527-37.

PsychodynamicConsidera5ons

Theoriesofdepression,aggression,anddevelopmentofstableconceptsofselfandof“other”providethepsychoanalyEcframeworkforunderstandingsuicide

ThePsychodynamicsoftheCrisisofSuicide

•  Suicideisasymptom,notadisease•  Developmentalfailuresimpairanindividual’sabilitytomaintainacoresenseofselfworth

•  Aggressionwhichisnotsublimatedandwhichisturnedagainsttheselfmakesanindividualvulnerabletosuicide

•  Innormaldevelopment,thecapacityforautonomyincreaseswithage–  ThereisongoingmaturaEonofhigherleveldefensemechanismstocopewithloneliness,depression,andanxiety

•  Suicidevulnerablepeoplehavenotdevelopedsustaininginnerresourcesbutdependuponexternalsupports– Whentheseexternalsupportsfail,suicideriskrises

DriveTheoryandEgoPsychology

•  ClassicalDriveTheorystatesthatweformasenseofselfbyorganizingourdrives

•  EgoPsychology,alsoknownasContemporaryDriveTheory,followsthisformulaEon

Formula5onofSuicideinDriveTheory

•  Humanbehavioristheproductofthestrugglebetweenthesexual/libidinaldriveandthedeathinsEnct

•  SuiciderepresentsaggressionturnedagainsttheegowithoutsublimaEonofitsintensity

•  FreudhypothesizedthatsuicideresultedifthedeathinsEnctprevailedovertheinsEnctforlove/life

Freud’sFounda5onalPapers•  1913--TotemandTaboo—”wefindthatimpulsestosuicidein

aneuroEcturnoutregularlytobeself-punishmentforwishesforsomeone’selse’sdeath”S.E.XIII154(footnote)

•  1915--MourningandMelancholia—ElaboraEonofhistheorythatmurderousimpulsesturnedinward(againsttheself)leadtosuicideS.E.XIV252

•  1920—BeyondthePleasurePrinciple—ThedualinsEncttheoryS.E.XVIII60(footnote)

•  1923—TheEgoandtheId—ElaboraEonofthedualinsEncttheoryoflibido(Eros),whichisexpressedasselfpreservaEon/lifeandaggression(Thanatos),whichisexpressedasdestrucEveness(selfpunishment)S.E.XIX40

ObjectRela5onsTheory*•  ObjectRela5onsTheory

statesthatwecreateasenseofselfbyorganizingourexperienceofourselvesinthecontextofaninteracEonwithanotherperson,withinanaffecEve“coloring”

•  SecureconnecEonswithcaring“others”providethefoundaEonforpersonalitydevelopment

*Kernberg,O.,etal.

Formula5onofSuicideinObjectRela5onsTheory

•  Whenaloveobjectislost,theegore-createsanimageofthelostobjectinsidetheself

•  Thisinternalimageisnotfullyintegratedintheselfbutis“splitoff”fromtheego

•  Ifthesplitoffpartoftheegoisexcessivelyharsh,it’sjudgmentalaTackcanincludeademandfordeath

•  Suicideoriginatesinturningthewishtokillthelostobjectagainsttheself.Suicidethusrepresentsbothwishfulfillmentandself-punishment

SelfPsychology*

SelfPsychologystatesthatwecreateasenseofselfbyhavinganimageofourselvesreflectedbacktousfromanotherpersonandthenremodelingthatimageinourinternalworld*Kohut,H.andtheChicagoSchool;Lichtenberg,J,Lachmann,F,andFosshage,J-theMoEvaEonalSystemsSchool

Formula5onofSuicideinSelfPsychology

•  AwarenessoftheinadequaciesoftheselfcreatesanegaEveaffecEvestate– Manycliniciansrefertothisasanunmanageablestateofshame

•  AbsenceofmirroringobjectsallowsthenegaEveselfstatetoremainunchallenged

•  SuicideistheaTempttoescapefromselfandfromtheworld

Rela5onalTheory*

Rela5onalTheorystatesthatwecreateandconEnuouslyremodelasenseofselfbyongoinginteracEonswithothers

*Bromberg,P;Mitchell,SandArons,L,etal.

Formula5onofSuicideinRela5onalTheory*

•  Requiresthedesiretodiebysuicideandthemeanstocompletesuicide:“Iamnotafraidtodie.”

•  ThedesiretodieisrootedintwopsychologicalfactorsheldsimultaneouslyandforanextendedperiodofEme–  Perceivedburdensomeness:“Iamaburden.”–  SocialalienaEon:“Iamalone.”*from“TheInterpersonal-PsychologicalTheoryofSuicidalBehavior,”

ThomasJoiner,PhDhTp://www.apa.org/science/about/psa/2009/06/sci-brief.aspx

ToRecap--

•  Analystslookatsuicideintermsofdevelopmentalfailuresthatmakeitimpossibletomaintainasenseofselfworth.• Manypeoplewhogrowupsuicide-vulnerablehavefailedtohave“goodenough”mothering(Winnicoe)•  Othershavereceived“goodenough”motheringbutcannotmakeuseofit.

Recap(con’t)

•  Innormaldevelopment,capacityforautonomyincreaseswithage,whichallowsonetoenduredegreesofloneliness,depression,andanxiety.

•  Suicidevulnerablepeoplefailtodevelopsustaininginnerresources;theydependonexternalsupports.

•  Whenthosesupportsfail,suicideisadanger.

TheSpiritualCrisisofSuicide

OldTestament:TheBookofJob

StThomasAquinas(1267-73)

– LifeisagiTfromGod– Suicidegoesagainstman’sins5nctforself-preserva5onandiscontrarytothecharitythatamanoughttobeartohimself

– Suicideinjuresthecommunityofwhichthepersonisapart

PopeFrancis(2015)

•  Saying“No”tolifeisdisrespecjultoourmissionintheworldandtothosearoundus

•  Suicideorassistedsuicidecanbeseenasasymptomofour“throwawayculture”

RiskFactorsSex--maleAge—bimodalpeak<19but>45DepressionPreviousaTemptEtOH—alcoholorothersubstanceuseorabuseRaEonalthinkingabsent—psychosis,demenEa,deliriumSocialsupportslackingOrganizedplanNoSpouseSeriousmedicalillness

GoogleImages

Protec5veFactors

•  Connectednesswithothers

•  Culturalorreligiousbeliefsthatdiscouragesuicide

Protec5veFactors

•  Flexiblecopingskills•  PosiEveselfimage•  Resiliency•  Curiosity/intellectualcompetence

Protec5veFactors

•  Engagementwithawidercommunity

•  Perceivedreasonsforliving

•  Ongoingtalkaboutsuicide•  Developingaplanandthemeanstocarryoutthatplan

•  Fearlessnessofdeath•  Perceivedburdensomeness•  Progressivealiena5onfromsupportandconnec5ons

•  Severeandpersistentagita5on•  Severeandpersistentinsomnia

MythsaboutSuicide*•  Itisalwaysanimpulsiveact•  Ifsomeoneisseriouslysuicidal,therewillbea note

•  Itisalwaysselfish•  Itisvengeful•  “Slowsuicide”existsandistheinten5oninunhealthyoraddic5vebehaviors

•  Itincreasesaroundholidays*from”UnderstandingandOvercomingMythsofSuicide,”ThomasJoiner,PhD,PsychiatricTimes,January19,2011

Summary

•  Suicideisasymptomofanexisten5alandspiritualcrisis,notadiagnosisordisease

•  Developmentalfailuresimpairanindividual’sabilitytomaintainacoresenseofselfworth

•  Aggressionwhichisnotsublimatedandwhichisturnedagainsttheselfmakesanindividualvulnerabletosuicide

Conclusion

•  Recogni5onofwarningsignsandthoughjulscreeningassessmentcanbelifesavingforpeopleinsuicidalcrisis

•  Theologians,clinicians,andteachers,needaprofessionalnetworkofsupportandconsulta5onforcopingwithsuicidalcrises

ThankYou