Addressing Internal Conflict to Understand Suicide

When Kevin Hines was 17 years old, he reached a point in his life at which he felt he was a burden to those around him. He had recently been diagnosed with bipolar disorder and had a difficult time managing his thoughts. The day he decided to take his life, his father recognized that something was off and tried to stay with him, but Kevin assured him that he was okay and insisted on going to school.

Throughout the day, Kevin worked to ensure his plan remained undetected. His mind was made up; he was determined to complete suicide. However, in the hour before his jump from the Golden Gate Bridge, he had a change of heart.

Although he didn’t know how to ask for help, he wanted nothing more than to be noticed; he desperately wanted somebody to ask him if he was okay.1 Despite the many stares he got because of the tears in his eyes and his obvious distress, nobody asked him the three words he desperately wanted to hear: “Are you okay?” Kevin’s final thought before jumping was, “Absolutely nobody cares.” (1) Yet, immediately after jumping, Kevin’s first thought was, “What have I done? I don’t want to die. God, please save me!” (1) Somehow, while free falling, Kevin managed to throw his head back and hit the water feet first. He believes this is the only reason he survived the 220-foot free fall. Later, he said that if one person had confronted him in the moments before his jump, he would have admitted his intent as opposed to jumping.

Kevin Hines’ story provides valuable insight for those interested in understanding and preventing suicide. First, in the moments prior to his jump, he experienced the competing forces of life and death found in the days, hours, and moments of virtually all who complete suicide.2 Second, when he decided to complete suicide, he recognized how important it was that his intentions remain undetected. Finally, in the moments before his fatal act, he desperately wanted somebody to simply ask him if he was okay. It’s sad to realize he was more fearful of asking for help than completing suicide.

Through his story, we learn how important it is to listen to our gut instinct and check on those we are worried about and, more importantly, the importance of fostering a culture that encourages seeking help. Because of the deep-seated stigma surrounding suicide that has led to disgust, contempt, and a lack of compassion, those who experience suicidal thoughts feel they must face them alone. (2) The alienation that comes from facing daunting thoughts of suicide alone works in a synergistic manner with the emotional pain and suffering with which a person is already dealing.

One way to prevent suicide is to be able to recognize people who are feeling suicidal and also to have the courage to ask them directly about suicide. Often, people in suicidal crisis don’t discuss their thoughts because they don’t want to worry or burden anybody. They may also feel humiliated, ashamed, or fearful of their suicidal ideations and dread the response they may receive from those who lack compassion and understanding. However, “by asking directly about suicide, you give them permission to tell you how they feel. People who have felt suicidal will often say what a huge relief it is to be able to talk about what they are experiencing.”3 Once people are able to talk about suicide, they experience the first step toward healing—that is, discovering alternatives to suicide. A common interpersonal feeling of those who are suicidal is intense hopelessness, and an anecdote to this hopelessness comes from meaningful social connection.

The internal conflict created by the ambivalence to suicide is rarely considered in suicide prevention, and because of this, there is a dearth of research available on suicide prevention. Likewise, there is no effective algorithm to predict suicide.4 Even the earliest social psychologists who wrote on conflict recognized that, at its very core, it is a competitive struggle for existence.5 And while conflict resolution is a fairly new field of study, the models of cooperative-constructive resolution show promise at mitigating the internal struggle involved in suicide. To complete suicide, you must overcome nature’s strongest force, self-preservation. (2) The survival instinct is so powerful that it will never be eliminated altogether; recognizing that it is always present provides hope for preventing a suicide. This desire to live remains present even up until the moment a person completes suicide. Moreover, the survival instinct has only one rival in strength, and that is the need to belong, which can serve as a buffer against suicide.

This article demonstrates the convergence of internal conflict and suicide and further describes how reframing this conflict as a mutual problem to be solved through public education and social support can create a culture that is more understanding of suicide. The only way to combat suicide and honor those who have died by suicide is to understand suicide and its many causes. Those suffering from the deep-seated pain that can lead to suicide shouldn’t be expected to face their journey alone; they need support from others. However, until the stigma surrounding suicide and mental health is erased, those suffering will continue to fear asking for help.

Suicide by the Numbers

In 2016, 45,000 people in the United States died by suicide, making it the 10th leading cause of death, and this number has increased by 33 percent since 1999.6 Suicide is a major public health concern that until recently received very little empirical research attention.7 Although twice as many people died by suicide than from AIDS in 2006, the National Institutes of Health (NIH) provided 90 times more funding to researching HIV/AIDs than suicide that year.8 Today, funding for suicide trails many other conditions with lower mortality rates including bowel disease, vision disorders, dietary supplements, sleep research, and indoor air pollution. One explanation for the lack of attention and funding was the historically negative stigma associated with suicide and suicidal thoughts. Limited funding has led to our limited ability to predict and treat suicidal behavior, and this is the major problem surrounding suicide prevention. (3)

Many of these negative stigmas emerged from deep-seated religious views claiming suicide was a sin against God and were further perpetuated by a lack of understanding behind the external causes that contribute to suicide. (2) However, in the late 19th century, Emile Durkheim published “Le Suicide,” which argued that suicide was not an individual choice but rather the result of external pressures placed on people by society.9 This concept has led several scholars to recognize that suicide is not simply an individual choice but rather a progressive illness with tractable causes similar to cardiovascular disease. Through his work, Durkheim challenged society as a whole to accept the responsibility for implementing change that can facilitate prevention. It is theorized that erasing stigma and encouraging people who are suffering in silence to reach out for help can prevent suicide.

Challenges

Individual vulnerabilities lead to suicide ideation, and life stressors exacerbate these vulnerabilities.10 Although few people with mental health disorders die by suicide, multiple researchers have concluded that nearly 100 percent of people who died by suicide had a mental health disorder at the time of their death.11-12 (4) Despite this, it has been determined that situational stressors are a more proximal cause of suicide than diagnosis of a mental health disorder. (8) By adding to Durkheim’s work, O’Conner and Kirtley identified high socially prescribed perfectionism as a contributor to the adverse psychological reaction to stress that can contribute to completed suicide.

Socially prescribed perfectionism is another way of describing a perceived zero-defect society. Despite the fact that mistakes and errors are inherent in life and in society, perceptions of socially prescribed perfectionism cause many to suffer in silence as opposed to addressing their underlying causes that can lead to suicide. O’Conner (10) explains that social perfectionists identify with what they believe others expect from them, and this can easily push them toward feelings of failure and defeat.

Social perfectionists are more sensitive to environmental signals of failure.13 This explains why certain populations, such as white males, firefighters, dentists, and physicians, are more prone to suicide. (13) The Centers for Disease Control and Prevention (CDC) recently found that those in protective service roles experience elevated rates of death by suicide compared to other occupational groups.14 It is posited that a contributor to their elevated rates of suicide is the expectations placed on these populations that lead to a sense of responsibility to others in the community. Simply stated, it’s harder for members of these groups to admit what they perceive as weakness.

Concurrently though, members in protective service roles such as firefighters can also experience elevated rates of certain mental health disorders. These disorders include depression, post-traumatic stress disorder (PTSD), sleep disturbances, alcoholism, and anxiety. According to Joiner (12), mental health disorders serve as a necessary but not sufficient causal factor in death by suicide. However, he explains that these disorders are treatable and, because of this, suicide is preventable. (12)

Moreover, despite their stigma, mental health disorders are surprisingly common. As a graduate student, Joiner discovered that when all mental health disorders are surveyed including substance abuse, dependence, and phobias, the percentages add up. In his graduate research, he was surprised to find that approximately 45 percent of people will meet diagnostic criteria for a mental health disorder in their lifetime. (2)

Sleep disorders are of particular interest to emergency responders because they are a well-known risk factor in terms of mood disorders, particularly major depressive disorder.15 Sleep disorders have also been found to confer increased risk of cardiovascular disease, certain cancers, PTSD, and reduced levels of testosterone. A recent national study of 7,000 firefighters conducted across 66 fire departments found that 37 percent of firefighters were at risk of a sleep disorder, and 81 percent of that cohort had not yet been diagnosed.16

Paul Antonellis17 explains that suicide occurs because of the silence that one feels is necessary in a society that stigmatizes mental health disorders and suicide. People choose suicide when they are in a great deal of emotional pain and their hopelessness exceeds their feelings of connection.18 If established, connectedness can foster a desire to live in those who are in a great deal of pain. Erasing the stigma behind mental health disorders and suicide can enable people who are suffering to open up about their struggles and either receive the help they need or feel less alienated.

Furthermore, despite the fact that nearly 100 percent of people who died by suicide had a diagnosable mental health disorder, 68 percent had not received mental health services in the year before their death. (8). According to Joiner (12), “Suicide stems from mental disorders, mental disorders are treatable, and suicide is preventable. Like natural disasters and cancer, mental disorders are forces of nature, and mental disorders are particularly insidious in that they can be invisible to others. That forces of nature like this sometimes kill people should come as no surprise, and to blame family members for a suicide or for family members to blame themselves makes as much sense as their being blamed for deaths stemming from earthquakes or from pancreatic cancer. Finally, to intimate that one should be open about suicidality but not about its connection to mental disorders is not just ironic but also misinformed and is further unfair to nonsuicidal people with mental disorders.”

Models of Suicide

There are three scientific models that explain suicide.

Interpersonal Theory of Suicide. This model was developed in 2005 by Joiner, and it posits that those who experience a co-occurrence of a perceived burdensomeness and failed belongingness for long enough will develop the desire to die. (2) Though, he explains, this desire only translates into suicide when a third construct exists, the ability to enact lethal self-injury. One can acquire the ability through a habituation toward painful and fearful experiences. Furthermore, this ability can be obtained by those whose job entails exposure to other’s pain and injury, because habituation can occur vicariously through witnessing another’s experience. (8) This explains why those in protective service organizations may have higher rates of suicide. In his model, the capability for suicide is a static variable that cannot be mitigated, but the other two variables are dynamic and can be altered through intervention.

Three-Step Theory. This model was constructed in 2015 as a means of determining the ideation to action framework. (18) It focuses on three claims. First, pain and hopelessness lead to suicide ideation; second, connectedness mitigates ideation; and third, a suicide attempt only occurs if one has the means and capacity. (18) This model attempts to explain that our ability to prevent suicide hinges on a better understanding of the transition from thoughts of suicide to action. Although it concludes that capability is the strongest predictor of action, prevention efforts that target hopelessness may be particularly useful. (18) The three-step theory has found that connection not only to people but also to a sense of purpose or a meaning can keep one invested in life. (18)

Integrated Motivational Volitional Model (IMV). This model, created in 2011 and updated in 2018, describes three phases that lead to completed suicide. The first phase is the premotivational phase, which includes background factors and triggering events such as childhood adversity and trauma. (10) The second phase, motivational phase, includes the relationship between defeat and humiliation and feelings of entrapment that lead to suicidal ideation. In this phase, entrapment translates to a “tunnel vision”’ that leads the individual to believe that there is no alternative to suicide. (10) The third phase, the volitional phase, includes broad factors that lead to acquired ability. In the IMV model, there is a cyclical relationship between the second and the third phase. The model identifies protective moderators that can buffer against the suicidal ideation/intent. They include belongingness, connectedness, and goal pursuit. (10) Conversely, lack of social support, feeling defeated, and burdensomeness will increase the likelihood of suicide ideation/intent.

All three models demonstrate the importance of connectedness as a protective factor against suicide. Placing emphasis on contemporary conflict resolution practices that properly identify the problem, evaluate it from all angles, and then create and evaluate solutions will generate an environment that fosters help-seeking behavior and can prevent suicide. Moving from the stigma-driven mentality that has discouraged compassion to eliminating socially prescribed perfectionism while generating connectedness will reduce suicide.

Using Conflict Resolution Strategies to Prevent Suicide

In response to the 33 percent increase in suicide, the CDC recommends focusing on populations considered at risk, such as protective service organizations. These respected organizations have an opportunity to model the behaviors necessary to reduce suicide across all populations. Suicide is a fearsome tragedy that must be understood to not only honor those who have died by suicide but also combat their cause of death and prevent future suicides. (2) Interestingly, the most recognized manner of preventing suicide is also through positive social support from family, friends, coworkers, the community, and culture.

Only recently have the practitioners of suicidology recognized that up until their moment of death, suicide decedents experience a strong ambivalence for both life and death. However, for life to win, people in suicidal crisis must be able to express themselves and have their viewpoints compassionately heard and understood. Currently, there is no effective algorithm to predict suicide, but by viewing it as a complex puzzle to be solved collaboratively, there is hope at creating a necessary algorithm. Suicide prevention requires problem-solving approaches designed to understand its inherent conflict. Fundamental components are (1) diagnosing conflict by determining its underlying issue and (2) developing alternate solutions. Suicide ideation has the potential to become an opportunity for growth through appropriately treating underlying issues that lead to suicide by creating alternate coping solutions.

Suicide and conflict have many other fundamental similarities. Just as suicide involves ambivalence, so do the elements of cooperation and competition involved in nearly all conflict. (5) More importantly, both suicide and conflict are caused by lack of knowledge and understanding. Broadly speaking, difficulty in diagnosing and determining the ideation to action of suicide is related to ignorance and socially prescribed perfection. More acutely, it’s related to fear of admitting weakness and fear of seeking help. One way to develop alternative solutions is by bridging interests and changing culture.

To resolve conflict is to solve a problem together. Many who are suffering from a suicidal crisis are in pain but fear sharing their pain because of the stigma surrounding suicide. In his research after the Chicago (IL) Fire Department experienced seven suicides in an 18-month period, Chief Dan DeGryse determined that “suicide is one outcome of serious, internal struggles for an individual that may manifest for some time before he/she reaches the decision to die by suicide.” (9) Simply stated, to prevent serious internal conflict from ending in suicide, it is critical to have a network of people who can extend social support. (5)

Combat the Stigma

The underlying issues that lead to suicide must be expressed and reframed early with the use of social support. For many, these underlying issues are common mental health disorders that are tractable, treatable, and nothing to be ashamed about. (2) Because the underlying problem to be solved in all conflict is lack of knowledge, techniques used in conflict resolution have the potential to help address, educate, and prevent suicide.

Suicide is the end result of serious internal struggles for an individual who is unable to connect with the social support necessary to treat the underlying conflict. To combat suicide, we must combat its stigma through proper public outreach and education.

Endnotes

1. Hines, K. (2013). Cracked, not broken: surviving and thriving after a suicide attempt. Lanham: Rowman & Littlefield.

2. Joiner, TE. (2011). Myths about suicide. Cambridge, MA: Harvard University Press.

3. Van Heeringen, K. (2018). The Neuroscience of Suicidal Behavior (Cambridge Fundamentals of Neuroscience in Psychology). Cambridge: Cambridge University Press.

4. Turecki, G & DA Brent. “Suicide and suicidal behavior,” (2016) The Lancet.

5. Coleman, PT, M Deutsch, & EC Marcus. (2014). The Handbook of Conflict Resolution: Theory and Practice (3rd ed). Wiley.

6. Hedegaard, H, S Curtin, & M Warner. (2018, October 03). Suicide Mortality in the United States, 1999-2017. Retrieved from https://222.cdc.gov/nchs/products/databreifs/db330.htm.

7. Van Orden, KA, KR Conner, S You. (2011).”Social connections and suicidal thoughts and behavior,” Psychology of Addictive Behaviors, 25(1), 180-184.

8. Joiner, TE, KA Van Orden, T Witte, & D Rudd. (2009). Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients. Washington: American Psychological Association.

9. DeGryse, D. (2015, Nov 30). Chicago Fire Department Suicide Study. Retrieved from http://www.rosecrance.org/chicago-fire-department-suicide-study/.

10. O’Connor, RC & OJ Kirtley. (2018). “The Integrated Motivational-Volitional Model of Suicidal Behavior,” Philosophical Transactions B,373, 1-10.

11. Bryan, CJ, KW Jennings, DA Jobes, & JC Bradley. (2012). “Understanding and Preventing Military Suicide,” Archives of Suicide Research,16(2), 95-110.

12. Joiner, TE, JM Buchman-Schmitt, C Chu. (2017). “Do Undiagnosed Suicide Decedents Have Symptoms of a Mental Disorder?” Journal of Clinical Psychology. 73(12), 1-17.

13. Storr, W. (2015, May). The male suicides: How social perfectionism kills. Retrieved from https://mosaicscience.com/story/male-suicide/.

14. Stanley, IH, JW Boffa, LJ Smith, JK Tran, NB Schmidt, TE Joiner, & AA Vujanovic. (2018). “Occupational stress and suicidality among firefighters: Examining the buffering role of distress tolerance,” Psychiatry Research,266, 90-96.

15. Emet, M, M Uzkeser, S Guclu, M Ergin, & S Aslan. (2016). “Sleep Disorders in Shift Workers in the Emergency Department and Efficacy of Melatonin,” Eurasian Journal of Emergency Medicine,15(1), 48-53. doi:10.5152/eajem.2016.84758.

16. Sullivan, J, C O’Brien, L Barger, S Rajaranam, C Czeisler, & S Lockley. (2017). “Randomized, Prospective Study of the Impact of a Sleep Health Program on Firefighter Injury and Disability,” Sleep, 40(1), 1-10. doi:10.1093/sleep/zsw001.

17. Antonellis, P Jr & D Thompson. (2012, Dec. 1). “A Firefighters Silent Killer: Suicide,” Fire Engineering; 165(12):1-10.

18. Dhingra, K, ED Klonsky, & V Tapola. (2018). “An Empirical Test of the Three-Step Theory of Suicide,” Suicide and Life-Threatening Behavior.

 

DENA ALI is a captain with the Raleigh (NC) Fire Department. She has a bachelor’s degree from North Carolina State University and obtained her MPA from the University of North Carolina at Pembroke, where her research focused on understanding suicide. She is a founding member of the Carolina Brotherhood and the founder and director of North Carolina Peer Support.

Dena Ali will present “Understanding and Preventing Fire Service Suicide” at FDIC International 2019 in Indianapolis on Thursday, April 11, 3:30 p.m.-5:15 p.m.

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 Originally ran in Volume 172, Issue 3.

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