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Suicide is the 10th leading cause of death in the United States and over three times more people will die by suicide than will be murdered every year. Yet myths about suicide and those who die by it abound.
Join today’s guest, Dr. Doreen Marshall, vice-president of the American Foundation for Suicide Prevention to learn about some of these damaging myths. What types of people die by suicide? Is it only people with mental illness who consider this tragic step? And most importantly, if someone is suicidal, what can you do — is suicide preventable?
As a psychologist with experience that spans clinical, educational, and professional settings, Dr. Doreen Marshall has been engaged in local and national suicide prevention and postvention work for more than 15 years.
Since joining AFSP in 2014, Dr. Marshall has expanded AFSP’s menu of programs and improved program delivery through AFSP’s nationwide network of chapters. Dr. Marshall oversees AFSP’s Prevention and Education and Loss and Healing programs, which includes community-based suicide prevention training, clinician training, AFSP’s Survivor Outreach Program for survivors of suicide loss, and programming for International Survivors of Suicide Loss Day. Dr. Marshall works to foster partnerships with mental health organizations, such as with the National Council for Behavioral Health to train people across the country in Mental Health First Aid, and oversees the development of new programming, including clinician trainings, community trainings and K-12 educator trainings.
Prior to joining AFSP, Marshall served as Associate Dean of Counseling/Chair at Argosy University, where she contributed to the CACREP-accreditation process for the university’s counseling programs, and chaired the counseling program on the Atlanta campus. She is also past-chair for the Suicide Prevention Coalition of Georgia, and previously served as Associate Director of The Link Counseling Center’s suicide prevention and aftercare program in Atlanta. She has served as a consultant for both national and state suicide prevention and postvention initiatives, which included providing suicide prevention training for the Division of Behavioral Health and Developmental Disabilities and serving on a task force of the National Action Alliance for Suicide Prevention.
Marshall holds a doctorate in Counseling Psychology from Georgia State University, a master’s degree in Professional Counseling, and a bachelor’s degree in Philosophy and English from The College of New Jersey.
Computer Generated Transcript of “Recognizing Suicidal Behavior” Episode
Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors.
Announcer: You’re listening tothe Psych Central Podcast, where guest experts in the field of psychology and mental health share thought-provoking information using plain, everyday language. Here’s your host, Gabe Howard.
Gabe Howard: Hey, everyone, you’re listening to this week’s episode of The Psych Central Podcast, sponsored by Better Help. Affordable, private online counseling, learn how to save 10 percent and get one week free at BetterHelp.com/PsychCentral. I’m your host Gabe Howard and calling into the show today, we have Dr. Doreen Marshall. Dr. Marshall is the vice president of mission engagement with the American Foundation for Suicide Prevention. And she is a psychologist with experience that spans clinical, educational and professional settings. Since joining AFSP in 2014, Dr. Marshall has expanded their menu of programs and improved program delivery through AFSP’s nationwide network of chapters. Dr. Marshall, welcome to the show.
Dr. Doreen Marshall: Thanks for having me. Gabe.
Gabe Howard: Now, before we get started, would you mind giving our listeners the suicide hotline numbers just in case anybody out there needs them?
Dr. Doreen Marshall: Sure, so the number for the National Suicide Prevention Lifeline is 1-800-273-8255. That’s 1-800-273-8255. Or it spells out TALK. Or you can text the word talk to 741741. Again, you can text the word talk to 741741. And I think it’s important that if you’re worried about someone, that you keep these numbers as a resource as well. I tell people to put it in their phone because you never know when someone may need that information. But you can also call it as somebody who’s worried about someone and get some guidance.
Gabe Howard: Thank you so much for that information. Now we’re talking about suicide. It’s a big, heavy topic. Suicide is one of those topics that everybody is familiar with. Yet when you really ask people follow up questions, you find out that many people are not familiar with it. What is the biggest myth that people have about suicide?
Dr. Doreen Marshall: I think a lot of people think that suicide is a foregone conclusion for someone, meaning that there’s nothing that we can do to prevent it when actually we know there’s a lot we can do to prevent suicide and that it can be prevented. But I think a lot of people think, oh, someone’s going to end their life, they’re just going to go ahead and do it, which is not the case. What we know is that, particularly when people are in a suicidal crisis, it tends to come and go. And so we know that if we can help somebody in that moment or even better before that moment, we can prevent suicide.
Gabe Howard: So just to clarify, suicide is preventable, because I think that, as you said, most people don’t believe that and in fact, most people believe that talking about suicide encourages suicide or gives people the idea to act on their feelings. Is that another one of those persistent myths that just won’t go away, that discussing suicide gives people the idea to do it?
Dr. Doreen Marshall: Yeah, that’s another big one that I think people think, oh, if I ask someone if they’re feeling suicidal, somehow I’m going to put that thought in their head if it wasn’t already there, and nothing could be further from the truth. What we actually know is that when you ask someone directly about suicide, it actually gives them a clue that you’re tuned into what’s going on with them, that you understand they’re in a lot of emotional pain. So we encourage people to ask, but that’s a big myth that people think, oh, if I say something, I’m going to somehow make the situation worse. And that’s not the case.
Gabe Howard: I imagine that it’s very difficult if you suspect that somebody is suicidal, or having thoughts of ending their own life, just to walk up to them and engage in a discussion. Can you give our listeners some hints or tips on what to do if they suspect a friend, family member or loved one is suicidal to begin that conversation?
Dr. Doreen Marshall: For most of us, what’s challenging is we have a feeling in our gut that something is not right or we’ve noticed some things that are happening with the person that we love. And I think the first thing is to trust your gut. That if you’re feeling like something feels off or you’re wondering if someone is maybe thinking about suicide, chances are pretty good you’re right. I would approach them by commenting on what you’re observing. So it may be, hey, I noticed you haven’t seemed like yourself lately. You seem really overwhelmed or it seems like life is throwing you a lot of curveballs lately. I’m wondering how you’re doing with all of that. And then I think ultimately to ask them by saying something like sometimes when people are feeling this overwhelmed or feeling this, that they may have thoughts of wanting to end their life or thoughts of wanting to die by suicide, I wonder if you’ve ever had those kind of thoughts or if you’re having them now? It helps to ask directly. But often most people need like a lead in. And this is really at its core, a caring conversation. Approaching it I think with that in mind and trusting yourself, trusting that what you’ve noticed is worth commenting on and bringing to this person’s attention, but then ultimately asking directly about suicide.
Gabe Howard: Does suicide happen without warning?
Dr. Doreen Marshall: It’s hard to say, I mean, many people who have lost someone to suicide will say that it felt like it came out of nowhere. And I think a lot of people do have that experience. What we know, though, is that the vast majority of people who go on to die by suicide do give some indicator that they’re struggling. So they may say something, but it’s an offhanded comment or it’s said in a way that it’s veiled or it’s not really direct or they may start to act in a way that’s different or unusual for them. Often when people are doing that, they’re hoping someone will notice, right? They’re in an ambivalent place and they want someone to recognize that they’re struggling. I wouldn’t say it happens without warning most of the time. Though, I certainly understand when people feel very surprised or shocked because I think as a society, we tend to minimize our hide our mental health concerns. We don’t talk as openly about them as we do other physical health concerns.
Gabe Howard: When you say that it doesn’t happen without warning, that means that there’re signs. Can you give our audience an example of what some of those signs to look out for may be?
Dr. Doreen Marshall: We tend to talk about warning signs as being in these three categories: talk, behavior and mood. Talk. What you’re listening for is some indication that the person is feeling very hopeless, is feeling like giving up. So they may say it directly, like I want to kill myself or they may say it very indirectly, like I don’t see any reason to go on or there’s nothing in life for me or some kind of veiled comment that indicates they’re feeling incredibly hopeless and maybe having thoughts of suicide. Behavior. We look for changes in behavior. So things that may indicate that someone’s mental health is worsening or they’re having a worsening of symptoms or that they’re doing some things that indicate they are ambivalent about living, like they start engaging in reckless behavior or they start to give away prized possessions or things that look like they’re wrapping things up where it doesn’t seem to make sense with what’s going on otherwise. You may see changes like they’re not sleeping, their substance use is changing. There may be drinking more or less. Just these changes in behavior that we think something is not quite usual for this person. And then finally, mood, we look for changes in mood, someone who’s incredibly anxious or feeling more depressed or more sad than normal, feeling a lot of shame. And again, you’re thinking about what’s usual for this person. But we’re looking for things that indicate a change. The key is to tune into your gut. If you’re feeling like something isn’t quite right, you’re probably right.
Gabe Howard: One of the things that I hear a lot, even when people notice those signs, is that the person is just being dramatic or they’re just trying to get attention. There’s all of these phrases and words to minimize what the person is going through and almost vilify them for, as you just said, the warning signs they’re showing. Has that been your experience? And if so, why do you think society views it that way?
Dr. Doreen Marshall: I think that’s one of these other prevailing myths that if someone’s talking or putting it out there, they’re just doing it to get attention. And I say, yeah, they may be trying to get attention. They’re trying to get your help. And we think about how we think about other health issues. If someone were walking around clutching their chest saying, I’m having chest pains, we wouldn’t say, oh, you’re just doing that for attention. We would probably start to mobilize and think, OK, why don’t you have a seat? Why don’t I call somebody and start asking them some questions? And for some reason, with mental health, we don’t respond in the same way, even though we know these are health issues at their core.
Gabe Howard: Dr. Marshall, when the public hears a person who is suicidal, we tend to get this idea in our head of what the person looks like. Is there a stereotype surrounding the type of person who is most likely to die by suicide or is it everybody?
Dr. Doreen Marshall: No one is immune. We look at someone’s mental health. We look at substance use. And we look at life stressors. For someone who’s suicidal, these things come together in a perfect storm for someone who’s in a moment of vulnerability or has some kind of vulnerabilities that are biological, but that also are based in kind of their life, in their environment. It’s complicated, but I think what I would say is that we should be looking out for everyone in our lives and not assume just because someone is successful or because they have a good job or because they never seem to have any mental health struggles that they’re somehow immune to this. When you asked me earlier about does suicide ever seem to happen without warning, I think what a lot of people will say is that some people who die by suicide didn’t seem to have kind of what we think of as typical things going on in their life. We imagine someone who’s completely down and out, having a very hard time in their life. And what we know is that even people who seem to have everything going well can have thoughts of suicide. And that’s the complicated piece about it. Sometimes people who feel like they have everything going on in their life actually have a harder time with knowing they may be struggling with their mental health. It’s harder for them to ask for help because they may be the person that everyone goes to. It’s important that we don’t think suicide is not an option for this person because of whatever, that we take the time and ask, because we know it can impact anybody.
Gabe Howard: Is it true that suicide, though, only impacts people with mental illnesses? Things like major depression or bipolar disorder or schizophrenia, or is it broader than that?
Dr. Doreen Marshall: It’s a really good question, Gabe. What I would say, though, is that any time we think about who’s at risk, we try and think of multiple factors, not just mental health, because we know many people live with mental health conditions and don’t ever feel suicidal. We’re still trying to understand how these other factors like life stressors, which we know experiencing a loss, can increase someone’s risk if they have other vulnerabilities. There’s some combination of things that happens for a person who is suicidal, and it’s important that we pay attention to all of it.
Gabe Howard: When somebody is suicidal, does that mean that they will always be suicidal? Is this just their lot in life and they just have to learn to manage it?
Dr. Doreen Marshall: It varies. For some people, their suicidal thoughts are much more chronic in nature, like any other health issue. But for lots of people, in fact, the numbers look something like 90 percent of people who make a suicide attempt go on to die from some other cause. So it doesn’t mean just because they’ve attempted suicide, that it’s a foregone conclusion that someday they’re going to die by suicide. The vast majority do not go on to die by suicide. So that tells us for some people, this is a singular occurrence. For others, it may be more of a chronic kind of management of thoughts or of impulses, but it’s definitely not a foregone conclusion for anybody. And in fact, we know that with support and treatment, many people, when they’re not in a suicidal crisis, look back on that moment and are almost confused by it and have this feeling of how did I get to that place? We know that with the right things in place around treatment and support, that most people who feel suicidal in a moment will not go on to die by suicide.
Gabe Howard: We’ll be back in a minute after these messages.
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Gabe Howard: And we’re back discussing suicide prevention with Dr. Doreen Marshall, the vice president of the American Foundation for Suicide Prevention. Up until now, we’ve been talking about how to recognize the thoughts or feelings of suicide in other people, but let’s flip that a little bit. Let’s talk about ourselves. What if you think that you’re at risk for suicide or how can you even do a litmus test to figure out if you’re at risk for suicide? And then, of course, what do you do about it if you fear that you are?
Dr. Doreen Marshall: Because so much of this may vary from individual to individual, what I’m going to say is general, but I think will be relevant for lots of folks. If I were somebody who has had suicidal thoughts in my life, I might notice a bit of a pattern to them. For example, I might notice that they tend to get very intense around certain times in my life or in response to certain things that are happening. I might notice they’re worse when I’m not sleeping or I might notice other indicators that tell me, OK, this is my way to do a bit of a check in with myself, because I know if these things are happening to me, that’s an indicator that something’s off. What I would tell people is that if you’re having suicidal thoughts and this is something that seems new for you or if you’ve had them over your life, but there’s something different about them in this moment, it’s always important to reach out to someone who can help you. And you can call a crisis line. You can reach out to a mental health provider. Just like we would go to a doctor if we were having pain in our arm that suddenly seemed like it was worse. You can go to someone who’s trained, who’s outside of you, and a little more objective, who can ask you some questions about it.
Dr. Doreen Marshall: And similar to how you would go to a doctor for pain in your arm, you might say, hey, I’ve had this pain. It seems to have gotten worse recently. I seem to have a hard time getting through my day because of it. Those kinds of things apply to suicidal thoughts, too. That we may notice for ourselves that either they’re happening when they haven’t happened before or if we’ve had them before, they got worse or more intense. The most important thing to do is make sure you’re not ignoring it, that you’re taking some action to let someone know this is happening and also to help you get some support around them. What we know is that many people feel suicidal thoughts in moments of isolation or in moments where they feel disconnected from others. It’s important to reach out in those moments and to establish a connection, even if it’s a new connection, like calling a crisis line or calling someone and saying, hey, I’m struggling. I just need to talk. If this is something that you’re seeing a therapist for and your thoughts are returning or becoming more intense, openly communicating with your therapist about them is key.
Gabe Howard: And I really like what you said there about the idea that it’s individualized, I think that so many people, they read something that is well-intentioned and absolutely excellent information and they think, oh, this doesn’t apply to me and then they think that is the whole story, that that 20 minute podcast or 800 word article that they read on the Internet or pamphlet that they got encompasses everything when it comes to how our mental health works, how suicidality works. And I like this idea that, hey, if something’s wrong, go get it checked out. You don’t know what it is. I really fear that some people believe that they have to be able to diagnose themselves with a mental health issue before they’re willing to seek help. And they don’t feel this way about other illnesses. They feel that something is wrong. So they go to the doctor to find out what it is. We have a confusing relationship with our mental health. But along that same vein, what are some things that an individual can do to monitor and manage their mental health?
Dr. Doreen Marshall: What you’re asking for is so important, Gabe, because this is really a goal for all of us, just like we take steps to take care of our physical health and to try and ward off things that may develop in our physical health, such as things like heart disease or high blood sugar. We can do those same things about our mental health. And most people don’t think of our mental health that way. They don’t think there’s things I can do to help my mental health or proactively take steps to reduce my risk. So some of the things certainly obviously, I think having a good relationship with a health provider and a mental health provider is important, just like we need to have good relationships with doctors. But there’s things we can do that are separate from that, too. Certainly right now with everything that’s been going on in life, people looking at their daily habits and their daily health habits, because we know there’s some things that are facilitative of good mental health, getting regular sleep and trying to have what we call good sleep hygiene, meaning trying to go to sleep and wake up about the same times every day can help. And if that’s something that you’re having a hard time doing, that might be an indicator that, well, if nothing’s changing with me doing that, I might need to engage a professional around some help. Certainly things like getting regular exercise, we know exercise, even just a brisk walk daily can have a positive impact on mood. So doing things like getting out as much as you can right now, seeing nature, getting some form of physical exercise, we know these can have a positive impact on mood. And taking some active steps to say, OK, what can I do about this situation? What within this situation is within my control? Because I think when many of us are feeling stressed, we tend to think there’s nothing we can do. And that’s not true. We can do deep breathing exercises. We can learn about mindfulness. We can also do things like make sure our living space feels good to us, removing things in our environment or limiting things like news coming in or things that tend to just elevate our stress level. So many of us are trying to stay plugged in to the news and everything, but for many of us the 24/7 news cycle can really stress us out.
Gabe Howard: Now we’ve talked a lot about the use of therapy and suicide prevention. Is therapy the only preventative measure or treatment modality for suicidal thinking?
Dr. Doreen Marshall: Therapy is one component of really multiple strategies that can help someone. If we had heart disease or high blood pressure, we wouldn’t just focus on the medication we’ve been prescribed. But we would also look at lifestyle changes. We would also look at ways we can impact this in a positive way for our overall health. Therapy is an important component, but it’s not the only thing to focus on. We also want people to focus on having supportive relationships and having others in their life who they can connect with.
Gabe Howard: Dr. Marshall, thank you so much. Now let’s talk about suicidality and like a 911 situation, an immediate need. You know, a lot of what we’re talking about is, you know, make an appointment, get it checked out, talk to somebody, call a crisis line. But we also know that suicidality exists on a spectrum. And if you’re right there, what is the best option for either you to do if you recognize it or, of course, your loved ones or family members, if they notice an immediate, an imminent threat of suicide in somebody?
Dr. Doreen Marshall: The barometer I usually use is do I feel safe being by myself right now or if it’s about a family member or do I feel safe leaving this person alone right now? And if I’m feeling so much stress or anxiousness about either of those questions, that tells me we’re in a different category of risk. And I keep likening this to health issues because I think it’s something we can all understand. If my loved one was having chest pains and I’m feeling nervous about leaving this person alone for fear that they might have a cardiac event. It’s the same kind of questioning I’m applying to a mental health concern. If this person is feeling suicidal. My gut tells me I don’t feel good about leaving this person by themselves or if I’m the person and I feel I don’t want to be by myself right now. That’s an indicator we’re in a different category of risk. And what any one of us can do is call a crisis line and you can call a crisis line if you’re worried about someone. Most people think if I call, it’s going to enact something and I don’t know what’s going to happen. And really, they’re going to talk you through. You say, I’m worried about someone. I’m here with this person and we don’t know what to do. So we’re calling for some assistance. They can talk you through. But at the end of the day, if you’re feeling like this is a major health event happening, which you should feel if you don’t feel safe, you can go to an emergency room or go to an emergency center and say, I’m feeling this way, I need some help.
Dr. Doreen Marshall: I think most of us tend to think we’re overreacting with mental health issues. And the reality is we’re not. The other thing I would just add really quick, Gabe, is that if we’re worried about someone and we know they have access to things in their home to harm themselves, it’s very important to put time and space between a person who’s struggling and a method to hurt themselves. So I really proactively ask people to strategize around firearm ownership. If you’re worried about someone and they own a firearm, this may be a time to talk to them about temporary offsite storage or at least making sure it’s secured under lock that they can’t access. Even if it’s just temporarily. Those steps can make a big difference, making sure they don’t have access to medication, for example, just putting some time and distance and helping them make their environment safe is another strategy while you’re trying to get some help for the person.
Gabe Howard: What message do you have for people who have lost someone to suicide?
Dr. Doreen Marshall: Losing someone to suicide is a very difficult experience and the grief that comes with it can feel different from other losses that we may have experienced. So I’d want those people to know that they’re not alone, that many of us that work in suicide prevention have been impacted in this way. Part of why I started my career in suicide prevention was I lost someone in my personal life to suicide. And getting connected to a community of other loss survivors can be helpful. And we do events and also programing for those that have been impacted by a suicide death to help them understand that they’re not alone and that there is a community out there to support them. Many communities have local support groups. And I would just encourage, if you’ve experienced a suicide death in your life, to not be afraid to reach out, no matter how long it’s been since that happened.
Gabe Howard: Before you go, can you tell our listeners about the American Foundation for Suicide Prevention and how to find you online?
Dr. Doreen Marshall: And I’m so thrilled to be on this episode, because I enjoy talking about what we do and the American Foundation for Suicide Prevention is an organization that has chapters in all 50 states. And many of those chapters are made up of people who have been impacted by suicide in some way. They either maybe struggled themselves. They’ve had a family member who has struggled or maybe they’ve lost someone in their life to suicide. And our chapters are volunteer driven. You can reach out to any one of our chapters. You can find them just by going to our website, going to AFSP.org/chapters and connect with them, because what you’ll find is a group of people who get it, who are talking about mental health and or who are really trying to do something to make a difference. And so much of the work we do is community based. Right now, a lot of our training is virtual and online. So if you want to learn more, you can just sign up for free virtual training and learn more about mental health and about the work of AFSP.
Gabe Howard: And that website, again, is AFSPA.org.
Dr. Doreen Marshall: Correct.
Gabe Howard: Thank you so much, Dr. Marshall, for being here and thank you to the American Foundation for Suicide Prevention for all that they’re doing to prevent suicide in our communities. Listen up everybody, wherever you downloaded this podcast, please subscribe and please rank and review. Use your words and tell other people why they should listen as well and share us on social media. My name is Gabe Howard and I am the author of Mental Illnesses Is an Asshole and Other Observations, which you can get on amazon.com. You can also head over to my website, gabehoward.com and get a signed copy for less money, and hey, I’ll throw in some swag. We’ll see everybody next week.
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