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Suicidal Worrying : Online and Telephone. IFOTES Göteborg July 11th 2013 Ad Kerkhof VU Vrije Universiteit Amsterdam. suicidal worries. Repetitive suicidal thinking Rehearsing suicidal thoughts Many hours a day Loosing control over thinking. Chaos in my head. Suicidal Worries.
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Suicidal Worrying:Online and Telephone IFOTES Göteborg July 11th 2013 Ad Kerkhof VU Vrije Universiteit Amsterdam
suicidal worries Repetitive suicidal thinking Rehearsing suicidal thoughts Manyhours a day Loosing control over thinking
Suicidal Worries Nobodyloves me I cannot live alone I have nofuture I amunlovable I cannot stand myfeelings I have to stop thinking
Motives for attempted suicide Major influence (males-females in %): The situation was sounbearablethat I couldnotthink of anyotheralternative (71-76%) My thoughtsweresounbearable, I couldnotendurethemanylonger (64-68%) I wanted to die (65-59%) Hjelmeland et al, SLTB, 2002, 32, 380-393
Suicidal Worries I will never benormalagainWhenwillthis stop? I am a total failure People are better off when I am dead, nobodywill miss me I cannot stand the pain I cannot live without partner
Clinicalobservations: • The continuousrepetition of these statements in the end becomesanobsessionthatcannotbecontrolledanymore
Clinical observations: The repetitive thinking aboutdying, about stopping consciousness, and about the motives to die, show characteristics of worrying
Worry: “A chain of thoughts and images negatively affect-laden and relatively uncontrollable, as an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes”. Borkovec, et al, Cognitive Therapy and Research, 1983, 22, 561-567
Rumination: “Behaviors and thoughts that focus one’s attention on one’s depressive symptoms and on the implications of these symptoms, … passively and repetitively focusing on one’s symptoms of distress and the circumstances surrounding these symptoms” Nolen-Hoeksema, 1991, 1997
Worry and Rumination: rumination, worry, anxiety, depression are allsignificantlycorrelated Watkins et al, Behaviour Research and Therapy, 2005, 43, 1577-1585.
Worry and suicidal ideation: Similar characteristics: • Repetitive • Uncontrollable • Without immediate cause • Future oriented • Threats to personal concerns • No solution
Worry and suicidal ideation: Similar consequences: • No problem solving • Obssessive attention • Stress and sleeplessness • Vital exhaustion • Wish to stop consciousness • hopelessness
Worriers and suicidalpatients: • Perceive personal threats • Overpredictnegativeoutcomes • Underestimatetheirabilities to cope • Maintaindemandingstandards • Repeatfutileattempts to solve • Suffer because of this
Worry as determinant of suicidal behaviour In suicidal behaviour people want to escape theirownrepetitive and tantalizingthoughts and feelings Escape fromself (Baumeister, 1990)
Warning: Worryingcanbe lethal
Suicidal induction With yourpermission: I am going to make yousomewhat suicidal now. Ifyou are suicidal yourself, youwillrecognise the mechanism I willtry to get you out of this state again, at the end of the exercise
Suicidal induction You have a song in yourhead This song willnot go away Whateveryou do, youwillhearit May be a nice song, maybe a boring Choose for yourself a song Or take ABBA: Waterloo………
Suicidal induction TonightyouwillhearAbbasinging Waterloo, Waterloo, Waterloo, etc Youcannot stop it The more youtry to stop it, the loudertheysing
Suicidal induction Whenyou go to sleep youhear ABBA Youcannot sleep because of ABBA Allnight long youhear ABBA Waterloo, Waterloo, Waterloo
Suicidal induction Tomorrowmorningyouhear ABBA Tomorrow, allday long youcannot stop ABBA Tomorrow evening youhear ABBA Waterloo, Waterloo, Waterloo
Suicidal induction Tomorrownightagainyoucannot sleep because of ABBA Second sleeplessnightyoucannot stop ABBA Waterloo, Waterloo, Waterloo
Suicidal induction FromSaturday to Sundayagainyoucannot sleep because of ABBA Thirdsleeplessnightyoucannot stop ABBA On Sundayyouwillhearnothing but ABBA
Suicidal induction Sunday evening you take more precautions: sleepingpills / alcohol Fourthsleeplessnightyoucannot stop ABBA Waterloo, Waterloo, Waterloo
Suicidal induction Mondayyou have to work, and youfearyourexhaustionwillbenoticed In yourcar, to yourwork, suddenly ABBA has gone, silence in yourhead Out of relief, you put on the radio……
ABBA Waterloo Waterloo Waterloo
Suicidal induction Monday evening you take even more precautions: sleepingpills / alcohol Fifthsleeplessnightyoucannot stop ABBA You are exhausted
Suicidal induction Later that week you take even more precautions: sleepingpills / alcohol You even don’tknowhowmanynightsyoucouldnot stop ABBA Youcannotendure ABBA anylonger You are exhausted
Suicidal induction Finallyafterhaving taken manypills / alcohol, youfallasleep You wake up in a brightlylit environment Turns out to beanEmergency Ward
Question? Didyouattempt suicide? Or didyoujustwanted to escape ABBA
Change ABBA into worries Imaginehowit is to have other suicidal thingsinstead of ABBA: Memories of beingraped Thoughtslikebeing a failure Thoughts of loneliness Thoughts of killingyourself
Warning: Youmight want to escape Worryingcanbe lethal
Remember This was onlyanexercise Youwillnothear ABBA for the rest of your life You have notbecome suicidal Think of thisexerxise as a metaphore Imaginethis to be important whenyou help the next suicidal caller
Volunteers: There is nobodywholoves me 1. How manytimes a day is thisthoughtgoingthroughyour mind? 2. How manyhours a day are youcontemplatingthisthought?
Volunteers: I willthrowmyself in front of a train 1. How manytimes a day is thisthoughtgoingthroughyour mind? 2. How manyhours a day are youcontemplatingthisthought?
Volunteers: My life has no meaning 1. How manytimes a day is thisthoughtgoingthroughyour mind? 2. How manyhours a day are youcontemplatingthisthought?
Volunteers: I have no future 1. How manytimes a day is thisthoughtgoingthroughyour mind? 2. How manyhours a day are youcontemplatingthisthought?
Experience: Mostlyonly a few suchthoughts are rehearsedveryfrequently These thoughts are prototypical They start as self-protection But in the end they are self-torturing Massive sufferingbecause of thisrepetition Try to understand the torturing mind
Treatment of suicidal worry CBT approachesforworrying are applicableforsuicidalworry (Tallis, Leahy) • Worrypostponement • Positiveworrying • Distraction • Selffulfillingproperties • Mindfulness • Overgeneralization • Tolerance of uncertainty over the future