Understanding the Person With Chronic Suicidal Thoughts

The popular image of someone who is in danger of suicide goes like this: A crisis occurs. The person has overwhelming urges to die by suicide. Through the benefit of a call to a crisis hotline, loving remarks by family and friends, good psychotherapy, hospitalization or simply the passage of time, the crisis resolves within days or weeks, if not much sooner. That’s the popular image, and, I'm happy to say, it does happen for many people. But for many other people, there is no crisis that stimulates suicidal thoughts. Or maybe there was a crisis long ago, and it planted a seed that over the years has grown into a towering tree, one not easily felled by crisis intervention, therapy or time. For these people, suicidal thoughts are chronic. The trajectory is similar to that of a person with any other kind of chronic condition: There may be flare-ups where it is far worse than normal, and then the symptoms subside, but only temporarily. And for some people, the symptoms never subside. They live with their symptoms – in this case, suicidal thoughts – every day. Chronic suicidal thoughts are especially common in people with borderline personality disorder, an illness characterized by difficulty regulating emotions, impulsive actions and unstable relationships. The psychiatrist Joel Paris says that, for many people with borderline personality disorder, “suicidality becomes a way of life.” However, chronic suicidal thoughts can occur in concert with other mental illnesses, such as recurrent episodes of depression, or even with no illness at all. See also: Suicide and the Perspective of Truth   Many people who regularly have suicidal thoughts will tell you they do not view the thoughts as a problem. In fact, they might have considered suicide for so long that it feels normal to them. Some have thought of suicide ever since they were young children. And some have made multiple suicide attempts, sometimes so many that they lost track long ago. Often the psychological pain of people with chronic suicidal thoughts is intense, but even seemingly minor challenges can awaken the wish to die. Frank King captures this dynamic well in his TedX talk, A Matter of Laugh or Death. Although King is a comedian, he provides this example in all seriousness: “See, people don’t understand. Let’s say my car breaks down. I have three choices: Get it fixed, get a new one, or I could just kill myself. I know, doesn’t that sound absurd? But that thought actually pops into my head…. It’s always on the menu.” Some people who think of suicide do not want to stop. They say it comforts them to know they can die by suicide if ever the pain of life gets to be too much for them. This dynamic led some experts to refer to “suicide fantasy as life-sustaining recourse.” As the philosopher Friedrich Nietzsche stated, “The thought of suicide is a great consolation: by means of it one gets successfully through many a bad night.” This is not to say that chronic suicidal thoughts are harmless. The more someone thinks of suicide, the more they might get used to the idea, thus dissolving their inhibitions and fears around suicide. And chronic suicidal thoughts typically indicate that an unhealed wound needs the person’s attention, whether that wound arises from past trauma, mental illness, grave loss, or some other cause. Even for people who do not view their recurrent suicidal thoughts as a problem, it certainly is better if they can come up other escape fantasies besides death. Better yet, they can be helped to develop problem-solving abilities, coping skills, hopefulness and reasons for living that will make the option of suicide unnecessary. So, for someone with chronic suicidal thoughts, therapy tends to take longer than it does for someone in an acute crisis. The goals of therapy are not only to keep a person safe but also to help them develop the skills and resources that will weaken suicide’s allure. Often, it is not a realistic goal for a person with longstanding suicidal thoughts to stop. Suicidal thinking has become a habit. And nobody can control what thoughts come to them, only how they respond to the thoughts. One way for someone to respond constructively is to observe their suicidal thoughts with curiosity and detachment. Some of my therapy clients say to themselves something like, “That’s not my real self talking. That’s my depression (or stress, or post-traumatic stress, or some other condition) talking.” Mindfulness can be especially useful here. The psychologist Marsha Linehan, PhD, developed dialectical behavior therapy, a form of cognitive behavior therapy combined with principles from Zen Buddhism. She uses a metaphor of a train passing by: You can sit on a hill and watch the cars of the train pass, or you can jump onto one of them and get carried away by it. So if you know someone with chronic suicidal thoughts, you don’t need to respond as though it is an emergency unless the suicidal thoughts have intensified to such a degree that the person is in danger. If the person is intent on acting on their suicidal thoughts soon, that’s an emergency. See also: Blueprint for Suicide Prevention   If the person is simply having the same thoughts that they have had for many years, then don’t panic. Compassionately listen and empathize with the person. Ask how you can be of help. Talk with the person about resources they can use, like the National Suicide Prevention Lifeline (800-273-8255) or the Crisis Text Line (741-741). Also talk about how they can keep their environment safe, like by removing firearms from the home. Chronic suicidal thoughts are not ideal, but they also are not a crisis in the absence of intent to kill oneself. As odd as it sounds, the option of suicide might be the very thing that helps some people to stay alive.