Exploring Thoughts and Feelings Inside a Suicidal Mind

Why someone would commit suicide is a perplexing question with elusive answers. Because it is impossible to ask the individual who died, those left behind may never find solace or closure. Instead, they may torture themselves with feelings of confusion, anger, guilt, and sadness, wondering what, if anything, they could have done to prevent the death.

In their search for answers, family members may turn to the psychiatrist or therapist who treated their loved ones before their untimely death. In some cases, family members may lash out and even blame clinicians for not doing more. Yet, this is an important part of our job, one that requires some reflection and preparation.

Losing a patient to suicide is an occupational hazard that can be particularly painful for a psychiatrist. For many, it is not a matter of if a patient will commit suicide, but when; 51% of psychiatrists have experienced the loss of a patient to suicide, and this can create significant disruptions in their professional and personal lives.¹ True grieving for a clinician often comes only after the family has been consoled and the institutional procedures have been completed. Even then, it can be hard to process.

The reasons for suicide are as unique as the patients who commit the act. But promising research is shedding light on what makes some individuals feel that death is the only solution to the overwhelming emotional pain they feel.

Suicide is a major public health problem in the United States. Between 1999 and 2019, suicide rates increased 33%, making it the 10th leading cause of death. In 2019, there were 47,500 suicides in the United States, or roughly 1 death every 11 minutes. About 12 million American adults seriously thought about suicide, 3.5 million planned a suicide attempt, and 1.4 million attempted suicide.²

Suicide affects all ages, races, and ethnicities. In the US, it is the second-leading cause of death for individuals aged 10 to 34, the fourth leading cause among 34- to 54-year-olds, and the fifth leading cause for ages 45 to 54.³ Those who commit suicide are more likely to be older and male, have an alcohol use disorder, comorbid health problems, severe suicide ideation, and familiarity with highly lethal methods.⁴

American Indian/Alaska Natives and non-Hispanic Whites have the highest rates of suicide deaths, along with veterans, those living in rural areas, and workers in industries such as mining and construction. Young individuals who identify as lesbian, gay, bisexual, or transgender are more likely to experience suicidal ideation and behavior than their peers.²

Sidebar 1. Warning Signs, Risk Factors, and Protective Factors

With warning signs, the risk of suicide is immediate or serious. Risk factors, on the other hand, increase the likelihood of suicide, but they are not an immediate symptom. Protective factors decrease the likelihood a person will commit suicide.²³

Warning Signs²⁴:

- Expressing the wish to die or wanting to kill oneself

- Talking about feeling hopeless, defeated, trapped, stuck, and having no purpose or meaning in life

- Speaking about being a burden on others or this world

- Feeling unbearable pain (emotional pain or physical pain)

- Searching for lethal methods online, like stockpiling pills or buying a gun

- Writing a goodbye note or bidding goodbye to family/close friends

- Giving up sentimental or prized personal items

- Sudden or abrupt changes in baselines, such as increased anger/agitation, poor frustration tolerance, increased anxiety, and reckless behavior

- Changes in sleep pattern, appetite

- Social isolation and withdrawn behavior

- Increased use of alcohol and/or illicit drugs

Major Risk Factors²⁵:

- Prior suicide attempt(s)

- Misuse and abuse of alcohol and/or drugs

- Mental disorders, particularly depression and other mood disorders

- Access to lethal means

- Knowing someone who died by suicide

- Family history of suicide

- Social isolation

- Chronic disease and disability, traumatic brain injury

- Lack of access to psychiatric care

- Perceived stigma toward mental illness

- Recent psychiatric hospitalization

- Other life stressors, such as the loss of a family member, work stress, and bullying

- Prior history of trauma or abuse

Protective Factors²⁵:

- Access to psychiatric care and a willingness to seek care

- Strong connections to family, friends, community, and social institutions

- Limited access to lethal means

- Life skills that include resilience in the face of adversity, problem-solving, coping, and adaptation to change

- Self-esteem and a sense of purpose or meaning in life

- Cultural, religious, or personal beliefs that discourage suicide

Researchers have long speculated about the steps that lead someone to suicide, and there are a number of theories that seek to explain the process. In his 1990 article, social psychologist Roy Baumeister, PhD, described suicide as a chain of events designed to “escape from aversive self-awareness.” According to Baumeister, the path to suicide begins when events fall grossly short of one’s expectations. Self-blame for these events quickly follows, along with an almost painful sense of self-awareness and self-loathing.⁵ This creates a negative feeling so powerful that an individual will do anything to avoid it. It may drive them to a state of cognitive deconstruction, generally characterized by concrete thinking, cognitive rigidity, and a rejection of meaning. Pushing aside any meaningful self-awareness and emotion, a person can become irrational and disinhibited. Anything is possible, and suicide is seen as a natural step to escape one’s self and the pain they are feeling.

In his 2007 book, Why People Die by Suicide, Thomas Joiner, PhD, identifies 2 contributing factors that comprise the suicidal mind. First, a person who is suicidal believes they are a burden to others, a perception often clouded by feelings of depression and anxiety. Second, they experience a sense of “thwarted belongingness,” expressed by withdrawing from social ties. This could include the loss of family, friends, and colleagues, whether through death, divorce, separation, or conflict.⁶

What pushes these factors toward suicide is the acquired capacity to follow through on the desire. Marked by a fearless attitude toward death, there are 3 factors that can lead to acquired capacity.

First, acquired capacity can come from a tendency towards natural risk-taking, such as those in law enforcement, thrill-seekers, or emergency department doctors. Second, acquired capacity can also be learned, often through painful and traumatic events, such as exposure to violence, abuse, life-threatening situations, repeated suicide attempts, injuries, and illness. The third involves how knowledgeable and comfortable an individual is with the lethal means to kill themselves, such as knowing how to fire a gun.

None of these factors on their own means someone will commit suicide. Rather, if they ever had the desire to do so, their lack of fear of death and pain gives them the ability to overcome any hesitation. Individuals who are severely suicidal may sometimes lack the ability to understand how their death might impact family and friends. One study observed older adults who had previously attempted suicide expressed a blunted response to empathy scenarios.⁷

For a closer look on warning signs, risk factors, and protective factors of suicide, see Sidebar 1.

Notes left behind can provide insight into the mind of an individual before they commit suicide. One study examined a collection of suicide notes in an effort to identify and create prevention strategies. Of the notes, 74% expressed apologies or shame, 60% expressed love “for those left behind,” 48% shared that life was “too much to bear,” 36% provided instructions on how to handle postmortem affairs, and 21% respectively described “hopelessness/nothing to live for” and dispensed advice for others left behind.⁸

In a 2017 study, Yale University researchers studied the brains of adolescents and young adults, aged 14 to 25, to try and determine who would be more likely to follow through on suicidal thoughts. While the sample size was small, 26 had bipolar disorder and had previously attempted suicide, 42 had bipolar but had not attempted suicide, and 45 had no diagnosis of a mental illness, nor had they attempted suicide.⁹ Researchers used a specialized machine to combine 3 imaging techniques—structural and functional MRIs and diffusion tensor imaging—in 1 sitting, a first for this kind of research.

Sidebar 2. 5 Ways to Provide Support to Someone Considering Suicide

1. Ask about suicidal thoughts: Directly asking a someone if they are thinking about killing themselves will not increase or precipitate suicidal thoughts. On the contrary, it can make them feel cared for and understood, prompting them to open up about their inner distress. It is important to avoid a judgmental tone. The key is to listen.

2. Listen and acknowledge: Letting a person freely communicate their thoughts and feelings can bring them tremendous relief and may help reduce their suicidal thoughts. Avoid confronting or contradicting their judgment, as this can cause them to shut down. Simply let them know that you care about them and are there to support them.

3. Offer support: An individual who is contemplating suicide might have a lot on their mind and can be easily overwhelmed by even small things in their daily routine. Offer to help with some of their routine tasks or chores.

4. Ensure their safety: Reduce access to any possible lethal means. For example, lock up all medication and remove any weapons or firearms from the home and surrounding areas. When asked in a supportive way, a suicidal individual might be willing to share details of their plan, which will make it easier for you to target items of concern.

5. Help them connect: Store the numbers for the National Suicide Prevention Lifeline (800-273-TALK (8255) and the Crisis Text Line (741741) on your phone so it is readily accessible. Reach out to a trusted family member, friend, spiritual advisor, or mental health professional for guidance.

6. Maintain Connection: Check in regularly with your friend or family member after the crisis has passed or they have been discharged from care. Acknowledge that it is OK to struggle and have bad days. Reassure them that you will listen without judgment, even if what is on their mind is sad, scary, or unpleasant. Studies have shown that this has a positive effect and helps stave off future thoughts of suicide or attempts.

They discovered 3 indicators linked to suicidal behavior. First, the connective wiring, or white matter, in the areas of the brain that regulate emotion was decreased in those who had attempted suicide. Second, they noticed less gray matter in the frontal-limbic system and frontal cortex. And third, by studying real-time blood flow between different areas of the brain, researchers noticed less connectivity between the limbic amygdala and the frontal cortex.

Understanding how suicide looks on the inside is vital to our understanding of the mind considering suicide and can inform valuable treatment methods. Studying commonalities among victims of suicide is another way to discover ways to provide intervention and support. For more on ways to support someone considering suicide, see Sidebar 2.

There are more suicide attempts on New Year’s Day than on any other holiday during the year. Sundays and Mondays are the most common days for adults to attempt suicide, while Mondays and Tuesdays tend to be favored by those under age 19.¹⁰ These are just some of the trends that influence suicide rates.

Spring and summer are likely to have the highest number of incidences compared to the winter season.¹¹ One theory explains this by pointing out that symptoms of depression tend to worsen during wintertime. Feelings of listlessness may deflate any interest in forming a plan for suicide. Springtime, on the other hand, can act as an energizing motivator. Another theory suggests that the arrival of spring is regarded with the expectation that gloomy feelings during winter may dissipate. If this does not occur, someone may give up all hope and turn to suicide.¹²

Suicides tend to be contagious. In 1774, Johann Wolfgang von Goethe launched his career with the publication of the novel, The Sorrows of Young Werther. In the story, Werther kills himself with a pistol in an act of unrequited love. The book became so popular that young men around Europe started dressing like the main character and killing themselves in a similar fashion. Government officials sought to have the book banned. Thus began the phenomenon of copycat suicides, also referred to as the Werther Effect.¹³

Copycat suicides, or clusters, can occur after a famous person or celebrity kills themself. The media—and their portrayal of the death—usually get blamed for copycat suicides, and it is why many publications have policies on how suicides are reported.

Copycat suicides are a particular problem in South Korea. Since 2003, the country has had one of the highest suicide rates, and suicide is the leading cause of death among young adults. Just a day after a famous suicide is reported, suicides in the area tend to increase by 16.4%. After popular Korean actress Choi Jin-sil committed suicide in 2008, suicides in the country increased by 162.3% in the 3 weeks thereafter. News of Choi’s suicide dominated the media during this time. South Korea’s top 3 newspapers published 905 articles about her death in just 3 weeks, complete with graphic details and photos of the scene.¹⁴

Copycat suicides are not always linked to real events. Similar to Goethe’s fictional story, the television series 13 Reasons Why coincided with a spike in suicides among adolescents 3 months after the show’s release date. In the show, a series of audiotapes describe the role various individuals played in the suicide death of one of the characters. Suicide prevention organizations were quick to criticize the show for not portraying suicide in a socially responsible way.¹⁵

Austria provides an example of a country that has taken steps to curb the Werther Effect and reduce the number of suicides and suicide attempts in the subway systems of Vienna. In 1987, the country launched a suicide-preventive experiment and issued guidelines on how the media can responsibly report suicide. Within 6 months, the number of suicides and attempts dropped by more than 80%.¹⁶

The World Health Organization has released guidelines for the media when reporting on suicides. These include suggestions to avoid prominent placement and undue repetition of stories about suicide, avoid detailed information about the site and method involved, and caution in using photos and video footage.¹⁷

While copycat suicides can be an alarming trend, there is another phenomenon that can affect suicide rates, thankfully, in a positive way. Known as the pulling together effect, suicide rates tend to dip after major events that are shared by large groups. It helps to explain why there are fewer suicides on Super Bowl Sundays, when groups of family and friends gather for a shared purpose. It is a powerful example of how the feeling of belonging and connectedness can be strong enough to stave off suicide.¹⁸ The most recent example of this was in 2020 when the world was gripped by the COVID-19 pandemic. Provisional suicide mortality rates dipped by 5.6% compared to 2019.¹⁹ This experience was similar to the aftermath of the 9/11 terrorist attacks when suicide rates in New York declined “significantly” for 180 days after the event.²⁰

This connection to others is a powerful tool that psychiatrists can use to discourage patients from suicide. But we need to understand that ultimately, the decision to end one’s life belongs solely to the patient. Our job as psychiatrists is to help patients recover to the best of our abilities. Even if we do everything right, we may still lose our patients to suicide. And if we are not prepared to fully accept this, true healing can elude the best of us.

After a patient’s suicide, 65% of psychiatrists reported stress levels on par with those who seek treatment after a parent dies. Younger, less-experienced clinicians were less prepared to deal with the effects than older, more experienced clinicians.²¹

While all psychiatrists receive training on prevention and intervention, there is less discussion of how a clinician might react should a patient commit suicide. In the aftermath of a suicide, attention to self-care often falls by the wayside, which can lead to chronic problems related to stress, anxiety, anger, and depletion.²² Clinicians are often overwhelmed with other duties, such as speaking with the patient’s family to provide comfort and answers. They have to manage institutional inquiry procedures and engage in various risk management-driven procedures. There are many questions to consider: Should you reach out to family? How can you communicate tactfully? Should you attend the memorial service or funeral? Are you worried about a lawsuit? What will your colleagues think of you?

Sidebar 3. Hotlines, Websites, and Resources

National Suicide Prevention Lifeline: Contact them 24/7 via telephone at 800-273-8255 (TALK) or online chat at https://suicidepreventionlifeline.org/chat

Speaking of Suicide: Information and resources for suicidal individuals, their loved ones, survivors, mental health professionals, and more.

Crisis Text Line: Text HOME to 741741. Available 24/7.

The Trevor Project: Offers suicide prevention and intervention to LGBTQ youth via hotline, chat, text, and online support center.

Veterans Crisis Line: A free and confidential resource staffed by qualified responders from the Department of Veterans Affairs.

SAMHSA’s National Helpline: The Substance Abuse and Mental Health Services Administration offers confidential treatment referrals to those struggling with mental health conditions, substance use disorders, or both. In the first quarter of 2018, the helpline received more than 68,000 calls every month.

National Institute of Mental Health: Shareable resources on suicide prevention.

National Action Alliance for Suicide Prevention: A public-private partnership that includes 250 partners to advance the National Strategy for Suicide Prevention.

For some clinicians, there is a process of grieving that takes more time than they, or their colleagues, anticipate. Some professionals have symptoms similar to posttraumatic stress disorder, including flashbacks, survivor guilt, and nightmares about losing the patient. Other clinician reactions can include shock, disbelief, a feeling of numbness; guilt about not doing enough; reviewing notes to see what they missed; professional humiliation; doubt in one’s skills as a doctor; a sense of defeat; feelings of fear, anger, or sadness; and crying spells that can occur days, months, and even years afterward, often catching them off guard.

To help counterbalance these effects, psychiatrists and the organizations they work for can take the following measures:

1. Establish a protocol on how to respond to a patient’s suicide. This involves understanding the code of ethics, malpractice requirements, and documentation policies. Support staff should be trained on what to expect when a family calls and how to respond.

2. Offer to meet with the family. Remember that your role is to provide support. Offer your condolences and be receptive to their questions and concerns without compromising patient confidentiality. Seek legal counseling on this if needed. Offer a judgment-free space for family members to express themselves. Avoid seeking solace for your own suffering, do not share personal information that might be a burden to others, or speculate why a patient killed themselves. Avoid feeling defensive or judgmental. Be prepared in case the family gets hostile, angry, or blames you for the death of their family member.

3. Meet with your supervisor or mentor, if you have one, to process difficult feelings and sense of trauma.

4. Provide adequate support and guidance for any other affected doctors. Set a tone of support rather than blame among colleagues and supervisors; even the perception of stigma can be quite overwhelming for a clinician. Offer them time off for a reasonable period to recuperate from the loss.

Ultimately, suicide is an act rooted in loneliness and despair. The most powerful tools we have to counteract these feelings are connection with others and the ability to process our experiences in a healthy way. That is when the journey of true healing can begin. Acknowledging that someone needs help is the first step.

1. Chemtob CM, Bauer GB, Hamada RS, et al. Patient suicide: occupational hazard for psychologists and psychiatrists. Professional Psychology: Research and Practice. 1989;20(5):294-300.

16. Niederkrotenthaler T, Herberth A, Sonneck G. Der “Werther-effekt”: mythos oder realität? [The “Werther-effect”: legend or reality?]. Neuropsychiatrie: Klinik, Diagnostik, Therapie und Rehabilitation: Organ der Gesellschaft Osterreichischer Nervenarzte und Psychiater. 2007;21(4):284-290.

18. Joiner TE, Hollar D, Van Orden K. On Buckeyes, Gators, Super Bowl Sunday, and the Miracle on Ice: “pulling together” is associated with lower suicide rates. Journal of Social and Clinical Psychology. 2006;25(2):179-195.

19. Ahmad FB, Anderson RN. The leading causes of death in the US for 2020. JAMA. 2021;325(18):1829–1830.