Kaitlin Luna: Welcome to Speaking of Psychology, a bi-weekly podcast from the American Psychological Association. I'm your host Kaitlin 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 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.
Samuel Knapp: Thank you.
Kaitlin Luna: My first question for you is, why do people die from suicide?
Samuel Knapp: 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 Joiner, a noted suicidologist, has used the term perceived burdensomeness to describe the 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 you know the mediate cause might be the disruption of a social relationship, a loss of a job, financial distress, some kind of humiliation, but usually there's a loss of social connectedness as well.
Kaitlin Luna: You mentioned Dr. Thomas Joiner, he and other psychologists developed the interpersonal theory of suicide can you explain what that theory is?
Samuel Knapp: It's a very helpful theory, and on its surface is very simple, but it's actually very useful in 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 instincts 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 in leading a person to die from suicide.
Kaitlin Luna: 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?
Samuel Knapp: Well I think it is the increased lack of social connectedness that we have in society. I know suicide is also multi determinant 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. If 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. A very high incarceration rate in the United States, and incarceration is often a life event that causes some people to attempt suicide.
Kaitlin Luna: And that report did note that in some states, especially in North Dakota, the suicide rate went up significantly during that time period, and Montana had the highest per capita rate in the, 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?
Samuel Knapp: Yes, in fact some people have referred to, they call the geographical suicide belt, which is you know western states, rural states having an increased rates of 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 factors that we know about.
Kaitlin Luna: 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?
Samuel Knapp: That whole issue is controversial. You know the relationship between a diagnosed mental illness and a suicide attempt. Now, Thomas Joiner whom I mentioned before, did a study where he looked at 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 what 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 percent higher as most studies find, was about, I think if I recall correctly, about 66 percent, 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 than 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.
Kaitlin Luna: So there's definitely a lot more involved in this than just some simply saying that these people didn't have…
Samuel Knapp: That's right, yea far more than that.
Kaitlin Luna: Going back to what you were talking about older people, there's an investigation by Kaiser Health News and PBS Newshour 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?
Samuel Knapp: Well there is what we call passive suicidal ideation. Now going back to the interpersonal theory, remember there is the desire to die and then the capability of dying. And some of the people in nursing homes may have the 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 passive suicidal ideation people just wish that God would take them away and wish that they then 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, I mean 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 in 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 that ageism 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 are people. they can't do this stuff or they're not interested in things. they just need to sit in the corner and you know maybe that's a factor too that I had not thought about before.
Kaitlin Luna: You've spoken a lot about the importance of social connections and I think they might apply in this case, I want to get your thoughts on it, but more than a million children and teens in the US were admitted to the emergency room for suicide, 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 you were talking about before?
Samuel Knapp: 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 isn't intrinsically bad for a teenager, but it becomes bad if it keeps them from engaging in experiences that are really helpful and good. But yes, disconnectedness, it's a very serious problem with adolescents, it's a society-wide problem that needs to be addressed.
Kaitlin Luna: I did a recent podcast earlier this year about loneliness, which is very fascinating, talked a lot about the importance of social connections for our physical and mental well-being. It was a very good, very good conversation. And, going back you also mention too when you're 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?
Samuel Knapp: Makes sense. You have the loss of income, you have financial and security you have males are socialized into a breadwinning role and if they failed to do that is the source of great humiliation, so that makes a lot of sense to me. That as income inequality rises, as financial insecurity increases, people who are vulnerable to suicide it's an added burden. One of the greatest spikes in suicide in the United States was in the early 1930s during the early years of the Great Depression and to me that's a typical example of the impact of economic security on suicide rates.
Kaitlin Luna: 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?
Samuel Knapp: Yeah so this relates to the interpersonal theory of suicide, and as I mentioned acquired capability is one of the factors that Thomas Joiner 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 it 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 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 when people have that, you know, 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 the suicide attempt.
So we have people these people, me I don't know them, only thing I know is you know is the very brief thing is that they had 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. 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 they 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.
Kaitlin Luna: And because these, the people I mentioned, had to experience these incredibly traumatic events in their lives. I think that the one thing that was really I guess struck me about those stories was how many years it was later. 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 it 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?
Samuel Knapp: It is a factor and hopefully most people experiencing trauma will be able to get some help to be able to put the trauma in the back of their lives, but you know not always, as these cases illustrate.
Kaitlin Luna: And I want to talk 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?
Samuel Knapp: Well we have we have two things going on, one is called contagion and the other is called cluster.
Kaitlin Luna: Can you explain what each one is?
Samuel Knapp: Sure, so after the death of a celebrity by suicide there's a great deal of publicity to it, and many studies 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, the 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 we 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 a year ago that says there is a slight impact of publicity of celebrities on suicide rates, a very small impact, when you look at all these different studies some which found an impact some which didn't, if you're looking at them all together there might be a slight contagion effect.
But we look at clusters which is different. Now clusters are when you know someone personally who's died from suicide. 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? Did the suicide of one person increase the risk of suicides for other people? 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's 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 glamourizing 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 died from suicide, your risk is going to be higher. If you know someone who knew someone who died from suicide it's gonna be a little bit higher, three degrees of separation it's going to be a tiny bit higher, and beyond that there's probably not an effect. But yeah it does appear to be a cluster effect.
Kaitlin Luna: 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?
Samuel Knapp: I think there is more attention on suicide, as it should be it's been neglected a great deal. Now part of the attention started because of the high suicide rates in the United States military, but now it's a 30 percent increase in suicides since 1999. So it deserves to be in the public spotlight, it's a very neglected area of public health. For example, on the Golden Gate Bridge there's been I think 2000 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 on 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.
Kaitlin Luna: Yeah that's exactly what I was gonna 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 as the more it gets discussed, but you know the research dollars need to catch up with that. The monitor article stated that psychologists who study 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?
Samuel Knapp: 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 are at risk to die from suicide, but now we have evidence that really shows without a doubt. That you have research by Craig Bryan and David Rudd cognitive behavior therapies, David Jobes on collaborative assessment management of suicidality, Marsha Linehan dialectical behavioral therapy, and you know, Guy Diamond's attachment-based therapy, we have these studies that show, yea we really have effective treatments. And we should study more on the phenomena of what happens in the suicidal crisis state. You know some really good research by Raymond Tucker and Megan Rogers and Thomas Joiner and Igor Galynker on the suicide crisis state, what happens immediately before a person attempts suicide. This is really opening a lot of possibilities 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 their research.
Kaitlin Luna: It'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 wanted to talk about some more of the practical tips for people. How do we recognize the signs of someone who might be contemplating suicide?
Samuel Knapp: Well it's not always easy to do. And there's been these lists of warning signs that people have developed, and sometimes these lists become very, very long and one of the problems is that they become so long that they become useless. Because there's so many factors that are, you know are so marginally related to suicide that, well one list I see is that if a teenager is disrespectful to a teacher, you, 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 lists become meaningless. But one of the best ways to find out is just ask someone. Or you can take a step back and just ask, “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. Think like a family, a parent and a child, or a child and an older parent, “how are you doing,” spend time with them, quality time. Now because of some of the research that 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 perceivers, sense of entrapment, humiliation, 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 are the some of the recent research that we've had.
Kaitlin Luna: So in terms of intervening if you're worried about a loved one it can be something like, as you mentioned, saying something “now how are you doing” that sort of thing. What are other ways you can intervene to keep someone safe?
Samuel Knapp: Well I mean if they're currently suicidal right now yeah so “are you suicidal,” “yes I am,” get them into treatment, and work with the treatment provider be one to be an 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 individual, 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 be 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.
Kaitlin Luna: And how do psychologists treat suicidal patient patients? What research-informed interventions do you use in your practice or do you suggest others use?
Samuel Knapp: I mentioned some of them, and you know cognitive behavioral therapy, dialectical behavioral therapy, collaborative assessment management suicide, there's also what we call suicide management strategies, but you know looking at the broad question, there's a very good book and its edited by Louis Castonguay and Clara Hill on why some therapists are better than others. And one of the chapters says, okay what do the 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 one's self 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 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 don't always assume that, sometimes people come in so demoralized that they think “nothing's gonna help me” or “I'm not worth saving,” that getting their buy-in is really important. Teaching specific skills, people in a great deal of emotional distress, and giving them skills.
For example, insomnia has a very strong link with suicide attempts. It greatly increases the risk that someone's going to attempt suicide if among all the other things they're not sleeping well at all, have chronic insomnia. And knowing that, there's things that people can do, there's sleep hygiene, there's imaginal rehearsal that can be done to reduce nightmares, there's some medications that can be done to in the short-term 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 naive psychotherapists miss but it's very crucial, and that is suicide management. That is being able to give concrete steps so a person is less likely to attempt suicide 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 that work on that. That really gives very concrete steps on things which have been empirically verified to help people reduce the risk of suicide. You know there's one study that was done which asked veterans “what kept you from killing yourself?” And the number one reason they gave, they gave many different reasons, but the most common one was “my psychotherapist cared about me.”
Kaitlin Luna: Wow that really does say a lot.
Samuel Knapp: 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 gotta go to a hospital” or “I have to tell your 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. But that can turn people off very quickly. But it's much better to listen to them. Instead of arguing with them “oh 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 gonna win that argument. But it's much better to give the experience that having someone listen to you, yeah, 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.
Kaitlin Luna: For people who've experienced a loss of a loved one by suicide, how do they best cope in the aftermath?
Samuel Knapp: 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 the family member died from suicide, the adjustment was far worse. And if 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, 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 they are consumed by grief, the most important thing in your life, and people aren't talking about or if you do bring it up they change the subject. So the reaction of others is very important in the post-death adjustment. So how do you go on, just go on like you would otherwise, you rebuild your life. And if possible you connect with other survivors who have gone through very similar experiences. And the American Association of Suicidology does have survivor groups that have opportunities for people to connect with others when there's been a loved one who's died from suicide.
Kaitlin Luna: Yeah those are great resources for people. Is there any advice for the long-term impact on 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?
Samuel Knapp: You know, I don't know. You know, the general trend is, after a 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 that statistically when a family member dies from suicide, that increases the suicide risk of everyone in the family. Now, it's even more of an effect than with a friend. And 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 of families.
Kaitlin Luna: Well thank you so much for joining us Dr. Knapp, it's been a really wonderful conversation, very informative.
Samuel Knapp: Oh thank you, I appreciate it.
Kaitlin Luna: The Monitor's story on suicide published online on July 1st .You can read it by visiting APA Monitor on Psychology. And a reminder to all of our listeners, we want to hear from, you can email me your comments and ideas at kluna@apa.org , that's kluna@apa.org. Also please consider giving us a rating on 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 our podcasts on iTunes, Stitcher or wherever you get your podcasts. You can also visit SpeakingofPsychology.org to view more episodes and to find resources on the topics we discuss. I'm Kaitlin Luna at the American Psychological Association.
Samuel Knapp, EdD, is a licensed psychologist in Pennsylvania who has worked in rural community mental health centers delivering psychotherapy and crisis intervention services. He is the author of the book, “
