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Loneliness, Depression, and Suicide
Barry Greenwald, Ph.D.
A UNIVERSAL EXPERIENCE
Few, if any of us, have escaped feeling depressed. We may have different words for it, e.g., "I
feel down," "I'm so blue," "I just don't seem to care about anything," "I've no energy for
anything," "I just want to crawl into bed and pull the covers over my head" but the underlying
emotional experience is essentially the same. Feeling "down in the dumps" from time to time
seems to be a part of the human experience. It is never a pleasant feeling; but it is usually
endurable because it doesn't go on forever. At least, in normal depressions, it doesn't go on
forever. Some people, however, seem more prone to depression. They have more frequent
experiences of the "moody blues" and the duration of these feelings often last for long period of
times. Both duration and intensity are key factors in determining the difference between "normal
depressions" and depressions that are the expression of unresolved psychological problems.
Depression is really a collection of symptoms and can be thought of as a symbolic communication
that there is something wrong in an individual's ability to maintain a comfortable psychological
SYMPTOMS AND COMPLAINTS
SOME ATTEMPTS AT EXPLANATION
Some theories propose that clinical depression in caused by a biological problem. Sleep and
eating (vegetative functions) problems are often used as evidence for the biological theories as is
the fact that people who are depressed often respond to anti-depressant medication. Recent
research made possible by non-invasive techniques (MRI, CAT) have shown that the brains of
people experiencing depression show marked variations in the absorption of serotonin and
norepinephrine. giving greater credibility to the biological bases for depression. Both the older
and newer generations of anti-depressant medications deal directly with these neurotransmitter,
often preventing their re-uptake making them more available at the synapses. If, ultimately,
depression as we know it turns out to be a "biochemical disorder," the temptation may be to
overlook the psychological components that are a part of this illness. Psychological reactions are a
part of every illness and need to be addressed if the suffering individual is to be helped.
Psychological: Failure to live up to ideal
Psychological theories have traditionally explained depression as "Anger turned inward against the
self." If you fail to live up to some internal standard of who or what you are supposed to be,
some internal watchdog notes your failure and begins to let you know that you haven't been all
that you could be--depression. People often talk about being angry with themselves because they
have not accomplished or achieved or done what they think they should have. This explanation
accounts for the diminished self esteem depressed people often report.
Psychological: Problems expressing anger
Often depressed people report having great difficulties expressing any kind of anger. Instead of
becoming angry with someone who has provoked them, the anger is turned inward against some
part of the self. They don't even kick the cat; they kick themselves. These people have a way of
making everything their own fault so that no matter what happens, they can blame themselves.
Others talk about anger as a useless emotion, i.e., "What good does getting angry do anyway?"
Intellectually, they attempt to convince themselves and others that anger accomplishes nothing so
why bother. What they don't realize is that this style drives anger beneath the surface and forces it
to find a more indirect avenue for expression.
Psychological: Empathic failures
Depression also seems to be the reaction to empathic failures on the part of others. When
important people fail to understand, recognize, acknowledge, appreciate, or respond in a way that
we hoped they would, that can be a sufficient injury to produce a depression. It is as if their
failure delivers the message that we are not good enough, worthwhile or important. It is a slight
to our self esteem and it does not even have to be of major proportions. Some people are more
sensitive to this kind of injury because of their personal history, so a small slight may well have the
same psychological importance as a major rebuff
Psychological: Reactions to life events
Certain events that occur as a part of life carry depression as a component. Endings, separations.
losses, and death elicit strong emotional reactions in those who are experiencing them; depression
is often a part. More specifically, divorce, moving to a new place, graduations, the end of a
romantic relationship, a good friend moving away, the completion of a major project, the death of
a loved one are examples of normal events that can evoke strong, reactive depressions. These
depressions are a part of a more global emotional state known as "mourning" when an individual
withdraws his energies from other activities and seemingly reinvests them in himself. Loss is
experienced as a wound and the individual needs time to heal, to restore his psychic equilibrium.
The period following loss is a time of reassessment and revision. Loss requires a new adjustment,
a learning to do without whatever has been lost. It is a slow process and often a confusing time
as people try to work out how their life is going to be now. Periods of mourning and its attendant
depression that stretch beyond three years, however, should be carefully assessed. This otherwise
normal process may have taken on some pathological elements.
THE CLINICAL SPECTRUM
Depression runs the gamut from mild to severe and at the severe end of the continuum, it is a
profoundly disabling disorder. The more common forms of depression are currently labeled
Dysthymia (Depressive Neurosis). A more severe version is considered to be a Major
Depression. At the severe end of the continuum are the Bipolar Disorders which are
characterized by depression or mania or a combination of both mood states. Milder forms of
this disorder are called cyclothymia. Depression may exist with or without psychotic features
(markedly impaired reality testing, peculiar or highly idiosyncratic thinking). It may be chronic (of
long standing) or episodic (intervening periods of normal moods).
Psychotic depressions are paralyzing, often characterized by complete withdrawal, the absence of
speech and the absence of movement. It is as if the person returns to an exclusively vegetative
state where only bare existence is maintained. Depressions that reach this level often require
hospitalization and are treated with antidepressant medication or electro-convulsive therapy
The manic side is quite a different picture. It is characterized by high states of agitation, driven
behavior, stream of consciousness thinking, emotionality, a need to be doing something all the
time, an exaggerated sense of well being, poor reality testing, poor judgement, and irritability.
The person who is in a manic state gives the impression of being incredibly "high" on something.
They are uncontainable, off in a million different directions simultaneously. Often, hospitalization
and medication is required in order to treat the person. Lithium is often prescribed as the drug of
choice since it tends to dampen the manic state and prevent future episodes when taken properly.
It is not uncommon for a person suffering from a bipolar or cyclothymic disorder to move back
and forth between depressed and manic positions. Some theorists believe that the manic phase is
really a defense against depression. The person is struggling mightily to keep from becoming
depressed by maintaining this exaggerated mental and physical activity level. It is also possible for
people to show only the depressed side or only the manic side.
In the more moderate range are the depressions that are not so profound but nevertheless painful
and troubling to the people who experience them. Hospitalization is seldom required and usually
psychotherapy will provide sufficient insight so that there will be relief from the symptoms of
depression. It is not unusual to discover that people suffering a moderate depression are also
being treated with antidepressant medication. What is important to remember is that talking is
often a very important means for the depressed person to find out why he/she is depressed. What
are the triggers in his/her life that sets the depression into motion.
STRATEGIES FOR DEALING WITH A DEPRESSED CALLER
(Because depression depletes the energy level of the person, the liner may need to be a bit more
active than usual in order to elicit material and move the call along.)
Once the caller has identified him/herself as feeling depressed or has offered some of the
symptoms listed above, find out as much as you can about the complaints, when they occur, how
are they affecting the person's life, i.e., just how disabling is the depression.
- Find out how long the symptoms have been going on and as much about the time they
began as possible. Listen for "significant others" so you know who is important to the
person. Listen for "significant events" so you know what is important to this person.
Then listen for disappointments, slights, failures, a feeling of having failed someone
important, losses, significant changes in the person life.
- As the person reveals his/her history to you, be sure to ask about the feelings that
surrounded the people or events that are described to you. "What were your feelings?"
"How did you feel about that?" "You didn't say what you felt about that." You want the
person to talk in feeling language as much as possible.
- Be alert to omissions. If a person describes something to you that could well have evoked
hurt, anger, insult, frustration and it is not mentioned, wonder about it. "Were you hurt
about that?" "You might have been angry?" "Sounds as if its difficult to put your finger
on what you were feeling. What was going on inside of you?"
- Listen for problems dealing with anger. An important part of your strategy is to help the
person discover, if appropriate, that his/her depression has something to do with
unexpressed angry feelings. "It sounds as if you work very hard not to be angry..."
"What became of the hurt feelings?" "Where do you put your anger when you don't
express it?" "It seems much easier for you to be angry with yourself than to be angry
with someone else."
- If unexpressed anger does not seem to be the pivotal issue, listen and explore for the other
possibilities discussed above.
- Our goal is to help a person understand what might have been the event and the emotional
interpretation placed on it that triggered the depressed response. Keep in mind the
"event" does not have to be major in order to trigger the depression: "He didn't call" "I'd
hoped she would remember." "I can't believe that just forgetting my name could be so
upsetting to me."
- Helping find the "trigger event" is easier when the depression has had a recent onset and
seems more like a mild to moderate reaction.
- Our goal with a person who reports a depression of long standing is likely to be different.
It is possible that this not the first time the person has been depressed and when that is so,
this is probably a pattern. Our ultimate goal with a caller who evidences repeated,
prolonged depressions is to refer for psychotherapy so that the person may explore the
significant issues in the context of a long term relationship.
A BRIEF "TRUE" AND "FALSE" EXERCISE...
Take the following test and see how well you do.
The answers for this exercise will be provided at the end of this section on Suicide.
- People who talk about suicide don't commit suicide. True or False (circle)
- Suicide happens without warning. True or False (circle)
- People who are suicidal are fully intent on dying True or False (circle)
- Once a person is suicidal, he or she is suicidal forever. True or False (circle)
- When a person reports feeling better after a suicidal crisis, the suicidal risk is over. True
or False (circle)
- Suicide strikes much more often among the rich or, conversely, it occurs almost
exclusively among the poor. True or False (circle)
- Suicide is inherited; it "runs in the family." True or False (circle)
- All suicidal individuals are mentally ill and suicide is always the act of an extremely
disturbed person. True or False (circle)
BY WAY OF INTRODUCTION
Not everyone who is depressed is a suicidal risk. Not everyone who has ever thought about
suicide is a real risk. From time to time, we have all considered the possibility that things would
be a whole lot easier if we weren't alive. These are the moments when we want relief from the
seemingly overwhelming pressures that make life extremely difficult. Suicidal thoughts, in these
instances, is the wish to be "out from under" the enormous burdens or disappointments or hurts
we are carrying.
On the other hand, depression and suicide are related and suicides and suicide attempts are usually
preceded by a period of serious depression. For some people, death becomes preferable to life. It
represents a solution to what seems to be the insurmountable problems in their lives. For some
people, it is a last, desperate plea to have acknowledged the incredible and interminable pain they
are in. And, for some people, it is an angry assault on those people who will be left behind who
must deal with the emotional aftermath of a suicide. And, when alcohol enters the picture, the
increase in risk becomes substantial.
Of all the emotionally loaded situations faced by crisis workers, suicide is the most frightening and
the situation most likely to be mishandled. The urgent life and death nature of suicide brings out
the RESCUER in all of us. We harbor the belief that we can be responsible for saving the suicide.
We also harbor the terrifying belief that we may push the person "over the edge" and become
responsible for the death. Neither belief, while understandable, is likely to promote appropriate
Before continuing with interventions, let us look at some of the signs that indicate high suicidal
This list of indicators is not exhaustive. It is the 10 most common indicators of high suicide
potential. In working the hotline, you will become familiar with your organization's suicide
assessment form that you fill out as you are taking a call. By answering a series of questions, you
will come up with a numerical score that gives a quick reference for just how suicidal the person
is. Of course, no test can take the place of your judgement (nor can you abdicate responsibility to
the test). It is a helpful instrument in that it focuses your thinking on dimensions relevant to
determining risk potential.
- Previous attempts; 50% to 80% of those who commit suicide have previously attempted
- Lethality of attempt: The more violent and painful a previous attempt (gunshot wound,
hanging) the greater the risk.
- Age: The highest risk age group is 75-79; the second highest is 55-64 and the third
highest age group is 15-24.
- Depression: This symptom combined with problems sleeping and eating increases the risk
approximately 500 times. People are more likely to be at risk when they are coming out
of a depression rather than when they are profoundly depressed.
- Lack of future plans: No plans for the future and talk of what people will do when they
are gone increases risk.
- Recent Loss: A person who has experienced the death of a loved one, an important
separation, or divorce can be at higher risk.
- Giving away personal property: If cherished items are being given away, there is increased
- Unemployment or financial difficulty: Economic problems due to lack of employment or
increased financial burden increase risk.
- Substance abuse: Barbiturates and alcohol can be a lethal combination. Alcohol is
involved with 90% of all suicide attempts.
- The presence of psychotic thinking: Often severely disturbed people believe death to be a
temporary rather than permanent state. They fully expect to return tomorrow after
committing suicide today. Confusion and disorientation also adds significantly to the risk
POLICY REGARDING A "SUICIDE IN PROGRESS"
The rationale for this policy is the conviction that some part of the caller wants to live. That's
why he or she called. As with all psychological conflicts, ambivalence is an important
component. This policy sides with the part of the person who wants to live even if the death
choosing side seems to be in ascendance.
- IF IT BECOMES YOUR BELIEF THAT A CALLER IS IN THE PROCESS OF
COMMITTING SUICIDE, IT IS YOUR OBLIGATION TO DO EVERYTHING
POSSIBLE TO BRING HELP AND ASSISTANCE TO THAT PERSON SO THAT
HIS OR HER LIFE MIGHT BE SAVED.
MANAGEMENT OF THE SUICIDAL CALLER
Some people call because they are contemplating suicide. It is something they are thinking about
doing in the near or distant future. It could be as soon as they hang-up or it could be weeks or
months from now. Suicidal thinking should be taken very seriously. It is important, however,
that the liner not panic. The absolute essence of good suicidal management is maintaining a
sense of calm when everything inside of you is pushing you in the opposite direction emotionally.
Handling suicidal calls is SCARY. Good technique and comfort with that technique helps. But a
liner should never get to the point where handling a suicidal caller becomes easy or a matter of
routine. It is a demanding, exhausting job and it tests you more as a person than it does as
someone who has mastered techniques of crisis intervention.
People hold differing views on suicide and the right of anyone to take his/her own life. The state
is very clear. Suicide is against the law. Although people who attempt suicide are seldom
prosecuted, it is certainly within the state's purview to do so. Individuals, however, vary
enormously about this question and it is not difficult to find proponents for the polar extremes of
this question. In recent years, there have been groups formed to provide information about
effective means for committing suicide for those who seriously plan to take their lives. The media
is full of coverage about doctor-assisted suicides. Regardless of your personal beliefs, you need to
know and understand the policy of the organization for whom you work or volunteer and be sure
that you are objective in its implementation.
It is important that you have come to grips with your own emotional as well as intellectual
positions on suicide. The hotline is not a place to impose your point of view no matter how
convinced you are of its ultimate "rightness" and "benefit to person kind." Our interventions and
strategies are to be for the caller's benefit, not to make ourselves more comfortable or to enhance
our self view as the "adequate crisis worker."
THE CALLER CONTEMPLATING SUICIDE
- Listen for the symptoms of depression listed earlier and for the indicators of risk also
previously discussed. Listen with your "gut" as well as your head since the suspicion of
suicide often is conveyed between the words. If something inside of you is sending up the
"suicide red flag" pay attention to it.
- It is important that you communicate in a calm manner that you are not afraid to talk
about suicide as very personal issue; as a very personal choice. This is not the place for a
political or philosophical treatise on personal rights. It is important that you convey a
sense of neutrality to the caller. To convey anything else is to make it impossible for the
caller to be as fully self disclosing and open as may be needed for your discussion.
- If the caller brings up the topic openly, be prepared to follow his/her lead. Our usual open
ended questions are useful in gaining more information about the circumstances that have
led a person to be seriously contemplating taking his/her own life.
- If the caller conveys that suicide is an issue but does not bring it up directly, it is likely that
the liner may have to introduce the topic. "I have the feeling your thinking about suicide
but having trouble bringing it up." "Are you thinking about killing yourself?" "It sounds
as if suicide might be on your mind." INTRODUCING THE TOPIC, SAYING THE
WORD SUICIDE WILL NOT MAKE A PERSON COMMIT SUICIDE NOR
WILL IT PLACE THE IDEA IN HIS OR HER MIND CAUSING THEM TO
COMMIT THE ACT.
- Because suicide is so frightening to most people, being able to talk about it openly and
forthrightly is often experienced as tension reducing. Most people respond to the
possibility of someone killing himself with reassurances that things will get better, that life
is worth living, and that he shouldn't be thinking or saying things like that. None of those
remarks reflect good intervention technique. They are designed to make clear that the
listener does not want to hear such terrifying ideas and feelings. We do! We want to hear
it all. We want the caller to talk in great detail about the pain in his life, the things that
s/he has tried, the things that have failed, the people s/he has turned to, the
disappointments s/he has experienced, the desperation he lives with. And then, we want
the caller to tell us in detail about his/her plans for the suicide. Saying these things out
loud may permit the caller to actually hear them for the first time. That, in and of itself,
can sometimes bring a new perspective to the situation.
- Keep in mind that the threat of suicide galvanizes people into action. If people have
become bored or disinterested in you and your problems and have begun to withdraw
from you, threatening suicide seems to breathe new life into the deteriorating relationship.
As such, threats of suicide can be used as manipulative strategies to get something that
might not ordinarily be given under ordinary circumstances. Assessing whether this is a
real suicidal caller or a caller who is using suicide as a manipulative strategy is amongst
the most difficult judgement calls you will ever have to make.
- While there are no hard and fast rules that work every time, paying very close attention to
your own emotional reactions can provide information. If you begin to feel manipulated
by the caller; if you begin to sense a lack of genuineness or sincerity; if you have a sense
of being milked for all your worth; if the call becomes circular and you have a sense that
this is really going nowhere, then you may be dealing with someone who has learned to
use suicide as a way of making people jump through hoops.
- If your judgement is that this is not a real suicide call, you can begin to test your
hypothesis by checking it with the caller. "I Have the feeling that people really respond
to you differently when you are feeling this suicidal." "It seems as if you've found a way
to make people pay attention." You may meet denial at first, but if your gut still feels
right, stick to your guns.
- While talking with the caller, you will be filling out a suicide assessment form in order to
determine the risk potential. Whether high or low risk, it is important to take the caller's
concerns seriously. The suicide form will help point you to questions you should ask in
order to get a more complete picture of what is going on.
- Suicide is a decision. Its consequences are irreparable and the devastation it leaves behind
is enormous. Nevertheless, if you want to be effective in managing a suicidal caller, you
need to approach this issue as a decision that can be discussed. If you come down "pro"
or "con" the caller will be forced to play to your position or to abandon the call. You
need to be able to discuss this option and to explore other options with the caller. You
need to discuss what the caller feels will be the impact of this act on others in his life and
you may even need to correct unrealistic expectations ("Nobody will care. Nobody will
even miss me") You will want to encourage the caller to take his/her time reminding
him/her that if successful, there are no second chances.
- While a call to the line may have an immediate, calming effect, it should be our goal to
refer this caller to an agency or private practitioner who will provide long term assistance.
Once the suicidal issues drop from immediate concern, there are many other issues that the
caller would profit from exploring and understanding.
A SUICIDE IN PROGRESS
- This is a call in which the caller has made it clear that he/she is in the process of
committing suicide or has the means (e.g., a gun) at hand and is planning to make use of
them at some point in the call or immediately thereafter. LINERS WILL FIND
THEMSELVES MORE ACTIVE DURING THESE TYPES OF CALLS.
- It is important to attempt to find out the name and the exact location of the caller so that
help can be sent.
- It is also important to find out if there is anyone with the caller, a neighbor, or a friend
who might be helpful should such help be needed. Callers are often reluctant to provide
this information. It should be actively sought and if not successful, the liner should return
to information gathering questions at other times during the call.
- If the caller refuses to provide the information needed in order to send help, it will be
necessary to begin a TRACE. Enlist the aid of a second liner in the office to undertake the
trace. If you are alone, ask the caller to hold on because you must attend to a second
phone. Keep in mind that traces are not instantaneous. They often take a good deal of
time. You will need to keep the caller on the phone if the trace is to be successful.
- Some hotlines now have Caller ID. While this new technology gives rise to important
ethical questions about "caller anonymity," the management of the "suicide in progress"
caller can be made enormously easier if a phone number is immediately available. Be sure
to check on your organization's guidelines and policies regarding this.
Each local phone company may have different procedures for beginning and carrying out a trace.
In some places, a liner can start the process. In other communities, the police need to be called
first and make the request for a trace. Be sure to be informed about the "how-to's" that apply to
your crisis service in advance of actually needing them.
A trace can take as long as 45 minutes; sometimes longer. Ultimately, it is the police's decision
whether or not to send assistance. Keep in mind, the police often will not break into the caller's
home. The caller needs to be encouraged to open or unlock the door to his home or apartment so
that the police can gain entry. In many places, the fire department is not governed by the same
restrictions as the police and may be a better choice when help is needed.
A trace is only successful if the line remains open. Should the caller hang up, the trace is no
longer possible. KEEP THE CALLER ON THE PHONE. Use any measure necessary short
of making the caller so angry that he/she hangs up.
This type of call is probably among the most difficult we handle. The feelings stirred by the
suicidal caller have both immediate and long term effects. No one handles these calls without
being stirred up. In fact, the absence of an emotional reaction should be viewed with real
suspicion. These calls should be processed with other liners, with your supervisors, and with the
directors of the line so that closure may be achieved.
NO ONE KEEPS ANYONE ELSE ALIVE. The person intent on killing him/herself will most
likely achieve his/her goal. Our job is to buy time in the hope that the help we provide will allow
the person to reconsider and, perhaps, come to a different decision.
If the caller is prevented from completing his/her suicidal attempt by police intervention or by a
friend, do not expect to be thanked. It is very likely that the caller who calls again will be very
angry at you for what you have done. The rewards for managing this call come from inside of
you; the knowledge that you have done everything possible to provide a person time to reconsider
the most important decision of his/her life.
THE ANSWERS TO THE "TRUE" AND "FALSE" TEST
- Question 1: FALSE Of any ten persons who kill themselves, eight have given definite
warnings of their suicidal intentions.
- Question 2: FALSE Studies reveal that the suicidal person gives any clues and warnings
regarding his suicidal intentions.
- Question 3: FALSE Most suicidal people are undecided about living or dying and they
"gamble with death," leaving it to others to save them. Almost no one commits suicide
without letting someone know how he is feeling.
- Question 4: FALSE Individuals who wish to kill themselves are "suicidal" only for a
limited period of time.
- Question 5: FALSE Most suicides occur within about three months following the
beginning of "improvement," when the individual has the energy to put his morbid
thoughts and feelings into action.
- Question 6: FALSE Suicide is neither the rich man's disease nor the poor man's curse.
Suicide is very "democratic" and is represented proportionately among all levels of
- Question 7: FALSE Suicide does not run in families. It is an individual pattern.
- Question 8: FALSE Studies of hundreds of genuine suicide notes indicate that although
the suicidal person is extremely unhappy, he is not necessarily mentally ill.
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