What is Suicidal Ideation?

Introduction

Suicidal ideation (or suicidal thoughts) means having thoughts, ideas, or ruminations about the possibility of ending one’s life.

Refer to Coping (Psychology), Suicide Prevention, and Suicide Awareness.

It is not a diagnosis, but is a symptom of some mental disorders and can also occur in response to adverse events without the presence of a mental disorder.

On suicide risk scales, the range of suicidal ideation varies from fleeting thoughts to detailed planning. Passive suicidal ideation is thinking about not wanting to live or imagining being dead. Active suicidal ideation is thinking about different ways to die or forming a plan to die.

Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor. During 2008-2009, an estimated 8.3 million adults aged 18 and over in the United States, or 3.7% of the adult US population, reported having suicidal thoughts in the previous year. An estimated 2.2 million in the US reported having made suicide plans in 2014. Suicidal thoughts are also common among teenagers.

Suicidal ideation is generally associated with depression and other mood disorders; however, it seems to have associations with many other mental disorders, life events, and family events, all of which may increase the risk of suicidal ideation. Mental health researchers indicate that healthcare systems should provide treatment for individuals with suicidal ideation, regardless of diagnosis, because of the risk for suicidal acts and repeated problems associated with suicidal thoughts. There are a number of treatment options for people who experience suicidal ideation.

Definitions

The ICD-11 describes suicidal ideation as “thoughts, ideas, or ruminations about the possibility of ending one’s life, ranging from thinking that one would be better off dead to formulation of elaborate plans”.

The DSM-5 defines it as “thoughts about self-harm, with deliberate consideration or planning of possible techniques of causing one’s own death”.

The CDC defines suicidal ideation “as thinking about, considering, or planning suicide”.

Terminology

Another term for suicidal ideation is suicidal thoughts.

When someone who has not shown a history of suicidal ideation experiences a sudden and pronounced thought of performing an act which would necessarily lead to their own death, psychologists call this an intrusive thought. A commonly experienced example of this is the high place phenomenon, also referred to as the call of the void. The urge to jump is called “mountain fever” in Brian Biggs’ book Dear Julia.

Euphemisms related to mortal contemplation include internal struggle, voluntary death, and eating one’s gun.

Risk Factors

The risk factors for suicidal ideation can be divided into three categories:

  1. Psychiatric disorders;
  2. Life events; and
  3. Family history.

Psychiatric Disorders

Suicidal ideation is a symptom for many mental disorders and can occur in response to adverse life events without the presence of a mental disorder.

There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation. For example, many individuals with borderline personality disorder exhibit recurrent suicidal behaviour and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts. The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. These are not the only disorders that can increase risk of suicidal ideation. The disorders in which risk is increased the greatest include:

Medication Side Effects

Antidepressant medications are commonly used to decrease the symptoms in patients with moderate to severe clinical depression, and some studies indicate a connection between suicidal thoughts and tendencies and taking antidepressants, increasing the risk of suicidal thoughts in some patients.

Some medications, such as selective serotonin re-uptake inhibitors (SSRIs), can have suicidal ideation as a side effect. Moreover, these drugs’ intended effects, can themselves have unintended consequence of an increased individual risk and collective rate of suicidal behaviour: Among the set of persons taking the medication, a subset feel bad enough to want to attempt suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt. Among this subset, a “sub-subset” may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g. lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide attempt and of completed suicide increase.

In 2003, the US Food and Drug Administration (FDA) issued the agency’s strictest warning for manufacturers of all antidepressants (including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) due to their association with suicidal thoughts and behaviours. Further studies disagree with the warning, especially when prescribed for adults, claiming more recent studies are inconclusive in the connection between the drugs and suicidal ideation.

Individuals with anxiety disorders who self-medicate with drugs or alcohol may also have an increased likelihood of suicidal ideation.

Life Events

Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk most significantly are:

  • Alcohol use disorder.
    • Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation.
    • Certain studies associate those who experience suicidal ideation with higher alcohol consumption.
    • Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment.
  • Minoritised gender expression and/or sexuality.
  • Unemployment.
  • Chronic illness or pain.
  • Death of family members or friends.
  • End of a relationship or being rejected by a romantic interest.
  • Major change in life standard (e.g. relocation abroad).
  • Other studies have found that tobacco use is correlated with depression and suicidal ideation.
  • Unplanned pregnancy.
  • Bullying, including cyberbullying and workplace bullying.
  • Previous suicide attempts.
    • Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts.
  • Military experience.
  • Community violence.
  • Undesired changes in body weight.
    • Women: increased BMI increases chance of suicidal ideation.
    • Men: severe decrease in BMI increases chance of suicidal ideation.
      • In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight.
  • Exposure and attention to suicide related images or words.

Family History

  • Parents with a history of depression.
    • Valenstein et al. studied 340 adult offspring whose parents had depression in the past.
    • They found that 7% of the offspring had suicidal ideation in the previous month alone.
  • Abuse.
    • Childhood: physical, emotional and sexual abuse.
    • Adolescence: physical, emotional and sexual abuse.
  • Family violence.
  • Childhood residential instability.
    • Certain studies associate those who experience suicidal ideation with family disruption.

Relationships with Parents and Friends

According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent-child relationships of adolescents in early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons, and fathers and daughters. The relationships between fathers and sons during early and middle adolescence show an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is “significantly related to suicidal ideation”. Liu goes on to explain the relationship found between closeness with the opposite sex parent and the child’s risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence.

An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% and in many cases its severity increases the risk of completed suicide.

Prevention

Refer to Suicide Prevention.

Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts.[citation needed] If signs, symptoms, or risk factors are detected early then the individual might seek treatment and help before attempting to take their own life. In a study of individuals who did commit suicide, 91% of them likely suffered from one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness. This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents early as 9th grade is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.

The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the number of individuals who seek treatment may include:

  • Increasing the availability of therapy treatment in early stage.
  • Increasing the public’s knowledge on when psychiatric help may be beneficial to them.
  • Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illness.

A study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that “risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior”. A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported “psychological distress (all categories)” 5.1% of the same participants reported suicidal ideation. Participants who scored “very high” on the Psychological Distress scale “were 77 times more likely to report suicidal ideation than those in the low category”.

In a one-year study conducted in Finland, 41% of the patients who later committed suicide saw a health care professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.

There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect. In a 2021 research study, Nguyen et al. (2021) propose that maybe the premise that suicidal ideation is a kind of illness has been an obstacle to dealing with suicidal ideation. They use a Bayesian statistical investigation, in conjunction with the mindsponge theory, to explore the processes where mental disorders have played a very minor role and conclude that there are many cases where the suicidal ideation represents a type of cost-benefit analysis for a life/death consideration, and these people may not be called “patients”.

Assessment

Assessment seeks to understand an individual by integrating information from multiple sources such as clinical interviews; medical exams and physiological measures; standardised psychometric tests and questionnaires; structured diagnostic interviews; review of records; and collateral interviews.

Interviews

Psychologists, psychiatrists, and other mental health professionals conduct clinical interviews to ascertain the nature of a patient or client’s difficulties, including any signs or symptoms of illness the person might exhibit.

  • Clinical interviews are “unstructured” in the sense that each clinician develops a particular approach to asking questions, without necessarily following a predefined format.
  • Structured (or semi-structured) interviews prescribe the questions, their order of presentation, “probes” (queries) if a patient’s response is not clear or specific enough, and a method to rate the frequency and intensity of symptoms.

Standardised Psychometric Measures

Refer to Assessment of Suicide Risk.

  • Beck Scale for Suicide Ideation.
  • Nurses’ Global Assessment of Suicide Risk.
  • Suicidal Affect-Behaviour-Cognition Scale (SABCS).
  • Columbia Suicide Severity Rating Scale.

Treatment

Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include:

  • Therapy;
  • Hospitalisation;
  • Outpatient treatment; and
  • Medication or other modalities.

Therapy

In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively.

Hospitalisation

Hospitalisation allows the patient to be in a secure, supervised environment to prevent the suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalised involuntarily. These circumstances are:

  • If an individual poses danger to self or others; and/or
  • If an individual is unable to care for oneself.

Hospitalisation may also be a treatment option if an individual:

  • Has access to lethal means (e.g. a firearm or a stockpile of pills).
  • Does not have social support or people to supervise them.
  • Has a suicide plan.
  • Has symptoms of a psychiatric disorder (e.g. psychosis, mania, etc.).

Outpatient Treatment

Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their personal belongings, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient’s level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a “no-harm contract”. This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themselves, to continue their visits with the physician, and to contact the physician in times of need. There is some debate as to whether “no-harm” contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast, and not wearing a seat belt, etc.).

Medication

Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients’ energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation.

Antidepressants may be effective. Often, SSRIs are used instead of TCAs as the latter typically have greater harm in overdose.

Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants within certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide. Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behaviour including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicide ideation reduced from 47% of patients down to 14% of patients. Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation.

Although research is largely in favour of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the FDA to issue a warning stating that sometimes the use of antidepressants may actually increase the thoughts of suicidal ideation. Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy. Lithium reduces the risk of suicide in people with mood disorders. Tentative evidence finds clozapine in people with schizophrenia reduces the risk of suicide.

What is Suicide Awareness?

Introduction

Suicide awareness is a proactive effort to raise awareness around suicidal behaviours.

Refer to Coping (Psychology), Suicide Prevention, and Suicidal Ideation.

It is focused on reducing social stigmas and ambiguity, by bringing attention to suicide statistically and sociologically, and encouraging positive dialogue and engagement as a means to prevent suicide. Suicide awareness is linked to suicide prevention as both address suicide education and the dissemination of information to ultimately decrease the rate of suicide. Awareness is a first stage that can ease the need for prevention.

Awareness signifies a fundamental consciousness of the threat, while prevention focuses on stopping the act. Suicide awareness is not a medical engagement, but a combination of medical, social, emotional and financial counselling. Suicide awareness in adolescents focuses on the age group between 10-24 years, beginning with the onset of puberty.

Stigma and Ambiguity

Stigma is a negative impact that society can often attribute to the suicidal condition, and which can hinder and prevent positive engagement with those demonstrating suicidal behaviour. It can be experienced as self-stigma or cultural, public stigma. Self-stigma is the adverse effect of internalised prejudice, manifesting itself in reduced self-esteem, decreased self-efficacy, and a feeling of “why try” or self-deprecation (undervaluing any attempts to get a job, be social, etc. because of lack of self-worth). It is experienced not only by those facing suicidal thoughts, but also by those directly and indirectly affected such as family members and friends. Public stigma is experienced by prejudice and discrimination through public misuse of stereotypes associated with suicide.

Stigma can create a detrimental barrier for some seeking help. Research has consistently illustrated the physical link between suicide and mental illness, but ignorance and outdated beliefs can sometimes lead to these disorders being identified as a weakness or a lack of willpower. Stigma can prevent survivors of suicide attempts, and those affected by suicide deaths, from reaching out for support from professionals and advocates to make positive change.

Historical Stigma

Historically, suicide has not always been considered a societal taboo. It is critical to understand the historical context in order to raise awareness of suicide’s impact on our current culture.

Suicide was embraced as a philosophical escape by the followers of the Greek philosopher Epicurus when life’s happiness seemed lost. It has been glorified in self-immolation as an act of martyrdom as in the case of Thich Quang Duc who burned himself to death in protest of South Vietnam’s religious policy. Assisted suicide as a release from suffering can be traced back to ancient Roman society. In Jewish culture, there is a reverence for the mass suicide at Masada in the face of attack by the Roman empire, showing how suicide has sometimes had a contradictory relationship with established religion. This indicates a tension between the presentation of suicide in this historical context, and its associations in our current society with personal anguish. Today, suicide is generally perceived as an act of despair or hopelessness, or a criminal act of terrorism (suicide attack). This negative backdrop was seen in Colonial America, where suicides were considered criminal and brought to trial, even if mental illness had been present.

Suicide was identified in Roman Catholicism as a sinful act, with religious burial prohibited until 1983, when the Catholic Church altered the canon law to allow funerals and burials within the church of those who died by suicide. Today, many current societies and religious traditions condemn suicide, especially in Western culture. Public consideration of suicide in our culture is further complicated by society’s struggle to rationalize such cult events as the Jonestown mass suicide. In light of these mixed historical messages, it can be confusing for youth, presented with an academic and historical profile for suicide. The ambiguity of accepted suicide and suicidal behaviour definitions impedes progress with its utilisation of variable terminology.

Public and Cultural Stigma

Today, even though suicide is considered a public health issue by advocates, the general public often still consider it a private shame; a final desperate solution for the emotionally weak. It is stigmatised in the public perception by being associated with weakness, a “cry for attention,” shame, and depression, without understanding the contributing factors. There can be a visceral and emotional reaction to suicide rather than an attempt to understand it. This reaction is based on stereotypes (overgeneralisations about a group: weak or crazy), prejudices (agreement with stereotypical beliefs and related emotional reactions: Sue attempted suicide; ‘I’m afraid of her’), and discrimination (unfair behaviour towards the suicidal individual or group: avoidance; ‘suicidal persons should be locked up’). Erving Goffman defined courtesy stigma as the discrimination, prejudice and stereotypes which family and friends experience as suicide survivors. Public stigma is felt by medical professionals whose clients die by suicide and whose treatment is then questioned by colleagues and in lawsuits, often contributing to their being less inclined to work with suicidal patients. Property can also be stigmatized by suicide: property sellers in certain jurisdictions in the United States, in California for example, are required by law to reveal if a suicide or murder occurred on the premises in the past three years, putting suicide in the same category as homicide. These issues compound and perpetuate the public stigma of suicide, exacerbating the inclination for suicidal individuals, and their family and friends, to bury their experiences, creating a barrier to care.

Emotional Stigma

Emotionally, the negative stigma of suicide is a powerful force creating isolation and exclusion for those in suicidal crisis. The use of stereotypes, discrimination and prejudices can strip the dignity of those experiencing suicidal behaviour. It also has the potential to inhibit compassion from others and to diminish hope. Fear of being socially rejected and labelled suicidal can prevent communication and support. Distress and reduced life satisfaction are directly affected by subjective feelings of being devalued and marginalised. This develops into an internalized stigma; it creates self-stigmatised emotions, self-deprecation and self-actualisation of negative stereotypes, causing further withdrawal, reduction in quality of life and the inhibiting access to care.

This emotional stigma also affects suicide survivors: those suffering a loved one’s loss, stirring up guilt, self-blame, isolation, depression and post-traumatic stress. Subjective experiences of feeling shunned or blamed for an incident can cause those close to the victim to bury the truth of what transpired.

Awareness Factors

Suicide awareness expresses the need for open constructive dialogue as an initial step towards preventing incidents of adolescent suicide. Once the stigmas have been overcome, there is an increased possibility that education, medical care and support can provide a critical framework for those at risk. Lack of information, awareness of professional services, judgement and insensitivity from religious groups, and financial strain have all been identified as barriers to support access for those youth in suicidal crisis. The critical framework is a necessary component to implementing suicide awareness and suicide prevention, and breaking down these barriers.

Protective Factors

Protective factors are characteristics or conditions that may have a positive effect on youth and reduce the possibility of suicide attempts. These factors have not been studied in as much depth as risk factors, so there is less research. They include:

  • Receiving effective mental health care.
  • Positive social connections and support with family and peers provides coping skills.
  • Participation in community and social groups (i.e. religious) that foster resilience.
  • Optimism enables youth to engage and acquire adaptive skills in reinterpreting adverse experiences to find meaning and benefit.
  • Life satisfaction, spiritual wellbeing and belief that a person can survive beyond their pain is protective against suicide.
  • Resiliency based on adaptive coping skills has can reduce suicide risk, and research suggests these skills can be taught.
  • Finding hope can be a key protective factor and a catalyst for the recovery process.

It is important to note, however, that in-depth training is paramount for those involved in any service that looks to the awareness and needs of those touched by suicide.

Social Media

Suicide awareness and prevention have in the past only relied on research from clinical observation. In bringing insights, intimate experience, and real-world wisdom of suicide attempt survivors to the table, professionals, educators, other survivors and suicide attempt survivors can learn firsthand from their “lived experience.”

Media and journalism, when reporting on suicide, have moved forward in their discussion of suicide. The Recommendations for Reporting on Suicide discovered the powerful impact media coverage, newspapers and journalists can have on the perpetuating stigma of suicide, and that it can lead to greater risk of occurrence. The specific rules that media representatives should follow are:

  • Don’t sensationalise the suicide.
  • Don’t talk about the contents of the suicide note, if there is one.
  • Don’t describe the suicide method.
  • Report on suicide as a public health issue.
  • Don’t speculate why the person might have done it.
  • Don’t quote or interview police or first responders about the causes of suicide.
  • Describe suicide as “died by suicide” or “completed” or “killed themselves,” rather than “committed suicide.”
  • Don’t glamorise suicide.

This is to prevent certain types of messaging around suicide that could increase the chances of at-risk youth considering or attempting suicide. This initiative brought awareness to the sensitivity of reporting on suicide in a constructive, destigmatised method of messaging.

Social Agency

Education in a non-threatening environment is critical to a growth in awareness among adolescents. Health education is closely related to health awareness. School can be the best place to implement a suicide education program because it is the pivotal location that brings together the major influences in an adolescent’s life. Pilot programmes for awareness, and coping and resiliency training should be put into place for all adolescent school-aged children to combat life stressors and to encourage healthy communication.

What is Suicide Prevention?

Introduction

Suicide prevention is a collection of efforts to reduce the risk of suicide. These efforts may occur at the individual, relationship, community, and society level. Suicide is often preventable.

Refer to Coping (Psychology), Suicide Awareness, and Suicide Ideation.

Beyond direct interventions to stop an impending suicide, methods may include:

  • Treating mental illness.
  • Improving coping strategies of people who are at risk.
  • Reducing risk factors for suicide, such as poverty and social vulnerability.
  • Giving people hope for a better life after current problems are resolved.
  • Call a suicide hotline number.

General efforts include measures within the realms of medicine, mental health, and public health. Because protective factors such as social support and social engagement – as well as environmental risk factors such as access to lethal means – play a role in suicide, suicide is not solely a medical or mental-health issue.

Suicide prevention measures suggested by the US Centres for Disease Control and Prevention.

Interventions

Lethal Mean Reduction

Means reduction ⁠- ⁠reducing the odds that a suicide attempter will use highly lethal means -— ⁠is an important component of suicide prevention. This practice is also called “means restriction”.

It has been demonstrated that restricting lethal means can help reduce suicide rates, as delaying action until the desire to die has passed. In general, strong evidence supports the effectiveness of means restriction in preventing suicides. There is also strong evidence that restricted access at so-called suicide hotspots, such as bridges and cliffs, reduces suicides, whereas other interventions such as placing signs or increasing surveillance at these sites appears less effective. One of the most famous historical examples of means reduction is that of coal gas in the United Kingdom. Until the 1950s, the most common means of suicide in the UK was poisoning by gas inhalation. In 1958, natural gas (virtually free of carbon monoxide) was introduced, and over the next decade, comprised over 50% of gas used. As carbon monoxide in gas decreased, suicides also decreased. The decrease was driven entirely by dramatic decreases in the number of suicides by carbon monoxide poisoning. A 2020 Cochrane review on means restrictions for jumping found tentative evidence of reductions in frequency.

In the United States, firearm access is associated with increased suicide completion. About 85% of attempts with a gun result in death while most other widely used suicide attempt methods result in death less than 5% of the time. Although restrictions on access to firearms have reduced firearm suicide rates in other countries, such restrictions are difficult in the United States because the Second Amendment to the United States Constitution limits restrictions on weapons.

Crises Hotline

Crisis hotlines connect a person in distress to either a volunteer or staff member. This may occur via telephone, text messaging, online chat, or in person. Even though crisis hotlines are common, they have not been well studied. One study found a decrease in psychological pain, hopelessness, and desire to die from the beginning of the call through the next few weeks; however, the desire to die did not decrease long term.

Social Intervention

In the United States, the 2012 National Strategy for Suicide Prevention promotes various specific suicide prevention efforts including:

  • Developing groups led by professionally trained individuals for broad-based support for suicide prevention.
  • Promoting community-based suicide prevention programmes.
  • Screening and reducing at-risk behaviour through psychological resilience programs that promotes optimism and connectedness.
  • Education about suicide, including risk factors, warning signs, stigma related issues and the availability of help through social campaigns.
  • Increasing the proficiency of health and welfare services at responding to people in need. e.g. sponsored training for helping professionals, increased access to community linkages, employing crisis counselling organisations.
  • Reducing domestic violence and substance abuse through legal and empowerment means are long-term strategies.
  • Reducing access to convenient means of suicide and methods of self-harm. e.g. toxic substances, poisons, handguns.
  • Reducing the quantity of dosages supplied in packages of non-prescription medicines e.g. aspirin.
  • School-based competency promoting and skill enhancing programmes.
  • Interventions and usage of ethical surveillance systems targeted at high-risk groups.
  • Improving reporting and portrayals of negative behaviour, suicidal behaviour, mental illness and substance abuse in the entertainment and news media.
  • Research on protective factors & development of effective clinical and professional practices.

Media Guidelines

Recommendations around media reporting of suicide include not sensationalizing the event or attributing it to a single cause. It is also recommended that media messages include suicide prevention messages such as stories of hope and links to further resources. Particular care is recommended when the person who died is famous. Specific details of the method or the location are not recommended.

There; however, is little evidence regarding the benefit of providing resources for those looking for help and the evidence for media guidelines generally is mixed at best.

TV shows and news media may also be able to help prevent suicide by linking suicide with negative outcomes such as pain for the person who has attempted suicide and their survivors, conveying that the majority of people choose something other than suicide in order to solve their problems, avoiding mentioning suicide epidemics, and avoiding presenting authorities or sympathetic, ordinary people as spokespersons for the reasonableness of suicide.

Medication

The medication lithium may be useful in certain situations to reduce the risk of suicide. Specifically it is effective at lowering the risk of suicide in those with bipolar disorder and major depressive disorder. Some antidepressant medications may increase suicidal ideation in some patients under certain conditions.

Counselling

There are multiple talk therapies that reduce suicidal thoughts and behaviours including dialectical behaviour therapy (DBT). Cognitive behaviour therapy for suicide prevention (CBT-SP) is a form of DBT adapted for adolescents at high risk for repeated suicide attempts. The brief intervention and contact technique developed by the World Health Organisation (WHO) also has shown benefit.

The WHO recommends “specific skills should be available in the education system to prevent bullying and violence in and around the school”.

Coping Planning

Coping planning is an strengths-based intervention that aims to meet the needs of people who ask for help, including those experiencing suicidal ideation. By addressing why someone asks for help, the risk assessment and management stays on what the person needs, and the needs assessment focuses on the individual needs of each person. The coping planning approach to suicide prevention draws on the health-focused theory of coping. Coping is normalised as a normal and universal human response to unpleasant emotions and interventions are considered a change continuum of low intensity (e.g. self-soothing) to high intensity support (e.g. professional help). By planning for coping, it supports people who are distressed and provides a sense of belongingness and resilience in treatment of illness. The proactive coping planning approach overcomes implications of ironic process theory. The biopsychosocial strategy of training people in healthy coping improves emotional regulation and decreases memories of unpleasant emotions. A good coping planning strategically reduces the inattentional blindness for a person while developing resilience and regulation strengths.

Strategies

The traditional approach has been to identify the risk factors that increase suicide or self-harm, though meta-analysis studies suggest that suicide risk assessment might not be useful and recommend immediate hospitalization of the person with suicidal feelings as the healthy choice. In 2001, the US Department of Health and Human Services, published the National Strategy for Suicide Prevention, establishing a framework for suicide prevention in the US The document, and its 2012 revision, calls for a public health approach to suicide prevention, focusing on identifying patterns of suicide and suicidal ideation throughout a group or population (as opposed to exploring the history and health conditions that could lead to suicide in a single individual). The ability to recognise warning signs of suicide allows individuals who may be concerned about someone they know to direct them to help.

Suicide gesture and suicidal desire (a vague wish for death without any actual intent to kill oneself) are potentially self-injurious behaviours that a person may use to attain some other ends, like to seek help, punish others, or to receive attention. This behaviour has the potential to aid an individual’s capability for suicide and can be considered as a suicide warning, when the person shows intent through verbal and behavioural signs.

A United States Army suicide prevention poster.

Specific Strategies

Suicide prevention strategies focus on reducing the risk factors and intervening strategically to reduce the level of risk. Risk and protective factors, unique to the individual can be assessed by a qualified mental health professional.

Some of the specific strategies used to address are:

  • Crisis intervention.
  • Structured counselling and psychotherapy.
  • Hospitalisation for those with low adherence to collaboration for help and those who require monitoring and secondary symptom treatment.
  • Supportive therapy like substance abuse treatment, psychotropic medication, Family psychoeducation and Access to emergency phone call care with emergency rooms, suicide prevention hotlines, etc.
  • Restricting access to lethality of suicide means through policies and laws.
  • Creating and using crisis cards, an easy-to-read uncluttered card that describes a list of activities one should follow in crisis until the positive behaviour responses settles in the personality.
  • Person-centred life skills training. e.g. problem solving.
  • Registering with support groups like Alcoholics Anonymous, Suicide Bereavement Support Group, a religious group with flow rituals, etc.
  • Therapeutic recreational therapy that improves mood.
  • Motivating self-care activities like physical exercise’s and meditative relaxation.

Psychotherapies that have shown most successful or evidence based are dialectical behaviour therapy (DBT), which has shown to be helpful in reducing suicide attempts and reducing hospitalisations for suicidal ideation and cognitive behavioural therapy (CBT), which has shown to improve problem-solving and coping abilities.

After a Suicide

Postvention is for people affected by an individual’s suicide. This intervention facilitates grieving, guides to reduce guilt, anxiety, and depression and to decrease the effects of trauma. Bereavement is ruled out and promoted for catharsis and supporting their adaptive capacities before intervening depression and any psychiatric disorders. Postvention is also provided to minimise the risk of imitative or copycat suicides, but there is a lack of evidence based standard protocol. But the general goal of the mental health practitioner is to decrease the likelihood of others identifying with the suicidal behaviour of the deceased as a coping strategy in dealing with adversity.

Risk Assessment

Warning Signs

Warning signs of suicide can allow individuals to direct people who may be considering suicide to get help.

Behaviours that may be warning signs include:

  1. Talking about wanting to die or wanting to kill themselves.
  2. Suicidal ideation: thinking, talking, or writing about suicide, planning for suicide.
  3. Substance abuse.
  4. Feelings of purposelessness.
  5. Anxiety, agitation, being unable to sleep, or sleeping all the time.
  6. Feelings of being trapped.
  7. Feelings of hopelessness.
  8. Social withdrawal.
  9. Displaying extreme mood swings, suddenly changing from sad to very calm or happy.
  10. Recklessness or impulsiveness, taking risks that could lead to death, such as driving extremely fast.
  11. Mood changes including depression.
  12. Feelings of uselessness.
  13. Settling outstanding affairs, giving away prized or valuable possessions, or making amends when they are otherwise not expected to die (as an example, this behaviour would be typical in a terminal cancer patient but not a healthy young adult).
  14. Strong feelings of pain, either emotional or physical considering oneself burdensome.
  15. Increased use of drugs or alcohol.

Additionally, the National Institute for Mental Health includes feeling burdensome, and strong feelings of pain – either emotional or physical – as warning signs that someone may attempt suicide.

Direct Talks

An effective way to assess suicidal thoughts is to talk with the person directly, to ask about depression, and assess suicide plans as to how and when it might be attempted. Contrary to popular misconceptions, talking with people about suicide does not plant the idea in their heads. However, such discussions and questions should be asked with care, concern and compassion. The tactic is to reduce sadness and provide assurance that other people care. The WHO advises to not say everything will be all right nor make the problem seem trivial, nor give false assurances about serious issues. The discussions should be gradual and specifically executed when the person is comfortable about discussing their feelings. ICARE (Identify the thought, Connect with it, Assess evidences for it, Restructure the thought in positive light, Express or provide room for expressing feelings from the restructured thought) is a model of approach used here.

Screening

The US Surgeon General has suggested that screening to detect those at risk of suicide may be one of the most effective means of preventing suicide in children and adolescents. There are various screening tools in the form of self-report questionnaires to help identify those at risk such as the Beck Hopelessness Scale and Is Path Warm?. A number of these self-report questionnaires have been tested and found to be effective for use among adolescents and young adults. There is however a high rate of false-positive identification and those deemed to be at risk should ideally have a follow-up clinical interview. The predictive quality of these screening questionnaires has not been conclusively validated so it is not possible to determine if those identified at risk of suicide will actually die by suicide. Asking about or screening for suicide does not create or increase the risk.

In approximately 75% of completed suicides, the individuals had seen a physician within the year before their death, including 45 to 66% within the prior month. Approximately 33 to 41% of those who completed suicide had contact with mental health services in the prior year, including 20 percent within the prior month. These studies suggest an increased need for effective screening. Many suicide risk assessment measures are not sufficiently validated, and do not include all three core suicidality attributes (i.e. suicidal affect, behaviour, and cognition). A study published by the University of New South Wales has concluded that asking about suicidal thoughts cannot be used as a reliable predictor of suicide risk.

Underlying Condition

The conservative estimate is that 10% of individuals with psychiatric disorders may have an undiagnosed medical condition causing their symptoms, with some estimates stating that upwards of 50% may have an undiagnosed medical condition which if not causing is exacerbating their psychiatric symptoms. Illegal drugs and prescribed medications may also produce psychiatric symptoms. Effective diagnosis and if necessary medical testing which may include neuroimaging to diagnose and treat any such medical conditions or medication side effects may reduce the risk of suicidal ideation as a result of psychiatric symptoms, most often including depression, which are present in up to 90-95% of cases.

Risk Factors

All people can be at risk of suicide. Risk factors that contribute to someone feeling suicidal or making a suicide attempt may include:

  • Depression, other mental disorders, or substance abuse disorder.
  • Certain medical conditions.
  • Chronic pain.
  • A prior suicide attempt.
  • Family history of a mental disorder or substance abuse.
  • Family history of suicide.
  • Family violence, including physical or sexual abuse.
  • Having guns or other firearms in the home.
  • Having recently been released from prison or jail.
  • Being exposed to others’ suicidal behaviour, such as that of family members, peers, or celebrities.
  • Being male.

Support Organisations

Many non-profit organisations exist, such as the American Foundation for Suicide Prevention in the United States, which serve as crisis hotlines; it has benefited from at least one crowd-sourced campaign. The first documented programme aimed at preventing suicide was initiated in 1906 in both New York, the National Save-A-Life League and in London, the Suicide Prevention Department of the Salvation Army.

Suicide prevention interventions fall into two broad categories: prevention targeted at the level of the individual and prevention targeted at the level of the population. To identify, review, and disseminate information about best practices to address specific objectives of the National Strategy Best Practices Registry (BPR) was initiated. The Best Practices Registry of Suicide Prevention Resource Centre is a registry of various suicide intervention programmes maintained by the American Association of Suicide Prevention. The programs are divided, with those in Section I listing evidence-based programmes: interventions which have been subjected to in depth review and for which evidence has demonstrated positive outcomes. Section III programmes have been subjected to review.

If you or someone you know displays sign or symptoms of suicidal thoughts or actions these prevention organisations are available:

  • Befrienders Worldwide.
  • American Foundation for Suicide Prevention.
  • Campaign Against Living Miserably.
  • Crisis Text Line.
  • International Association for Suicide Prevention.
  • The Jed Foundation.
  • National Suicide Prevention Lifeline.
  • Samaritans.
  • SOSAD Ireland.
  • Suicide Prevention Action Network USA.
  • The Trevor Project.
  • Trans Lifeline.

Economics

In the United States it is estimated that an episode of suicide results in costs of about $1.3 million. Money spending on appropriated interventions is estimated to result in a decrease in economic losses that are 2.5 fold greater than the amount spent.

What is Coping (Psychology)?

Introduction

Coping means to invest one’s own conscious effort, to solve personal and interpersonal problems, in order to try to master, minimise or tolerate stress and conflict.

The psychological coping mechanisms are commonly termed coping strategies or coping skills. The term coping generally refers to adaptive (constructive) coping strategies, that is, strategies which reduce stress. In contrast, other coping strategies may be coined as maladaptive, if they increase stress. Maladaptive coping is therefore also described, based on its outcome, as non-coping. Furthermore, the term coping generally refers to reactive coping, i.e. the coping response which follows the stressor. This differs from proactive coping, in which a coping response aims to neutralise a future stressor. Subconscious or unconscious strategies (e.g. defence mechanisms) are generally excluded from the area of coping.

The effectiveness of the coping effort depends on the type of stress, the individual, and the circumstances. Coping responses are partly controlled by personality (habitual traits), but also partly by the social environment, particularly the nature of the stressful environment.

Types of Coping Strategies

Hundreds of coping strategies have been identified. Classification of these strategies into a broader architecture has not been agreed upon. Researchers try to group coping responses rationally, empirically by factor analysis, or through a blend of both techniques. In the early days, Folkman and Lazarus split the coping strategies into four groups, namely problem-focused, emotion-focused, support-seeking, and meaning-making coping. Weiten has identified four types of coping strategies:

  1. Appraisal-focused (adaptive cognitive);
  2. Problem-focused (adaptive behavioural);
  3. Emotion-focused; and
  4. Occupation-focused coping.

Billings and Moos added avoidance coping as one of the emotion-focused coping. Some scholars have questioned the psychometric validity of forced categorisation as those strategies are not independent to each other. Besides, in reality, people can adopt multiple coping strategies simultaneously.

Typically, people use a mixture of several coping strategies, which may change over time. All these strategies can prove useful, but some claim that those using problem-focused coping strategies will adjust better to life. Problem-focused coping mechanisms may allow an individual greater perceived control over their problem, whereas emotion-focused coping may sometimes lead to a reduction in perceived control (maladaptive coping).

Lazarus “notes the connection between his idea of ‘defensive reappraisals’ or cognitive coping and Freud’s concept of ‘ego-defenses'”, coping strategies thus overlapping with a person’s defence mechanisms.

Appraisal-Focused Coping Strategies

Appraisal-focused (adaptive cognitive) strategies occur when the person modifies the way they think, for example: employing denial, or distancing oneself from the problem. People may alter the way they think about a problem by altering their goals and values, such as by seeing the humour in a situation: “some have suggested that humor may play a greater role as a stress moderator among women than men”.

Adaptive Behavioural Coping Strategies

People using problem-focused strategies try to deal with the cause of their problem. They do this by finding out information on the problem and learning new skills to manage the problem. Problem-focused coping is aimed at changing or eliminating the source of the stress. The three problem-focused coping strategies identified by Folkman and Lazarus are: taking control, information seeking, and evaluating the pros and cons. However, problem-focused coping may not be necessarily adaptive, especially in the uncontrollable case that one cannot make the problem go away.

Emotion-Focused Coping Strategies

Emotion-focused strategies involve:

  • Releasing pent-up emotions.
  • Distracting oneself.
  • Managing hostile feelings.
  • Meditating.
  • Mindfulness practices.
  • Using systematic relaxation procedures.

Emotion-focused coping “is oriented toward managing the emotions that accompany the perception of stress”. The five emotion-focused coping strategies identified by Folkman and Lazarus are:

  • Disclaiming.
  • Escape-avoidance.
  • Accepting responsibility or blame.
  • Exercising self-control.
  • Positive reappraisal.

Emotion-focused coping is a mechanism to alleviate distress by minimizing, reducing, or preventing, the emotional components of a stressor. This mechanism can be applied through a variety of ways, such as:

  • Seeking social support.
  • Reappraising the stressor in a positive light.
  • Accepting responsibility.
  • Using avoidance.
  • Exercising self-control.
  • Distancing.

The focus of this coping mechanism is to change the meaning of the stressor or transfer attention away from it. For example, reappraising tries to find a more positive meaning of the cause of the stress in order to reduce the emotional component of the stressor. Avoidance of the emotional distress will distract from the negative feelings associated with the stressor. Emotion-focused coping is well suited for stressors that seem uncontrollable (e.g. a terminal illness diagnosis, or the loss of a loved one). Some mechanisms of emotion focused coping, such as distancing or avoidance, can have alleviating outcomes for a short period of time, however they can be detrimental when used over an extended period. Positive emotion-focused mechanisms, such as seeking social support, and positive re-appraisal, are associated with beneficial outcomes. Emotional approach coping is one form of emotion-focused coping in which emotional expression and processing is used to adaptively manage a response to a stressor. Other examples include relaxation training through deep breathing, meditation, yoga, music and art therapy, and aromatherapy, as well as grounding, which uses physical sensations or mental distractions to refocus from the stressor to present.

Reactive and Proactive Coping

Most coping is reactive in that the coping is in response to stressors. Anticipating and reacting to a future stressor is known as proactive coping or future-oriented coping. Anticipation is when one reduces the stress of some difficult challenge by anticipating what it will be like and preparing for how one is going to cope with it.

Social Coping

Social coping recognises that individuals are bedded within a social environment, which can be stressful, but also is the source of coping resources, such as seeking social support from others.

Humour

Humour used as a positive coping strategy may have useful benefits in relation to mental health and well-being. By having a humorous outlook on life, stressful experiences can be and are often minimised.

This coping method corresponds with positive emotional states and is known to be an indicator of mental health. Physiological processes are also influenced within the exercise of humour. For example, laughing may reduce muscle tension, increase the flow of oxygen to the blood, exercise the cardiovascular region, and produce endorphins in the body.

Using humour in coping while processing through feelings can vary depending on life circumstance and individual humour styles. In regards to grief and loss in life occurrences, it has been found that genuine laughs/smiles when speaking about the loss predicted later adjustment and evoked more positive responses from other people. A person of the deceased family member may resort to making jokes of when the deceased person used to give unwanted “wet willies” (term used for when a person sticks their finger inside their mouth then inserts the finger into another person’s ear) to any unwilling participant. A person might also find comedic relief with others around irrational possible outcomes for the deceased funeral service.

It is also possible that humour would be used by people to feel a sense of control over a more powerless situation and used as way to temporarily escape a feeling of helplessness. Exercised humour can be a sign of positive adjustment as well as drawing support and interaction from others around the loss.

Negative Techniques (Maladaptive Coping or Non-Coping)

Whereas adaptive coping strategies improve functioning, a maladaptive coping technique (also termed non-coping) will just reduce symptoms while maintaining or strengthening the stressor. Maladaptive techniques are only effective as a short-term rather than long-term coping process.

Examples of maladaptive behaviour strategies include dissociation, sensitization, safety behaviours, anxious avoidance, rationalisation and escape (including self-medication).

These coping strategies interfere with the person’s ability to unlearn, or break apart, the paired association between the situation and the associated anxiety symptoms. These are maladaptive strategies as they serve to maintain the disorder.

Dissociation is the ability of the mind to separate and compartmentalise thoughts, memories, and emotions. This is often associated with post traumatic stress syndrome.

Sensitization is when a person seeks to learn about, rehearse, and/or anticipate fearful events in a protective effort to prevent these events from occurring in the first place.

Safety behaviours are demonstrated when individuals with anxiety disorders come to rely on something, or someone, as a means of coping with their excessive anxiety.

Rationalisation is the practice of attempting to use reasoning to minimise the severity of an incident, or avoid approaching it in ways that could cause psychological trauma or stress. It most commonly manifests in the form of making excuses for the behaviour of the person engaging in the rationalisation, or others involved in the situation the person is attempting to rationalise.

Anxious avoidance is when a person avoids anxiety provoking situations by all means. This is the most common method.

Escape is closely related to avoidance. This technique is often demonstrated by people who experience panic attacks or have phobias. These people want to flee the situation at the first sign of anxiety.

Further Examples

Further examples of coping strategies include emotional or instrumental support, self-distraction, denial, substance use, self-blame, behavioural disengagement and the use of drugs or alcohol.

Many people think that meditation “not only calms our emotions, but…makes us feel more ‘together'”, as too can “the kind of prayer in which you’re trying to achieve an inner quietness and peace”.

Low-effort syndrome or low-effort coping refers to the coping responses of a person refusing to work hard. For example, a student at school may learn to put in only minimal effort as they believe if they put in effort it could unveil their flaws.

Historical Psychoanalytic Theories

Otto Fenichel

Otto Fenichel summarised early psychoanalytic studies of coping mechanisms in children as “a gradual substitution of actions for mere discharge reactions…[&] the development of the function of judgement” – noting however that “behind all active types of mastery of external and internal tasks, a readiness remains to fall back on passive-receptive types of mastery.”

In adult cases of “acute and more or less ‘traumatic’ upsetting events in the life of normal persons”, Fenichel stressed that in coping, “in carrying out a ‘work of learning’ or ‘work of adjustment’, [s]he must acknowledge the new and less comfortable reality and fight tendencies towards regression, towards the misinterpretation of reality”, though such rational strategies “may be mixed with relative allowances for rest and for small regressions and compensatory wish fulfillment, which are recuperative in effect”.

Karen Horney

In the 1940s, the German Freudian psychoanalyst Karen Horney “developed her mature theory in which individuals cope with the anxiety produced by feeling unsafe, unloved, and undervalued by disowning their spontaneous feelings and developing elaborate strategies of defence.” Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states.

The healthy strategy she termed “Moving with” is that with which psychologically healthy people develop relationships. It involves compromise. In order to move with, there must be communication, agreement, disagreement, compromise, and decisions. The three other strategies she described – “Moving toward”, “Moving against” and “Moving away” – represented neurotic, unhealthy strategies people utilise in order to protect themselves.

Horney investigated these patterns of neurotic needs (compulsive attachments). The neurotics might feel these attachments more strongly because of difficulties within their lives. If the neurotic does not experience these needs, they will experience anxiety. The ten needs are:

  • Affection and approval, the need to please others and be liked.
  • A partner who will take over one’s life, based on the idea that love will solve all of one’s problems.
  • Restriction of one’s life to narrow borders, to be undemanding, satisfied with little, inconspicuous; to simplify one’s life.
  • Power, for control over others, for a façade of omnipotence, caused by a desperate desire for strength and dominance.
  • Exploitation of others; to get the better of them.
  • Social recognition or prestige, caused by an abnormal concern for appearances and popularity.
  • Personal admiration.
  • Personal achievement.
  • Self-sufficiency and independence.
  • Perfection and unassailability, a desire to be perfect and a fear of being flawed.

In Compliance, also known as “Moving toward” or the “Self-effacing solution”, the individual moves towards those perceived as a threat to avoid retribution and getting hurt, “making any sacrifice, no matter how detrimental.” The argument is, “If I give in, I won’t get hurt.” This means that: if I give everyone I see as a potential threat whatever they want, I won’t be injured (physically or emotionally). This strategy includes neurotic needs one, two, and three.

In Withdrawal, also known as “Moving away” or the “Resigning solution”, individuals distance themselves from anyone perceived as a threat to avoid getting hurt – “the ‘mouse-hole’ attitude … the security of unobtrusiveness.” The argument is, “If I do not let anyone close to me, I won’t get hurt.” A neurotic, according to Horney desires to be distant because of being abused. If they can be the extreme introvert, no one will ever develop a relationship with them. If there is no one around, nobody can hurt them. These “moving away” people fight personality, so they often come across as cold or shallow. This is their strategy. They emotionally remove themselves from society. Included in this strategy are neurotic needs three, nine, and ten.

In Aggression, also known as the “Moving against” or the “Expansive solution”, the individual threatens those perceived as a threat to avoid getting hurt. Children might react to parental in-differences by displaying anger or hostility. This strategy includes neurotic needs four, five, six, seven, and eight.

Related to the work of Karen Horney, public administration scholars[40] developed a classification of coping by frontline workers when working with clients (see also the work of Michael Lipsky on street-level bureaucracy). This coping classification is focused on the behavior workers can display towards clients when confronted with stress. They show that during public service delivery there are three main families of coping:

  • Moving towards clients:
    • Coping by helping clients in stressful situations.
    • An example is a teacher working overtime to help students.
  • Moving away from clients:
    • Coping by avoiding meaningful interactions with clients in stressful situations.
    • An example is a public servant stating “the office is very busy today, please return tomorrow.”
  • Moving against clients:
    • Coping by confronting clients.
    • For instance, teachers can cope with stress when working with students by imposing very rigid rules, such as no phone use in class and sending everyone to the office when they use a phone.
    • Furthermore, aggression towards clients is also included here.

In their systematic review of 35 years of the literature, the scholars found that the most often used family is moving towards clients (43% of all coping fragments). Moving away from clients was found in 38% of all coping fragments and Moving against clients in 19%.

Heinz Hartmann

In 1937, the psychoanalyst (as well as a physician, psychologist, and psychiatrist) Heinz Hartmann marked it as the evolution of ego psychology by publishing his paper, “Me” (which was later translated into English in 1958, titled, “The Ego and the Problem of Adaptation”). Hartmann focused on the adaptive progression of the ego “through the mastery of new demands and tasks”. In fact, according to his adaptive point of view, once infants were born they have the ability to be able to cope with the demands of their surroundings. In his wake, ego psychology further stressed “the development of the personality and of ‘ego-strengths’…adaptation to social realities”.

Object Relations

Emotional intelligence has stressed the importance of “the capacity to soothe oneself, to shake off rampant anxiety, gloom, or irritability….People who are poor in this ability are constantly battling feelings of distress, while those who excel in it can bounce back far more quickly from life’s setbacks and upsets”. From this perspective, “the art of soothing ourselves is a fundamental life skill; some psychoanalytic thinkers, such as John Bowlby and D. W. Winnicott see this as the most essential of all psychic tools.”

Object relations theory has examined the childhood development both of “[i]ndependent coping…capacity for self-soothing”, and of “[a]ided coping. Emotion-focused coping in infancy is often accomplished through the assistance of an adult.”

Gender Differences

Gender differences in coping strategies are the ways in which men and women differ in managing psychological stress. There is evidence that males often develop stress due to their careers, whereas females often encounter stress due to issues in interpersonal relationships. Early studies indicated that “there were gender differences in the sources of stressors, but gender differences in coping were relatively small after controlling for the source of stressors”; and more recent work has similarly revealed “small differences between women’s and men’s coping strategies when studying individuals in similar situations.”

In general, such differences as exist indicate that women tend to employ emotion-focused coping and the “tend-and-befriend” response to stress, whereas men tend to use problem-focused coping and the “fight-or-flight” response, perhaps because societal standards encourage men to be more individualistic, while women are often expected to be interpersonal. An alternative explanation for the aforementioned differences involves genetic factors. The degree to which genetic factors and social conditioning influence behaviour, is the subject of ongoing debate.

Physiological Basis

Hormones also play a part in stress management. Cortisol, a stress hormone, was found to be elevated in males during stressful situations. In females, however, cortisol levels were decreased in stressful situations, and instead, an increase in limbic activity was discovered. Many researchers believe that these results underlie the reasons why men administer a fight-or-flight reaction to stress; whereas, females have a tend-and-befriend reaction. The “fight-or-flight” response activates the sympathetic nervous system in the form of increased focus levels, adrenaline, and epinephrine. Conversely, the “tend-and-befriend” reaction refers to the tendency of women to protect their offspring and relatives. Although these two reactions support a genetic basis to differences in behaviour, one should not assume that in general females cannot implement “fight-or-flight” behaviour or that males cannot implement “tend-and-befriend” behaviour. Additionally, this study implied differing health impacts for each gender as a result of the contrasting stress-processes.

What is Defence Mechanism?

Introduction

In psychoanalytic theory, a defence mechanism is an unconscious psychological mechanism that reduces anxiety arising from unacceptable or potentially harmful stimuli.

Defence mechanisms may result in healthy or unhealthy consequences depending on the circumstances and frequency with which the mechanism is used. Defence mechanisms (German: Abwehrmechanismen) are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses and to maintain one’s self-schema or other schemas. These processes that manipulate, deny, or distort reality may include the following: repression, or the burying of a painful feeling or thought from one’s awareness even though it may resurface in a symbolic form; identification, incorporating an object or thought into oneself; and rationalisation, the justification of one’s behaviour and motivations by substituting “good” acceptable reasons for the actual motivations. In psychoanalytic theory, repression is considered the basis for other defence mechanisms.

Healthy people normally use different defence mechanisms throughout life. A defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected. Among the purposes of ego defence mechanisms is to protect the mind/self/ego from anxiety or social sanctions or to provide a refuge from a situation with which one cannot currently cope.

One resource used to evaluate these mechanisms is the Defence Style Questionnaire (DSQ-40) (see here for online version).

Refer to Coping (Psychology).

Theories and Classifications

Different theorists have different categorisations and conceptualisations of defence mechanisms. Large reviews of theories of defence mechanisms are available from Paulhus, Fridhandler and Hayes (1997) and Cramer (1991). The Journal of Personality published a special issue on defence mechanisms (1998).

In the first definitive book on defence mechanisms, The Ego and the Mechanisms of Defence (1936), Anna Freud enumerated the ten defence mechanisms that appear in the works of her father, Sigmund Freud: repression, regression, reaction formation, isolation, undoing, projection, introjection, turning against one’s own person, reversal into the opposite, and sublimation or displacement.

Sigmund Freud posited that defence mechanisms work by distorting id impulses into acceptable forms, or by unconscious or conscious blockage of these impulses. Anna Freud considered defence mechanisms as intellectual and motor automatisms of various degrees of complexity, that arose in the process of involuntary and voluntary learning.

Anna Freud introduced the concept of signal anxiety; she stated that it was “not directly a conflicted instinctual tension but a signal occurring in the ego of an anticipated instinctual tension”. The signalling function of anxiety was thus seen as crucial, and biologically adapted to warn the organism of danger or a threat to its equilibrium. The anxiety is felt as an increase in bodily or mental tension, and the signal that the organism receives in this way allows for the possibility of taking defensive action regarding the perceived danger.

Both Freuds studied defence mechanisms, but Anna spent more of her time and research on five main mechanisms: repression, regression, projection, reaction formation, and sublimation. All defence mechanisms are responses to anxiety and how the consciousness and unconscious manage the stress of a social situation.

  • Repression: when a feeling is hidden and forced from the consciousness to the unconscious because it is seen as socially unacceptable.
  • Regression: falling back into an early state of mental/physical development seen as “less demanding and safer”.
  • Projection: possessing a feeling that is deemed as socially unacceptable and instead of facing it, that feeling or “unconscious urge” is seen in the actions of other people.
  • Reaction formation: acting the opposite way that the unconscious instructs a person to behave, “often exaggerated and obsessive”.
    • For example, if a wife is infatuated with a man who is not her husband, reaction formation may cause her to – rather than cheat – become obsessed with showing her husband signs of love and affection.
  • Sublimation: seen as the most acceptable of the mechanisms, an expression of anxiety in socially acceptable ways.

Otto F. Kernberg (1967) developed a theory of borderline personality organisation of which one consequence may be borderline personality disorder. His theory is based on ego psychological object relations theory. Borderline personality organisation develops when the child cannot integrate helpful and harmful mental objects together. Kernberg views the use of primitive defence mechanisms as central to this personality organisation. Primitive psychological defences are projection, denial, dissociation or splitting and they are called borderline defence mechanisms. Also, devaluation and projective identification are seen as borderline defences.

In George Eman Vaillant’s (1977) categorisation, defences form a continuum related to their psychoanalytical developmental level. They are classified into pathological, immature, neurotic and “mature” defences.

Robert Plutchik’s (1979) theory views defences as derivatives of basic emotions, which in turn relate to particular diagnostic structures. According to his theory, reaction formation relates to joy (and manic features), denial relates to acceptance (and histrionic features), repression to fear (and passivity), regression to surprise (and borderline traits), compensation to sadness (and depression), projection to disgust (and paranoia), displacement to anger (and hostility) and intellectualisation to anticipation (and obsessionality).

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association (1994) included a tentative diagnostic axis for defence mechanisms. This classification is largely based on Vaillant’s hierarchical view of defences, but has some modifications. Examples include: denial, fantasy, rationalisation, regression, isolation, projection, and displacement.

Vaillant’s Categorisation

Psychiatrist George Eman Vaillant introduced a four-level classification of defence mechanisms: Much of this is derived from his observations while overseeing the Grant study that began in 1937 and is on-going. In monitoring a group of men from their freshman year at Harvard until their deaths, the purpose of the study was to see longitudinally what psychological mechanisms proved to have impact over the course of a lifetime. The hierarchy was seen to correlate well with the capacity to adapt to life. His most comprehensive summary of the on-going study was published in 1977.The focus of the study is to define mental health rather than disorder.

  • Level 1: Pathological defences (psychotic denial, delusional projection).
  • Level 2: Immature defences (fantasy, projection, passive aggression, acting out).
  • Level 3: Neurotic defences (intellectualization, reaction formation, dissociation, displacement, repression).
  • Level 4: Mature defences (humour, sublimation, suppression, altruism, anticipation).

Level 1: Pathological

When predominant, the mechanisms on this level are almost always severely pathological. These defences, in conjunction, permit one effectively to rearrange external experiences to eliminate the need to cope with reality. Pathological users of these mechanisms frequently appear irrational or insane to others. These are the “pathological” defences, common in overt psychosis. However, they are normally found in dreams and throughout childhood as well. They include:

  • Delusional projection: Delusions about external reality, usually of a persecutory nature.
  • Denial: Refusal to accept external reality because it is too threatening; arguing against an anxiety-provoking stimulus by stating it does not exist; resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality.
  • Distortion: A gross reshaping of external reality to meet internal needs

Level 2: Immature

These mechanisms are often present in adults. These mechanisms lessen distress and anxiety produced by threatening people or by an uncomfortable reality. Excessive use of such defences is seen as socially undesirable, in that they are immature, difficult to deal with and seriously out of touch with reality. These are the so-called “immature” defences and overuse almost always leads to serious problems in a person’s ability to cope effectively. These defences are often seen in major depression and personality disorders. They include:

  • Acting out: Direct expression of an unconscious wish or impulse in action, without conscious awareness of the emotion that drives the expressive behaviour.
  • Hypochondriasis: An excessive preoccupation or worry about having a serious illness.
  • Passive-aggressive behaviour: Indirect expression of hostility.
  • Projection: A primitive form of paranoia.
    • Projection reduces anxiety by allowing the expression of the undesirable impulses or desires without becoming consciously aware of them; attributing one’s own unacknowledged, unacceptable, or unwanted thoughts and emotions to another; includes severe prejudice and jealousy, hypervigilance to external danger, and “injustice collecting”, all with the aim of shifting one’s unacceptable thoughts, feelings and impulses onto someone else, such that those same thoughts, feelings, beliefs and motivations are perceived as being possessed by the other.
  • Schizoid fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts.

Level 3: Neurotic

These mechanisms are considered neurotic, but fairly common in adults. Such defences have short-term advantages in coping, but can often cause long-term problems in relationships, work and in enjoying life when used as one’s primary style of coping with the world. They include:

  • Displacement: Defence mechanism that shifts sexual or aggressive impulses to a more acceptable or less threatening target; redirecting emotion to a safer outlet; separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening.
  • Dissociation: Temporary drastic modification of one’s personal identity or character to avoid emotional distress; separation or postponement of a feeling that normally would accompany a situation or thought.
  • Intellectualisation: A form of isolation; concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions; separation of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting on them; avoiding unacceptable emotions by focusing on the intellectual aspects (solitude, rationalisation, ritual, undoing, compensation, and magical thinking)
  • Reaction formation: Converting unconscious wishes or impulses that are perceived to be dangerous or unacceptable into their opposites; behaviour that is completely the opposite of what one really wants or feels; taking the opposite belief because the true belief causes anxiety
  • Repression: The process of attempting to repel desires towards pleasurable instincts, caused by a threat of suffering if the desire is satisfied; the desire is moved to the unconscious in the attempt to prevent it from entering consciousness; seemingly unexplainable naivety, memory lapse or lack of awareness of one’s own situation and condition; the emotion is conscious, but the idea behind it is absent.

Level 4: Mature

These are commonly found among emotionally healthy adults and are considered mature, even though many have their origins in an immature stage of development. They are conscious processes, adapted through the years in order to optimise success in human society and relationships. The use of these defences enhances pleasure and feelings of control. These defences help to integrate conflicting emotions and thoughts, whilst still remaining effective. Those who use these mechanisms are usually considered virtuous. Mature defences include:

  • Altruism: Constructive service to others that brings pleasure and personal satisfaction.
  • Anticipation: Realistic planning for future discomfort.
  • Humour: Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about directly) that gives pleasure to others. The thoughts retain a portion of their innate distress, but they are “skirted around” by witticism, for example, self-deprecation.
  • Sublimation: Transformation of unhelpful emotions or instincts into healthy actions, behaviours, or emotions, for example, playing a heavy contact sport such as football or rugby can transform aggression into a game.
  • Suppression: The conscious decision to delay paying attention to a thought, emotion, or need in order to cope with the present reality; making it possible later to access uncomfortable or distressing emotions whilst accepting them.

Other Defence Mechanisms

Pathological

  • Conversion:
    • The expression of an intrapsychic conflict as a physical symptom; examples include blindness, deafness, paralysis, or numbness.
    • This phenomenon is sometimes called hysteria.
  • Splitting:
    • A primitive defence.
    • Both harmful and helpful impulses are split off and segregated, frequently projected onto someone else.
    • The defended individual segregates experiences into all-good and all-bad categories, with no room for ambiguity and ambivalence.
    • When “splitting” is combined with “projecting”, the undesirable qualities that one unconsciously perceives oneself as possessing, one consciously attributes to another.

Immature

  • Idealisation:
    • Tending to perceive another individual as having more desirable qualities than he or she may actually have.
  • Introjection:
    • Identifying with some idea or object so deeply that it becomes a part of that person.
    • For example, introjection occurs when we take on attributes of other people who seem better able to cope with the situation than we do.
  • Projective identification:
    • The object of projection invokes in that person a version of the thoughts, feelings or behaviours projected.
  • Somatisation:
    • The transformation of uncomfortable feelings towards others into uncomfortable feelings toward oneself: pain, illness, and anxiety.
  • Wishful thinking:
    • Making decisions according to what might be pleasing to imagine instead of by appealing to evidence, rationality, or reality.

Neurotic

  • Isolation:
    • Separation of feelings from ideas and events, for example, describing a murder with graphic details with no emotional response.
  • Rationalisation (making excuses):
    • Convincing oneself that no wrong has been done and that all is or was all right through faulty and false reasoning.
    • An indicator of this defence mechanism can be seen socially as the formulation of convenient excuses.
  • Regression:
    • Temporary reversion of the ego to an earlier stage of development rather than handling unacceptable impulses in a more adult way, for example, using whining as a method of communicating despite already having acquired the ability to speak with an appropriate level of maturity.
  • Undoing:
    • A person tries to ‘undo’ an unhealthy, destructive or otherwise threatening thought by acting out the reverse of the unacceptable. Involves symbolically nullifying an unacceptable or guilt provoking thought, idea, or feeling by confession or atonement.
  • Upward and downward social comparisons:
    • A defensive tendency that is used as a means of self-evaluation. Individuals will look to another individual or comparison group who are considered to be worse off in order to dissociate themselves from perceived similarities and to make themselves feel better about themselves or their personal situation.
  • Withdrawal:
    • Avoidance is a form of defence.
    • It entails removing oneself from events, stimuli, and interactions under the threat of being reminded of painful thoughts and feelings.

Relation with Coping

There are many different perspectives on how the construct of defence relates to the construct of coping; some writers differentiate the constructs in various ways, but “an important literature exists that does not make any difference between the two concepts”. In at least one of his books, George Eman Vaillant stated that he “will use the terms adaptation, resilience, coping, and defense interchangeably”.

Refer to Coping (Psychology).

Book: Building Motivational Interviewing Skills

Book Title:

Building Motivational Interviewing Skills: A Practitioner Workbook.

Author(s): David B. Rosengren.

Year: 2017.

Edition: Second (2nd).

Publisher: The Guildford Press.

Type(s): Paperback and Kindle.

Synopsis:

Many tens of thousands of mental health and health care professionals have used this essential book – now significantly revised with 70% new content reflecting important advances in the field – to develop and sharpen their skills in motivational interviewing (MI).

Clear explanations of core MI concepts are accompanied by carefully crafted sample dialogues, exercises, and practice opportunities. Readers build proficiency for moving through the four processes of MI – engaging, focusing, evoking, and planning – using open-ended questions, affirmations, reflective listening, and summaries (OARS), plus information exchange.

In a large-size format with lay-flat binding for easy photocopying, the volume includes more than 80 reproducible worksheets. Purchasers get access to a companion website where they can download and print the reproducible materials.

New to This Edition

  • Fully revised and restructured around the new four-process model of MI.
  • Chapters on exploring values and goals and “finding the horizon.”
  • Additional exercises, now with downloadable worksheets.
  • Teaches how to tailor OARS skills for each MI process.
  • Integrates key ideas from positive psychology.

Book: Man Down: A Guide for Men on Mental Health

Book Title:

Man Down: A Guide for Men on Mental Health.

Author(s): Charlie Hoare.

Year: 2020.

Edition: First (1st).

Publisher: Vie.

Type(s): Paperback, Audiobook, and Kindle.

Synopsis:

How often do you put on a ‘coping’ front, when in reality you are troubled with insecurities and anxieties?

Do you find it difficult to open up about how you’re feeling?

You might be surprised to learn that you are not alone, and that many men find it challenging to talk about their worries.

From tips on how to reach out, to advice on navigating mental health issues, this volume is full of guidance on how to look out for your well-being. Topics covered include:

  • Anxiety and depression.
  • Stress.
  • Suicidal thoughts.
  • Dealing with traditional gender expectations.
  • Self-care and mindfulness methods.
  • How to open up and communicate.
  • Where to seek help.

With personal experiences and insights, this book will improve your awareness of mental health, offer tools and techniques to enable you to manage it better, and help you to live a happier, healthier life.

Book: Coping Skills for Teens Workbook

Book Title:

Coping Skills for Teens Workbook – 60 Helpful Ways to Deal with Stress, Anxiety and Anger.

Author(s): Janine Halloran (Author), Amy Maranville (Editor), and Meg Garcia (Illustrator).

Year: 2020.

Edition: First (1st).

Publisher: Encourage Play, LLC.

Type(s): Paperback and Kindle.

Synopsis:

A teen version of the #1 Bestselling Coping Skills for Kids Workbook, this version is written specifically with a tween/teen audience (age 11+) in mind.

There are 60 coping strategies included in the book, and it is divided into Coping Styles to make searching for a coping skill easier.

This book also includes several pages to support teens as they work on their coping skills, including: Feelings Tracker Worksheet Identifying Triggers and Making a Plan Positive to Negative Thoughts Worksheet Journal Pages Wellness Worksheets, including a Self-Care PlanThere’s also a rich resource section full of apps, books, card decks, and other resources to help teens deal with stress, anxiety and anger.

What are the Psychological Factors Associated with Financial Hardship & Mental Health?

Research Paper Title

Psychological factors associated with financial hardship and mental health: A systematic review.

Background

A review of the literature investigating the role of psychological factors in the relationship between financial hardship and mental health was completed.

Methods

The review sought to identify which factors have been most consistently and reliably indicated, and the mechanisms by which these factors are proposed to contribute to the association between hardship and mental health.

Results

Although the review identified that a broad variety of factors have been investigated, skills related to personal agency, self-esteem and coping were most frequently and reliably associated with the relationship between financial hardship and mental health outcomes.

Just over half of the studies reviewed concluded that the psychological factor investigated was either eroded by financial hardship, increasing vulnerability to mental health difficulties, or protected mental health by remaining intact despite the effects of financial hardship.

The remaining studies found no such effect or did not analyse their data in a manner in which a mechanism of action could be identified.

Conclusions

The methodological quality of the research included in the review was variable.

The valid and reliable measurement of financial hardship, and conclusions regarding causation due to the use of predominantly cross-sectional design were areas of particular weakness.

Reference

Frankham, C., Richardson, T. & Maguire, N. (2020) Psychological factors associated with financial hardship and mental health: A systematic review. Clinical Psychology Review. doi: 10.1016/j.cpr.2020.101832. Epub 2020 Feb 11.

Book: The Oxford Handbook of Emotion, Social Cognition, and Problem Solving in Adulthood

Book Title:

The Oxford Handbook of Emotion, Social Cognition, and Problem Solving in Adulthood.

Part of the Oxford Library of Psychology.

Author(s): Paul Verhaegen and Christopher Hertzog (Editors).

Year: 2014.

Edition: First.

Publisher: Oxford University Press.

Type(s): Hardcover and Kindle.

Synopsis:

Over the last decade, the field of socio-emotional development and ageing has rapidly expanded, with many new theories and empirical findings emerging. This trend is consistent with the broader movement in psychology to consider social, motivational, and emotional influences on cognition and behaviour.

The Oxford Handbook of Emotion, Social Cognition, and Problem Solving in Adulthood provides the first overview of a new field of adult development that has emerged out of conceptualisations and research at the intersections between socio-emotional development, social cognition, emotion, coping, and everyday problem solving.

This field roundly rejects a universal deficit model of ageing, highlighting instead the dynamic nature of socio-emotional development and the differentiation of individual trajectories of development as a function of variation in contextual and experiential influences.

It emphasises the need for a cross-level examination (from biology and neuroscience to cognitive and social psychology) of the determinants of emotional and socio-emotional behaviour.

This volume also serves as a tribute to the late Fredda Blanchard-Fields, whose thinking and empirical research contributed extensively to a life-span developmental view of emotion, problem solving, and social cognition.

Its chapters cover multiple aspects of adulthood and ageing, presenting developmental perspectives on emotion; antecedents and consequences of emotion in context; everyday problem solving; social cognition; goals and goal-related behaviours; and wisdom.

The landmark volume in this new field, The Oxford Handbook of Emotion, Social Cognition, and Problem Solving in Adulthood is an important resource for cognitive, developmental, and social psychologists, as well as researchers and graduate students in the field of ageing, emotion studies, and social psychology.