Suicidal Worrying:Online and Telephone

IFOTES Göteborg July 11th 2013

Ad Kerkhof

VU Vrije Universiteit Amsterdam

suicidal worries

Repetitive suicidal thinking

Rehearsing suicidal thoughts

Many hours a day

Loosing control over thinking

Chaos in my head

Suicidal Worries

Nobody loves meI cannot live aloneI have no futureI am unlovableI cannot stand my feelingsI have to stop thinking

Continuously

Motives for attempted suicide

Major influence (males-females in %):

The situation was so unbearable that I could not think of any other alternative (71-76%)

My thoughts were so unbearable, I could not endure them any longer (64-68%)

I wanted to die (65-59%)

Hjelmeland et al, SLTB, 2002, 32, 380-393

Suicidal Worries

I will never be normal againWhen will this stop?I am a total failurePeople are better off when I am dead, nobody will miss meI cannot stand the painI cannot live without partner

Unbearable

Clinical observations:

The continuous repetition of these statements in the end becomes an obsession that cannot be controlled anymore

Clinical observations:

The repetitive thinking about dying, about stopping consciousness, and about the motives to die, show characteristics of worrying

Worry:

“A chain of thoughts and images negatively affect-laden and relatively uncontrollable, as an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes”.

Borkovec, et al, Cognitive Therapy and Research, 1983, 22, 561-567

Rumination:

“Behaviors and thoughts that focus one’s attention on one’s depressive symptoms and on the implications of these symptoms, … passively and repetitively focusing on one’s symptoms of distress and the circumstances surrounding these symptoms”

Nolen-Hoeksema, 1991, 1997

Worry and Rumination:

rumination, worry, anxiety, depressionare all significantly correlated

Watkins et al, Behaviour Research and Therapy, 2005, 43, 1577-1585.

Worry and suicidal ideation:

Similar characteristics:

• Repetitive• Uncontrollable• Without immediate cause• Future oriented• Threats to personal concerns• No solution

Worry and suicidal ideation:

Similar consequences:

• No problem solving• Obssessive attention• Stress and sleeplessness• Vital exhaustion• Wish to stop consciousness• hopelessness

Worriers and suicidal patients:

Perceive personal threats Overpredict negative outcomes Underestimate their abilities to cope Maintain demanding standards Repeat futile attempts to solve Suffer because of this

Worry as determinant of suicidal behaviour

In suicidal behaviour people want to escape their own repetitive and tantalizing thoughts and feelings

Escape from self (Baumeister, 1990)

Warning:

Worrying can be lethal

Suicidal induction

With your permission: I am going to make you somewhat suicidal now.

If you are suicidal yourself, you will recognise the mechanism

I will try to get you out of this state again, at the end of the exercise

Suicidal induction

You have a song in your head This song will not go away Whatever you do, you will hear it May be a nice song, may be a boring

Choose for yourself a song

Or take ABBA: Waterloo………

Suicidal induction

Tonight you will hear Abba singing Waterloo, Waterloo, Waterloo, etc

You cannot stop it

The more you try to stop it, the louder they sing

Suicidal induction

When you go to sleep you hear ABBA

You cannot sleep because of ABBA

All night long you hear ABBA

Waterloo, Waterloo, Waterloo

Suicidal induction

Tomorrow morning you hear ABBA

Tomorrow, all day long you cannot stop ABBA

Tomorrow evening you hear ABBA

Waterloo, Waterloo, Waterloo

Suicidal induction

Tomorrow night again you cannot sleep because of ABBA

Second sleepless night you cannot stop ABBA

Waterloo, Waterloo, Waterloo

Suicidal induction

From Saturday to Sunday again you cannot sleep because of ABBA

Third sleepless night you cannot stop ABBA

On Sunday you will hear nothing but ABBA

Suicidal induction

Sunday evening you take more precautions: sleeping pills / alcohol

Fourth sleepless night you cannot stop ABBA

Waterloo, Waterloo, Waterloo

Suicidal induction

Monday you have to work, and you fear your exhaustion will be noticed

In your car, to your work, suddenly ABBA has gone, silence in your head

Out of relief, you put on the radio……

ABBA

Waterloo

Waterloo

Waterloo

Suicidal induction

Monday evening you take even more precautions: sleeping pills / alcohol

Fifth sleepless night you cannot stop ABBA

You are exhausted

Suicidal induction

Later that week you take even more precautions: sleeping pills / alcohol

You even don’t know how many nights you could not stop ABBA

You cannot endure ABBA any longer You are exhausted

Suicidal induction

Finally after having taken many pills / alcohol, you fall asleep

You wake up in a brightly lit environment

Turns out to be an Emergency Ward

Question?

Did you attempt suicide?

Or did you just wanted to escape ABBA

Change ABBA into worries

Imagine how it is to have other suicidal things instead of ABBA:

Memories of being raped Thoughts like being a failure Thoughts of loneliness Thoughts of killing yourself

Warning:

You might want to escape

Worrying can be lethal

Remember

This was only an exercise You will not hear ABBA for the rest of

your life You have not become suicidal Think of this exerxise as a metaphore Imagine this to be important when

you help the next suicidal caller

Volunteers:

There is nobody who loves me

1. How many times a day is this thought going through your mind?

2. How many hours a day are you contemplating this thought?

Volunteers:

I will throw myself in front of a train

1. How many times a day is this thought going through your mind?

2. How many hours a day are you contemplating this thought?

Volunteers:

My life has no meaning

1. How many times a day is this thought going through your mind?

2. How many hours a day are you contemplating this thought?

Volunteers:

I have no future

1. How many times a day is this thought going through your mind?

2. How many hours a day are you contemplating this thought?

Experience:

Mostly only a few such thoughts are rehearsed very frequently

These thoughts are prototypical They start as self-protection But in the end they are self-torturing Massive suffering because of this

repetition Try to understand the torturing mind

Treatment of suicidal worry

CBT approaches for worrying are applicable for suicidal worry (Tallis, Leahy)

1. Worry postponement2. Positive worrying3. Distraction4. Self fulfilling properties5. Mindfulness6. Overgeneralization7. Tolerance of uncertainty over the future