From the outset, let's clarify three points. First, suicide is the deliberate taking of life and thus a serious sin. Second, nothing in the literature of behavioral research provides a clear understanding of suicide. Third, the mental confusion and emotional pain of the tortured soul who has taken his life (including those contemplating suicide) as well as the anguish and incomprehensibility of the act suffered by the surviving loved ones, is almost beyond human description.
In my training to become a clinical psychologist, we were instructed on the rules regarding self-disclosure to our prospective patients (in this case the readers of this article). The reasons for self-disclosure are:
- Enhancing therapeutic alliance (Norcross & Goldfried, 1992).
- Communicating that others have undergone similar problems (Williams, 1997).
- Normalizing the reaction (Goldfried, Burckell, & Eubanks-Carter, 2003).
- Modeling the advantages of procedures to be employed (Dryden, 1990).
I have something to disclose. A close member of my family committed suicide. This was by far the most intense psycho-spiritual pain I have ever experienced. The reasons for why my family member took his life are still unfathomable to me. The only comfort I have found is by trusting in Christ my anchor. I lean on the words of St. Paul, "For now we see in a mirror dimly, but then face to face. Now I know in part; then I shall understand fully, even as I have been fully understood. So faith, hope, love abide, these three; but the greatest of these is love" (1 Corinthians 13:12-13).
According to the National Institute of Health (NIH), "Suicide is the act of deliberately taking one's own life. Suicidal behavior is any deliberate action with potentially life-threatening consequences, such as taking a drug overdose or deliberately crashing a car" (http://www.nlm.nih.gov/medlineplus/ency/article/001554.htm). Further detail is provided by the United States Department of Health and Human Services which compiled a list of specialized terms and definitions related to suicide including (http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3517/appendixe.asp):
- Suicidal act (also referred to as suicide attempt) - a potentially self-injurious behavior for which there is evidence that the person probably intended to kill himself or herself; a suicidal act may result in death, injuries, or no injuries.
- Suicidal behavior - a spectrum of activities related to thoughts and behaviors that include suicidal thinking, suicide attempts, and completed suicide.
- Suicidal ideation - self-reported thoughts of engaging in suicide-related behavior.
- Suicidality - a term that encompasses suicidal thoughts, ideation, plans, suicide attempts, and completed suicide.
- Suicide - death from injury, poisoning, or suffocation where there is evidence that a self-inflicted act led to the person's death.
- Suicide attempt - a potentially self-injurious behavior with a nonfatal outcome, for which there is evidence that the person intended to kill himself or herself; a suicide attempt may or may not result in injuries.
- Suicide attempt survivors - individuals who have survived a prior suicide attempt.
- Suicide survivors - family members, significant others, or acquaintances who have experienced the loss of a loved one due to suicide; sometimes this term is also used to mean suicide attempt survivors.
In the last report by the National Institute of Mental Health, suicide was the second leading cause of death among children, ages 10-14 (1.3 per 100,000); adolescents, ages 15 -19 (8.2 per 100,000); and young adults, ages 20 - 24 (12.5 per 100,000). In young children suffocation was listed as the main method, the overall method for these young victims, combined, however, was firearms, suffocation and poisoning (NIMH) (2004, http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention.shtml),
Among all the causes of death in the United States, suicide was the eleventh leading cause of death with a rate was 10.9 per 100,000. This accounted for 32,439 individuals lost to suicide, what NIMH labels a preventable public health problem. Even more disturbing is the report that 8 to 25 suicide attempts occur for every actual death. One study by Harris and Barrachough (1997) indicated previous suicide acts (suicide attempts) were one of the important risk factors in completed suicides. These individuals were 38 to 40 times to commit suicide than those who did not have suicide attempts.
There are sex differences both in terms of the rate of suicide and the method used. NIMH reports that for males, suicide is the eighth leading cause of death; for females, it is the sixteenth leading cause of death. However, for males, suicide accounts for four times the total number of deaths than for females. As with our young people, the usual methods are: firearms, suffocation and poison. Males are more likely to use firearms, while females are more likely to use poison.
According to the NIMH statistics, older Americans are disproportionately likely to commit of suicide with a rate of 14.3 per 100,000. Non-Hispanic Caucasians and Native Americans had the highest overall rate: 12.4 - 12.9 per 100,000. Non-Hispanic Blacks, Asian and Pacific Islanders and Hispanics themselves had the lowest rate of suicide, between 5.3 to 5.9 per 100,000.
Special Risk Groups: Veterans and Active Military Personnel
Very relevant to the current state of world affairs is the high suicide rate among veterans in the United States. War veterans have twice the suicide rate of their civilian counterparts, according to a study by Kaplan, McFarland and Newsom (2007). These authors also noted that the suicide rate was even higher among "veterans with daily-life activity limitations," and veterans were 58 percent more likely to use firearms to terminate their lives.
An even more detailed statistical analysis was provided by the acting chairman of the Department of Epidemiology and Biostatistics at the University of Georgia, for a recent CBS News report (http://www.cbsnews.com/stories/2007/11/13/cbsnews_investigates/main3496471.shtml). The veteran suicide rate was between 18.7 to 20.8 per 100,000. What is most disturbing among the veteran statistics is that for young veterans, between the ages of 20 and 24 who have served in Afghanistan and Iraq, the suicide rate is between 22.9 and 31.9 per 100,000.
Figures released on May 29, 2008 by the Department of Defense indicate the U.S. Army has lost over 580 soldiers to suicide since the commencement of the United States attack on Afghanistan and Iraq. Spokesmen indicated this causality rate is equivalent to the makeup of an infantry battalion task force. "This ranks as the fourth leading manner of death for soldiers, exceeded only by hostile fire, accidents and illnesses," they said. "Even more startling is that during this same period, 10 to 20 times as many soldiers have thought to harm themselves or attempted suicide" (http://www.msnbc.msn.com/id/24874573/).
Co-Related Factors of Suicide
It would be beyond the scope of the current state of behavioral science research to call this section causes of suicide. There are a number of factors, however, that are related to suicide risk such as previous suicide ideation, depression, hopelessness, lack of reasons for living, lethal method availability, poor impulse control, poor treatment compliance, previous attempted suicide, poor (or perception of poor) social support, alcohol and/drug abuse, psychotic symptoms or diagnosis, and severe current life stressors (Brown, Beck, Steer, & Grisham, 2000).
It is noteworthy that suicide ideation, also called depression-resistant suicide (Brown, Holloway and Beck, 2008), and hopelessness are among the most commonly recognized and validated risk factors. These risk factors were related to significant cognitive impairment, including irrationality and dysfunction. This includes severe attenuated problem solving and coping skills (Ellis and Newman, 1996).
Researchers Segal, Teasdale and Williams (2002) proposed that when mood disorder becomes elevated, even negligible increase can evoke dysfunctional cognitive patterns of reasoning and deliberation. Self-evaluations of failure and inadequacy can ensue. The authors liken this to a "rumination loop" which produces a deepening depression whirlpool.
In the case of the significant rate of suicide and suicide attempts in the military services, a 2007 U.S. Army report concluded that the "main situational indicators" for the suicides in 2006 were failed relationships; legal and financial problems; and what are termed "occupational/operational" issues (http://www.cnn.com/2008/US/05/29/army.suicides/index.html#cnnSTCText). The 2008 U.S. Army reported these same indicators have been found (http://news.yahoo.com/s/ap/20080529/ap_on_go_ca_st_pe/military_suicides). In addition there has been reported a 46.4 % increase in Post Traumatic Stress Disorder (PTSD) among the military over the previous year (http://www.msnbc.msn.com/id/24842653/). PTSD features include distressing recollections of the traumatic event, dreams and sleep disturbances, hallucination concentration difficulties, attenuated affect, and exaggerated startle response. Because of the availability of firearms among the military it is not surprising that the typical profile of the military individual committing suicide is that they used a firearm.
The Inherent Value of Life Clashes with the "Right to Die"
Just a few short decades ago almost everyone lamented suicide. Today, people (including Orthodox Christians) have become more ambivalent. Why is that?
It could be because society has become increasingly secularized and thus the mindset of Christians is more accepting of suicide. Secularism embodies moral relativism where almost any moral viewpoint is rendered as true and good as another. Secularism reduces what previously was the moral compass of Christians — the teachings of Christ — to lesser authority, and as one of many possible views. Society, to quote Pope John Paul II (1993), has become not only "dechristianized," but Christianity itself has become "irrelevant."
Perhaps the fading authority of Christian morality and the dimming awareness that life is valuable go hand in hand. One of the great gifts of Christianity (and Judaism before it) is the teaching that we have only one life to live. This view is rooted in the book of Genesis. Creation has a beginning and an end and thus so does man. Moreover, mankind is created by God and in His image and likeness, which thereby confers upon him the greatest and highest value, and the promise that the end of this life is the beginning of another.
Each person has only one life with a distinct beginning and a distinct end, at least in earthly terms where biological life must inevitably cease. Christianity's gift to this original Judaic comprehension is that biological death is transformed into a doorway into a life that does not in fact end, but continues on forever. Mankind is created to live once and is born into a life that has no end.
Orthodox ethicist Tristam Englehardt made this point as well: "[S]ome appear to have concluded that, if one only lives once, life is worth saving at any expense." This view would make not only the efforts to sustain life at any cost comprehensible, but also explain the pain of the loss of loved ones, especially as in suicide (which objectively could be avoided).
One could elaborate on Dr. Englehardt's point. Not only does the conviction that one only lives once contribute to the value of a human life, it also adds meaning and purpose to the command that we love one another. The pain we feel at the death of loved ones occurs because we love them. If there was no love, death would most likely be met with a passing moment of sadness or other emotions, but the raw, psychic pain of deep grief is reserved only for those whom we deeply love. Sometimes the depth of the pain of loss indicates of the depth of the love we have for someone.
The Christian View of Death: Joy in the Midst of Pain
Consequently, Christianity recognizes that the pain of separation and love are deeply related. These are hard emotions to reconcile but meaning, and therefore comfort and peace, are found at the Cross of Christ — the death of the Son of God — who, in rising from the dead, vanquished death and brought joy into the world. "Through the cross," St. Paul reminded us, "joy comes into the world."
Christianity has always viewed death as the doorway to life; a joyous transformation although not always without pain. St. Ephraim of Syria sums up the Christian view of those who die in Christ:
Those who labor, and accomplished strugglers of piety, rejoice at the hour of departure. Seeing before their eyes the great labor of their struggle, vigilance, fasting, prostrations, prayer, tears and sackcloths, their souls rejoice when they are summoned from their bodies to enter into repose.
The contrast of joy and sorrow is beautifully expressed in the Latin hymn Stabat Mater. Here we see the grieving Mother of Jesus deeply expressing her loss but at the same time sublimating her pain into hope and trust in the Almighty Father - that sublime combination of human sorrow and spiritual joy. Note a few of the verses focusing on the pain of loss:
At the Cross her station keeping, Stood the mournful Mother weeping, Close to Jesus at the last.
Christ above in torment hangs. She beneath behold the pangs, Of her dying, glorious Son.
Can the human heart refrain, From partaking in her pain, In that Mother's pain behold.
Let me share with you His pain, Who for all our sins was slain, Who for me in torments died.
At the end of the hymn is the complete turn around from seeming despair to hope and joy of the triumphal resurrection:
Christ, when You shall call me hence, Be your mother my defense, Be your cross my victory.
While my body here decays, May my soul your goodness praise, Safe in heaven eternally. Amen
The Orthodox Christian prays in the same feeling of deep human mourning, but united with the spiritual mind of Godly triumph during the Holy Friday Lamentation Service:
In a grave they laid thee, O my life and my Christ: And the armies of the angels were sore amazed, As they sang the praise of they submissive love.
Who will give me water, For the tears I must weep So the maiden wed to God cried with loud lament, That for my sweet Jesus I may rightly mourn.
I am rent with grief, And my heart with woe is crushed and broken, As I see them slay thee with doom unjust: So bewailing Him His grieving Mother cried.
Dirges at the tomb, Goodly Joseph sings with Nicodemus, Bringing praise to Christ who by men was slain, And in song with them are joined the seraphim.
Ev'ry generation, To thy Grave comes bringing, Dear Christ, its dirge of praises.
Death Himself by thy Death, O my God, hast thou slain, By power of thy Godhead.
Grant thy Church peace, And thy flock Salvation, By thy Resurrection.
Secularism and the Suicide Option
As the culture becomes more secularized, the wisdom that resolves the conflicting constituents of human experience (like love and pain described above) grows increasingly dim. This wisdom shaped the moral tradition that disseminates it into the world. When morality becomes relative however, when man becomes the touchstone — the authority — of all that is good and right and true, the wisdom is lost.
First to go is referencing the hardships of life to God. This takes many forms. For some Christians, the embrace of hardship is replaced with a cold pragmatism where the moral prohibitions are softened. We see this with suicide. Following secular trends, some Christians increasingly see suicide as one option among many as a way to alleviate pain.
This is a tragic development. For the committed Orthodox Christian, suicide is prohibited because ultimately it violates God's "law of love." Jesus said, "If you love me, you will keep my commandments (John 14:15). Suicide is interwoven with the pride of the creature who makes decisions reserved for God alone about the manner and time of their death. Objectively this separates the suicide victim from God and dooms them to eternal separation from Him. This is indeed the great lamentation.
This is a hard saying, especially for those of us who have suffered through the suicide of a loved one. But God is merciful both to us and the person committing suicide as we shall discuss in more detail below. Nevertheless, as St. Paul taught us, we should not use our liberty as an occasion for sin. The moral prohibition against suicide is clear. Calling on the mercy of God to justify the idea that suicide is an option for relieving pain is a distortion of Christian teaching and finds no favor with God.
Our Holy Fathers on Suicide
Blessed Augustine said in That Christians Have No Authority for Committing Suicide in Any Circumstances Whatever:
For if it is not lawful to take the law into our own hands, and slay even a guilty person, whose death no public sentence has warranted, then certainly he who kills himself is a homicide, and so much the guiltier of his own death, as he was more innocent of that offence for which he doomed himself to die.
Do we justly execrate the deed of Judas, and does truth itself pronounce that by hanging himself he rather aggravated than expiated the guilt of that most iniquitous betrayal, since, by despairing of God's mercy in his sorrow that wrought death, he left to himself no place for a healing penitence? How much more ought he to abstain from laying violent hands on himself who has done nothing worthy of such a punishment!
For Judas, when he killed himself, killed a wicked man; but he passed from this life chargeable not only with the death of Christ, but with his own: for though he killed himself on account of his crime, his killing himself was another crime. Why, then, should a man who has done no ill do ill to himself, and by killing himself kill the innocent to escape another's guilty act, and perpetrate upon himself a sin of his own, that the sin of another may not be perpetrated on him.
It is not without significance, that in no passage of the holy canonical books there can be found either divine precept or permission to take away our own life, whether for the sake of entering on the enjoyment of immortality, or of shunning, or ridding ourselves of anything whatever. Nay, the law, rightly interpreted, even prohibits suicide, where it says, "Thou shalt not kill" (http://faculty.washington.edu/miceal/lgw/lucretia/Augustine.html).
Later the Saint stated: "The commandment is, 'Thou shall not kill man'; therefore neither another nor yourself, for he who kills himself still kills nothing else than man."
St. Clement of Alexandria likened those who commit suicide to boastful heretics who do so seeking eminence but whose end is only in a vain death. He stated:
Now some of the heretics who have misunderstood the Lord, have at once an impious and cowardly love of life; saying that the true martyrdom is the knowledge of the only true God (which we also admit), and that the man is a self-murderer and a suicide who makes confession by death; and adducing other similar sophisms of cowardice. To these we shall reply at the proper time; for they differ with us in regard to first principles.
Now we, too, say that those who have rushed on death (for there are some, not belonging to us, but sharing the name merely, who are in haste to give themselves up, the poor wretches dying through hatred to the Creator) — these, we say, banish themselves without being martyrs, even though they are punished publicly. For they do not preserve the characteristic mark of believing martyrdom, inasmuch as they have not known the only true God, but give themselves up to a vain death (http://en.wikisource.org/wiki/Ante-Nicene_Fathers/Volume_II/CLEMENT_OF_ALEXANDRIA/The_Stromata,_or_Miscellanies/Book_IV./Chapter_IV).
Now if this is the empty consequence of those who commit suicide with good intentions, what is the fate of those who commit suicide for self-serving motives?
Canonical Penalties for Suicide
It is important to consider the deliberation given to confessors in a chapter entitled "Instruction to the Spiritual Father" in the book Exomologetarion: A Manual of Confession by St. Nikodemos the Hagiorite. In his discussion of suicide the saint stated: "Namely, for a person to kill himself, while having a sound intellect, being conquered by despair." The qualification, "while having a sound intellect" is critical in understanding the application of canonical penalties and the voluntary or involuntary aspect of the offense.
The objective seriousness of suicide has already been established. However, in evaluating sin it is also critical to consider the degree of voluntariness of the sinful action. Fr. George Dokos, the translator of the essay has a long footnote (pp. 80-82) discussing this issue. Fr. George concluded that St. Nikodemos' view of this issue is closest to his contemporary George Koressios. Koressios wrote in his book Theology that, " desire becomes a mortal sin because the movement of desire is threefold: involuntary, incompletely voluntary, and completely voluntary. The first movement is not called sin; the second is called a pardonable sin; the third is mortal" (emphasis added). (Note: "Mortal" in this sense means serious.)
The importance of this distinction cannot be overstated. All that has been gleaned from the state of medical research on factors relating to suicide indicates significant attenuation of cognitive function. As this directly relates to the degree of voluntary desire capable of by the victim, it mitigates the mortal sinfulness of the act of suicide as a rejection or turning away from God.
This would also have the effect of easing God's judgment of such an act. St. Isaac the Syrian, noted, "Just because the terms 'wrath,' 'anger,' 'hatred' and the rest are used of the Creator in the Bible, we should not imagine that He actually does anything in anger, hatred or zeal. Many figurative terms are used of God in the Scriptures, terms which are far remove from His true nature." Again, quoting the holiest of Syrian Saints, "Among all God's actions there is none which is not a matter of mercy, love and compassion: this constitutes the beginning and end of His dealing with us" (Brock, 1997).
The moral reprehensibility of suicide has surely been established. However, other reflections are essential. Consider all of the references to God's mercy, the scriptures, the Church Fathers, and the liturgy. The psalmist wrote:
- “Surely goodness and mercy shall follow me all the days of my life; and I shall dwell in the house of the Lord for ever” (Psalm 22:6).
- ”Do not thou, O Lord, withhold thy mercy from me, let thy steadfast love and thy faithfulness ever preserve me!” (Psalm 39:11).
- “Have mercy on me, O God, according to thy steadfast love; according to thy abundant mercy blot out my transgressions” (Psalm 50:1).
- “Answer me, O Lord, for thy steadfast love is good; according to thy abundant mercy, turn to me;” (Psalm 68:16) “ who redeems your life from the Pit, who crowns you with steadfast love and mercy, ” (Psalm 102:4).
- “Praise the Lord! O give thanks to the Lord, for he is good; for his steadfast love [mercy] endures for ever!”
In the Holy Gospels we see constant references to the mercy of Our Lord, God and Savior Jesus Christ:
But he [a lawyer], desiring to justify himself, said to Jesus, "And who is my neighbor?" Jesus replied, "A man was going down from Jerusalem to Jericho, and he fell among robbers, who stripped him and beat him, and departed, leaving him half dead. Now by chance a priest was going down that road; and when he saw him he passed by on the other side. So likewise a Levite, when he came to the place and saw him, passed by on the other side. But a Samaritan, as he journeyed, came to where he was; and when he saw him, he had compassion, and went to him and bound up his wounds, pouring on oil and wine; then he set him on his own beast and brought him to an inn, and took care of him. And the next day he took out two denarii and gave them to the innkeeper, saying, `Take care of him; and whatever more you spend, I will repay you when I come back.' Which of these three, do you think, proved neighbor to the man who fell among the robbers?" He said, "The one who showed mercy on him." And Jesus said to him, "Go and do likewise” (Luke 8:29-37).
We are to be like the Samaritan. Did not Jesus tell us to be merciful: “Blessed are the merciful for they shall obtain mercy” (Matthew 5:7)? From the cross not only did Jesus say about His executioners “Father, forgive them for they know not what they do!” but He also showed us how God reconciles those who sin. God's conditions for reconciliation and repentance are so merciful, as to almost go unnoticed. Consider St. Luke's report of the two thieves on their crosses next to the crucified Jesus:
One of the criminals who were hanged railed at him, saying, "Are you not the Christ? Save yourself and us!" But the other rebuked him, saying, "Do you not fear God, since you are under the same sentence of condemnation? And we indeed justly; for we are receiving the due reward of our deeds; but this man has done nothing wrong." And he said, "Jesus, remember me when you come into your kingdom." And he said to him, "Truly, I say to you, today you will be with me in Paradise (emphasis added) (Luke 23: 39-49).
It is important to reflect on the words of St. James “ yet mercy triumphs over judgment.”
The Holy Fathers on God’s Mercy
St. Ephraim the Syrian wrote, “Only hope in the manifestation of Thy Grace, O man-befriending Master, consoles me and keeps me from despair. Whether Thou so desirest or not, save me, O all-good Lord, according to Thy great kindness.”
“God’s mercifulness is far more extensive than we can conceive.” (St. Isaac of Syria quoted by Brock, 1997). God’s love according to St. Isaac is the driving force of all He has done, is doing. and will ever do. Bishop Hilarion Alfeyev (2000) quoting St. Isaac the Syrian noted: “In love did He [God] bring the world into existence; In love is He going to bring it into that wondrous transformed state, and in love will the world be swallowed up in the great mystery of Him who has performed all these things; in love will the whole course of the governance of creation be finally comprised.”
It is only in the context of understanding God and all His works as love that St. Isaac’s understanding of the end of time becomes comprehensible. St. Isaac wrote: “Accordingly the kingdom and gehenna [hell] are matters belonging to mercy; they were conceived of in their essence by God as a result of His eternal goodness That we should further say or think that the matter is not full of love and mingled with compassion would be an opinion laden with blasphemy and an insult to our Lord God. By saying that He will even hand us over to burning for the sake of sufferings, torment and all sorts of ills, we are attributing to the Divine Nature an enmity towards the very rational beings which He created through grace; the same is true if we say He acts or thinks with spite and with a vengeful purpose, as though he were avenging himself.”
With this in mind, St. Isaac’s reference of God being in hell, still trying to draw the demons and those there to love Him, is humanly fathomable. St. Isaac, based on his “mystical union of with the love of God” (Alfeyev, 2000), would consider the final judgment, as described in the Parable of the Last Judgment (cf. Matthew 25: 31-4): the separation of the sheep from the goats to be the state of the soul at death, but a state not final or irreversible. Both demons and sinners would still have the possibility to respond, by God’s eternally enduring, merciful, and loving grace, so “they will gaze towards God with the desire of insatiable love ”
What a beautiful way for us to pray for God’s mercy and to show mercy and love to all who have attempted or succeeded in committing suicide. Elder Paisios of the Holy Mountain told us: “We must always be considerate and lenient to our fellow men, so God can also be the same with us” (Ageloglou, 1998). Our commitment to God is to put all our trust in Him. Let us pray the words of King David as he fled from Saul: “ This I know, that God is for me. In God, whose word I praise, in the Lord, whose word I praise, in God I trust without a fear” (Psalm 56: 9-11).
Theology can use Science to Understand Suicide
In Orthodox theology and practice there is a fundamental "synergia" (cooperation of man with God) in the healing practice (Morelli, 2006d). St. Gregory of Nyssa said, "Medicine is an example of what God allows men to do when they work in harmony with Him and with one another." Another holy Church Father, St. Basil of Caesarea, said, "God's grace is as evident in the healing power of medicine and its practitioners as it is in miraculous cures" (Demakis 2004).
Not to be overlooked is the great tradition of the Church of Christ as hospital (Morelli, 2006). St. John Chrysostom wrote that the Parable of the Good Samaritan (Luke 1:33ff) portrays Christ as the Great Physician who comes to broken mankind (the man beaten by robbers and lying on the road) in order to bring healing. The inn into which the Good Samaritan delivered the suffering man is the Church (Vlachos, 1994, 1994). This expresses in clear theological terms the relationship between healing of soul and body as practiced by the early healers.
Healing centers in the church were more than just rhetoric. In the fourth century various healing centers were opened and administrated by the Orthodox Church, including homes for the poor, orphans, aged, and hospitals (Demakis, 2004). Many of these centers were associated with monasteries. The health care workers, the physicians, nurses, and psychologists of the day were often the monks themselves. St. Basil of Caesarea (370-379) was trained in medicine and worked with the monks in ministering to the ill and infirm.
As Patriarch of Constantinople, St. John Chrysostom (390) used the wealth of the Church to open hospitals and other philanthropic institutions, which earned him great love from the people. Within two centuries the rapid growth of these centers necessitated state funding although the Church retained the active administration and care-giving in the arrangement. Emperor Justinian moved the most important physicians into the hospitals, which enhanced the reputation of these centers (Demakis 2004). One monastery, the Pantocrator, was in fact a very large healing center.
Lest anyone conclude that these practices were only for the early church, reflect on the words of advice given physicians by a contemporary holy elder, Paisios of the Holy Mountain. “You doctors, must take good care of your patients in order to avoid unpleasant situations. You should have a practical mind. Generally speaking, everyone of us must take advantage of his mind which is a gift from God” (Ageloglou, 1998).
Psychological Intervention Models
Two psychological models seem to hold promise in intervening in suicide behavior. The first is Cognitive-Behavioral Therapy (CBT) (Ghrahamanlou-Holloway, Brown and Beck, 2008). Previous studies suggested modest intervention effects for CBT (Dahlsgaard, Beck and Brown, 1998). Recent research conducted by Brown, Ten Have, Henriques, Xie, Hollander and Beck (2005), suggested that comparatively brief cognitive therapy intervention led to a reduction in repeated attempted suicides among adults by up to 50%. This is not surprising considering Thomas Ellis’s (2006) observation that based on research studies cognitive therapy has shifted from “an assemblage of therapeutic techniques” to more precise cognitive-behavioral interventions for specific disorders.
The second model showing promise is Dialectical Behavior Therapy (DBT) (Linehan, Comtois, Murray, Brown, Gallup, Heard, Korslund, Tutek, Reynolds & Lindenboim, 2006). This two-year study reported that suicidal patients were half as likely to attempt suicide after Dialectical Behavior Therapy treatment. I explain below that two intervention techniques employed by the DBT model that can be easily integrated into the familiar Cognitive-Behavior Model noted above.
Use of Intervention Models
While full clinical use of these models requires professional training, introductory understanding of these therapies may aid clergy, family members, and friends as well as individuals suffering from depression and suicidal ideation themselves to gain understanding and skills for dealing with emotional dysfunction, developing emotional control, and give a partial glimpse into the cognitive turmoil that leads to suicide. It should be noted that self-help manuals both in Cognitive-Behavior Therapy (Burns, 1980) and Dialectical Behavior Therapy (McKay, Wood, and Brantley, 2007) are readily available and that these authors, as well as most responsible authors of self-help manuals, recommend seeking professional advice. This is in line with the advice of the Church Fathers. Hausherr (1990) quotes an anonymous spiritual father saying, "When evil thoughts harass you, do not hide them, but tell them at once to your Spiritual Father. The more one hides one's thoughts, the more they multiply and the stronger they become."
The reason for this revelation is to provide the Spiritual Father with the basis for discernment (Gr. diakrisis). The Fathers knew the importance of disclosure and extended this to actual techniques not unlike the disputation processes whose efficacy has been demonstrated by modern cognitive-behavioral psychological clinicians today. There is wisdom in the aphorism: Only the fool has himself as his physician.
Cognitive Behavioral Suicide Intervention Model
Ghahramanlou-Holloway, Brown and Beck (2008) recommend that three important questions be asked during the clinical interview to assess suicidal ideation intent and planning.
- Are you currently having any thoughts of killing yourself?
- Do you have any desire to kill yourself?
- Do you have any specific plan to kill yourself?
These questions would usually be asked as part of a thorough clinical mental status examination by a trained licensed mental health clinician. However, these questions can also be asked by clergy, parents, teachers and even friends as part of their interactions with anyone they are in contact with, whether as duty or concern. Any affirmative answers to these questions behoove an immediate referral related to competent clinicians. Strong affirmative responses necessitate immediate response: This may entail emergency service agencies, Emergency Medical Technicians (EMT), fire, and or police. Lower level responses still require follow-up. Consultation with mental health clinicians, family physician and especially trained clergy would be suggested. Parish priests in all cases should be familiar with the psychological processes involved in suicide and should be prepared to provide spiritual intervention.
One of the myths about suicide is that by mentioning it, let alone discussing it, one would be “implanting the seeds” of suicide in someone’s mind. However, Ghahramanlou Holloway state: “Do not avoid using the word suicide, because it gives the impression that you stigmatize the concept” (Ghahramanlou-Holloway, et al., 2008). A simple but counter-intuitive intervention is to listen to the thoughts, desires, and plans the potential suicidal victim has. This is not to say: agree, confirm, consent or endorse any suicidal ideation, intent or plan. It is merely to “listen.” This actually will be one of the first strategies used by trained clinicians in intervention (Ellis and Newman, 1996). Research has shown that people who feel understood in terms of how they are “hurting” are more open to considering “alternatives” to suicide. I am not suggesting untrained individuals perform intervention strategies. But empathy, love and concern: “I love you, etc. is something all can do.
Basically, two measures have been shown to be quite predictive of suicide: suicide ideation and hopelessness. Two scales of suicide ideation have been shown to be useful. One scale measures the severity of suicide ideation (Scale of Suicidal Ideation, SSI), and the other the severity of suicidal ideation at its worst point (Scale of Suicidal Ideation – Worst, SSI-W). The latter scale is more predictive of suicide than the former (Beck, Brown, Steer, Dahlsgaard & Grisham, 1999).
Hopelessness, however, is a very significant predictor of suicide. Individuals who display hopelessness frequently endorse such propositions as: “Things will never get better;” “There are no solutions to my problems;” “I will never be happy again;” “I will never get over what happened;” “I don't see things ever improving;” “There is no point in trying anymore;” “I just want to give up.” The Beck Hopelessness Inventory (BHS) is a 20 item inventory measuring such ideation. A cutoff score of nine and above indicates a significant propensity to suicide (Beck & Steer, 1988). It should be noted that in the Cognitive Therapy Model, assessment continues throughout the intervention.
I would think the reader would recognize that the construct of hopelessness is related to the theological virtue of hope. This will be a gateway to a powerful spiritual intervention into suicide prevention. The cultivation of the virtue of hope will be discussed later.
Cognitive Treatment: Rationale
Cognitive therapy intervention for suicide prevention is based on the cognitive model of depression (Beck, Rush, Shaw, & Emery, 1979). According to this model, individuals upset themselves over people and events by their interpretations of them, thereby making themselves dysfunctionally angry, anxious or depressed or simply functionally annoyed, concerned, and disappointed. If our thinking is clear, rational and non-distorted, we have normal feelings like bearable nuisances and livable letdowns. If our “interpretations” are irrational or distorted we get enraged, intensely worried and despondent. Ellis has long pointed out that emotions such as anger add to our problems as in a domino effect. Originally we have a problem, the "Activating Event." Our angry emotional response is a new problem added to the original, which in turn is linked to other dysfunctional outcomes, etc.
After recognizing and labeling of the cognitive distortions eliciting anger, clinicians aid patients in re-structuring them. There are three questions that lead to restructuring: 1) Where is the evidence? 2) Is there any other way of looking at it? 3) Is it as bad as it seems? Using the examples above, some restructured interpretations might be:
- Selective Abstraction: “True, my son got a "D," but he also received some A's and B's.”
- Arbitrary Inference: “Father didn't say 'hello,' he may not like me, but maybe he has something on his mind and he didn't even hear me."
- Personalization: “The waiter is so busy with other tables, maybe he doesn't even see me.”
- Polarization: “My wife, Jill, missed dinner today, there are many other things that make up our relationship besides one dinner.”
- Generalization: “Let me talk to Jack about his work schedule and at least ask him to call me if he is going to be late.”
- Demanding Expectations: “I prefer that my son not talk back to me, let me praise him when he talks correctly and fine him a nickel whenever he talks back.”
Beck (1976) pointed out that alongside these cognitive distortions, depression also involves the cognitive theme of loss and what he termed the cognitive triad: a negative view of self, world, and future. In other words, if a clinician were to analyze the self-talk of depressed patients, the cognitive distortions mentioned above would be present in some manner as well as the cognitive theme of loss.
Relation to Suicide
In relation to suicide, Holloway, Brown and Beck (2008) pointed out a “suicide mode” can be initiated in some patients. Such patients appear to have an exaggerated sense of “loss-related cognitions.” The authors cite statements that appear to be descriptive of extreme loss, such as, “I have lost all that is important to me.” Also cited is what would be termed directly “suicide-related cognitions” such as “Life is no longer worth living.” They also note that increased melancholy and delay in seeking help are factors. Interestingly, they also point out that impulsivity and suicidal planning before suicidal attempts also fit the “suicidal mode.” I suggest the hypothesis be explored that such planning be considered a direct communication of intent.
Basically, the rationale of the cognitive therapeutic intervention must be credible, that is believable, to the patient (Beck, 1976). There are two aspects of establishing credibility. One approach suggested by Beck is for the therapist and the patient to neutrally examine the disturbing cognitions the patient has (“They may or may not be correct”). If the patient feels the therapist is willing to listen attentively to their viewpoint, he in turn may be more open and ready to listen and consider the therapist’s challenge to the rationality and reconstruction of their distorted ideation. On the clinician’ part, the characteristics of empathy would encompass this process: caring, regard, and warmth. The therapist would be able to describe the world as the patient views it. An important caveat: If empathy is perceived by the patient as therapist approval of their distorted cognitions, then this would be counter-therapeutic, namely, the patient may assume the therapist approves of suicide. (Ellis, 1962).
As Beck noted, the findings of social psychologists indicate, “dogmatism tends to widen the gap between persons with different opinions.” This is to say, the opposing positions become more rigid and extreme and closes down the therapeutic process. On the other hand, superficially compliant patients, who ingest the clinicians’ “interpretations and suggestions as sacred pronouncements,” deprive the patient of the self-controlled cognitive processes required to evaluate their own core belief systems and perceptions.
Another way of establishing credibility is to point out how the patient’s own self-produced inappropriate cognitions add to their problems. For example, a patient may have had a life setback, a loss of a job or a relationship, but by viewing the situation as unchangeable and catastrophic they now have two problems instead of one. It could be pointed out to the patient that if they only look at the original problem as a problem “to be solved,” they could focus much of their effort on problem solving the initial problem, instead of now having to deal with the additional problem of their own making.
The second way of establishing credibility is to place the cognitive therapy procedure in the context of the body of behavioral science research that demonstrates the efficacy of the cognitive therapeutic procedures for the diagnosis. Judith Beck (1995) called this process “educating the patient about his disorder.”
Attention to Culture and Life Context
Any therapeutic intervention (and spiritual direction) must take into account the family culture of the patient. It is far beyond the scope of this paper to go into the particulars of each family culture. However, it is necessary to stress a point made in the overview of an of important work: Ethnicity and Family Therapy by McGoldrick, Giordano, & Garcia-Preto (2005). These researchers stated:
It is almost impossible to understand the meaning of behavior unless one knows something of the cultural values of a family. Even the definition of “family” differs greatly from group to group. The dominant American (Anglo) definition focuses on the intact nuclear family, whereas for Italians there is no such thing as the nuclear family. To them, family means a strong, tightly knit three or four-generational family, which also includes godparents and old friends. African American families focus on an even wider network of kin and community. Asian families include all ancestors, going all the way back to the beginning of time, and all descendents, or at least male ancestors and descendents, reflecting a sense of time that is almost inconceivable to most Americans.
It is also important to be aware of the immediate life circumstances of the patient. This could be accomplished by asking the individual if anything significant has changed in their lives since their last encounter. Sometimes a person may be reluctant to state an event but would feel more comfortable saying they were particularly distressed or elated. With patient permission, consultation with family members or close friends is a way to assess the changing life situation. Ghahramanlou-Holloway, Brown and Beck (2008) suggested that enterprising therapist involvement in the daily life of the suicide risk patient is necessary to increase treatment compliance. This may include reminder phone calls, flexible scheduling, phone sessions, team intervention and dealing with everyday “difficulties in transportation, child care, housing, medication adherence and follow-up.”
Patient Evaluation of Therapy Efficacy
Therapeutic effectiveness is also related to the patient’s perceived efficacy, or their perception of the likely success of the intervention procedure. One suicide researcher, Reinecke (2006), specifically linked the self-efficacy concept of Bandura, (1977), i.e., a person’s perception of their own capacity to do things that will influence their life to the motivational variable of problem-solving appraisal and thus considers it an “important predictor of hopelessness and suicidal thoughts.”
Psychologically therapeutic effectiveness is related to confidence. Spiritually, it is related to the virtue of Hope. This spiritual evaluation is especially important when Christ enlivens the psychological interventions. In this case, it is important to remind ourselves of St. Gregory’s words quoted above: "Medicine is an example of what God allows men to do when they work in harmony with Him and with one another."
The Three Phases of Cognitive Therapy for Suicidal Behavior
Phase I: Effective clinical intervention first involves helping the patient recognize and label the cognitive distortions and themes (Morelli, 2006b). In dealing with suicidal risk individuals, Ghahramanlou-Holloway, Brown and Beck (2008) suggested additional factors have to be taken into account. These clinician-researchers suggest “a patient can be helped to understand that hopelessness equals inertia and powerlessness, whereas realistic hope (i.e., “hoping smart”) can result in activity, gained power, and subsequent life change.” The cognitive distortion of polarization has to be challenged and restructured. The suicide prone individual has to be aided to “visualize a hope continuum for various life domains.” This would include different family and occupational situations and subsequent effect on mood.
In this first phase a safety plan is also established. This is a backup to allow a pause before engaging in impulsive behavior. Contact information is planned, practiced, and is made readily available. This would include an “on-call therapist”, “a local, 24 hour emergency psychiatric” facility, a crisis hotline and active involvement of family or close friends in the safety chain.
A case conceptualization is also established in the first phase. This involves asking the suicide prone person to “tell their story” in a non-judgmental setting. This is the story of their most recent suicide attempt and the events that occurred, both before and during the suicidal behavior. Ghahramanlou-Holloway, Brown and Beck (2008), pointed out that the patient narrative may be cathartic, especially with therapist interest and empathy. The story also provides information for cognitive-behavioral planning and intervention. Another result is that it helps the patient understand the reciprocal interaction of their thoughts, emotions and behaviors.
Phase II: Following up learning to recognize and label the cognitive distortions in the first phase, the patient is now helped to restructure these distortions (Morelli, 2006b). As Ghahramanlou-Holloway, Brown and Beck (2008) stated, these core beliefs and cognitive distortions, accepted as simply true from early years, can be tested and changed. As pointed out in previous papers (Morelli, 2006b), three questions are helpful in challenging the patient's thinking so that restructuring can occur:
- Where is the evidence?
- Is there any other way of looking at the situation?
- Is the situation as bad as it seems?
For example, a patient may be have a suicide related automatic thought such as, “All is hopeless, life is not worth living, nothing can ever be right again.” The evidence and alternatives for the thought are explored, including consideration of past successes and experiences.
This phase also includes teaching coping responses for every day problems. Ghahramanlou-Holloway, Brown and Beck (2008), list the following steps in this process:
- Indentifying and listing problems.
- Prioritizing problems.
- Connecting problems in living to suicidality.
- Assessing the functionality and adaptiveness of responses.
- Generating alternatives and plans.
- Weighing pros and cons of proposed solutions.
- Working out discrete tasks to achieve the goal.
- Reviewing the consequences of the chosen solution(s).
Learning competing responses is also introduced in Phase II. Competing responses to suicide may include physical activities such as breathing exercises, muscle relaxation, and physical exercise. Other activities are suggested such as taking a bath, phoning a friend, taking a nap or, imagery exercises, like imagining a pleasant walk in a garden, or a beautiful beach day with a cool breeze and deep blue sky. Using the social support network of adjunctive medical-psycho-social services is also re-emphasized. Ghahramanlou-Holloway, Brown and Beck (2008) point out the goal of these competing responses is to get the suicidal patient to “procrastinate relative to the suicidal impulse.”
Phase III: Guided imagery exercises which are considered the response prevention task (RPT) make up this last phase of intervention. Cognitions, images and emotions associated with recent suicidal behavior in a neutral, safe setting are engendered. The patient reconstructs the entire episode in a detailed step by step sequence and the therapist explores the patients’ ability to replace previous dysfunctional cognitions, emotions and behaviors with alternative functional responses “The patients’ ability to respond adaptively to this activated state” is evaluated and used to make a decision as to the desirability of treatment termination.
Two Dialectical Behavior Therapy Interventions
In clinical and pastoral use of Cognitive-Behavior Therapy (CBT) I have found two interventions in the Dialectical-Behavior Therapy Model (DBT) which are compatible, easily integrated and support CBT: Distress Tolerance and Mindfulness. In DBT focus is on balancing and contrasting events that are initially perceived as different and contradictory and accepting (but not condoning) them without personal judgment (Linehan, 1993a). This involves reciprocal acceptance and change.
Let us apply the processes of acceptance and change to distressing events. A good example comes from the work of Albert Ellis: “And we have Rational-Emotive imagery, where we get people to imagine the worst and then feel terrible, and then work on their feeling. We have my famous shame attacking exercise, because shame is the essence of much disturbance, where we get you and other people and our clients to go out and do something asinine, ridiculous, foolish, and not feel ashamed. Now don't get in trouble; don't walk naked in the streets or anything like that. But yell out the stops, if you're civilized enough in your city to have a subway, like we're civilized enough in New York. And stop somebody on the street and say, "I just got out of the loony bin. What month is it?" and not feel ashamed when they look in horror at you and think you're off your rocker, which they think you are but you're really not; you're being very much saner than they are” (http://www.intuition.org/txt/ellis.htm).
As applied to suicide prone individuals, when they experience they can tolerate the distress involved in such exercises, they then can be prompted to apply this to other distressing situations. Common examples might include: poor job performance evaluation; social conflicts, such as insults and put-downs; anticipatory anxiety of natural disasters, or other emergencies; life changes, such as moving, children moving away from home and the like.
The suicidal patient is taught to accompany acceptance of the distressing event with coping thoughts. Below is a partial list of such coping thoughts compiled from suggestions from McKay, Davis and Fanning, (1997):
- This situation won’t last forever.
- I have been through similar painful experiences and have survived.
- I can do what I have to while still being anxious.
- This is an opportunity to learn to bear with my fears.
- My anxiety or sadness won’t kill me; it just doesn’t feel so good right now.
In my pastoral-clinical experience I have given patients homework exercises that are geared to practice distress tolerance. I might accompany the person during the exercise either close or at a distance as necessary. Debriefing takes place as soon as possible after the exercise. During debriefing, the patient is helped to identify the feelings accompanying the exercise and importantly to recognize that they can modify the thought pattern they attached to the exercise. They did survive, thus change is possible and can be acquired. Such exercises are repeated as necessary.
Kabat-Zinn (2003) defined mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmental to the unfolding of experience moment by moment.” In DBT, mindfulness focuses on the sensory and physical aspects of the present moment, recognizes cognitions, emotions and physical sensations occurring in the present moment, develops cognizance of the streams of awareness in the present moment, and practices separation of the cognitions from emotional and physical sensations. The goal of this process in DBT is to consider all decisions that could be made, rejecting choices that are under emotional control while making choices based on the reasonable mind and intuition (what feels right).
DBT mindfulness exercises also include controlled breathing and meditation regimens. Linehan (1993b) made reference to the “enteric brain,” the large complex matrix web of nerve fibers in the gastrointestinal region and its ligature with the cerebral brain. It is hypothesized that this neuropsychological linkage underlies the interactive relationship connecting intuition, reason, breathing, and meditation together with mindfulness.
Clinically, mindfulness is similar to procedures cognitive-behavioral psychologists call metacognition. Metacognition is considered by CBT as ‘thinking about your own thinking.” It is a regulatory or control processes to guide thinking and problem solving. It involves planning, regulating, monitoring, and evaluating in a step-by-step process leading from where the person currently is to an end goal to be solved or achieved.
Mindfulness is also not unlike the General Problem Solver (GPS) created by Newell & Simon in 1972. It started as a computer program written to simulate human problem-solving techniques (Ericsson & Simon, 1984). Newell and Simon defined a problem as not knowing the immediate steps to achieve a concrete goal.
Problem solving begins with the goal and then determines what sequences of operations or actions are needed to attain it (Ashcraft, 1994). In clinical terms, two important processes are involved. The first is the application of means-ends analysis. This involves assessing the difference between the stage that the individual presently occupies and the completed task. The second process is called the sub-goal strategy. The individual takes an action or operation to close the gap between where they are at present and completing the goal.
Failure to employ mindfulness is equivalent to the CBT cognitive distortions of:
- Selective Abstraction: The focusing on one event while excluding others. In one case Rick (all names are changed), an electronics technician, selectively focused on a rebuke he just received from his supervisor while ignoring the star (a company term) he received the previous week from the senior project manager. This irrational selective focusing on the reprimand led to depression, hopelessness, and suicidal ideation.
- Emotional Reasoning: The judgment that one's feelings are facts. Pam had a feeling that her new boss hated her. When asked how she knows this, she responded that her "feelings are always right." She failed to distinguish between the fact that although feelings are real, feelings cannot prove whether something is true or false. I tell my patients that no matter how strongly some people "felt" the world was flat when Christopher Columbus set sail, Columbus proved the world was round. Feelings are not facts.[l]