Humans are so powerfully wired for survival that it can be hard to understand suicide – especially in adolescents. What happens in the brain that can override such a profound instinct for self-preservation?
Dr. Sakina Rizvi, a researcher and psychotherapist in Toronto, Canada specializing in suicide prevention, reveals the social, biological, and psychological facets of suicidal ideation.
Hear how childhood trauma, current life stressors, and brain impairment may all play a role in suicide, and learn how to recognize warning signs in a loved one.
Plus… the do’s and don’ts of talking to someone at risk.
Phil Stieg: Today, we are joined by Dr. Sakeena Rizvi, a scientist and psychotherapist at St. Michael’s Hospital and an associate professor of psychiatry at the University of Toronto. Dr. Rizvi’s research delves into the neurobiology of suicide risk and treatment-resistant depression. Beyond her scientific work, she is deeply involved in community-based suicide prevention and mental health education. Today, she will help us to understand the brain science behind the difficult topic of suicide. Dr. Rizvi, welcome to the show, and thank you for being with us today.
Sakina Rizvi: Thank you so much. I’m so happy to be here.
Phil Stieg: Can you describe how complex suicide can be – the biology of it, the psychology of it, and the social component of it?
Sakina Rizvi: Suicide is something that’s so complex. It’s very multifaceted. It’s not just one thing that’s contributing to it. It’s not just the biology. It’s not just the systemic factors. It’s not just the psychology. There’s a mix of the three. I think that that’s an important place to start.
Language is really powerful, and I think sometimes we can forget that. When people talk having committed suicide, that comes from back in the day when it actually was illegal. There was a crime that was committed. We’re moving away from that stigma around suicide. When we talk about suicide, we refer to a suicide death, someone died by a suicide. Or when people say there was no successful attempt, we don’t say that. We just say that someone made an attempt. And just moving away from certain types of language around suicide risk.
No one really wants to die by suicide. We have this instinct to survive. With suicide, what ends up happening is that there’s some deep emotional pain that just feels inescapable. It’s about not knowing how to live with that pain.
Then within that, there’s going to be certain biological factors, whether it’s how your brain is activating in certain regions, the different psychology that you have, so the way that you might be thinking, decision making, attention, memory, or social factors like gender can play a role, socioeconomic status, things like that are all going to be playing a role in how that shows up.
Phil Stieg: When you’re thinking about the biological component, the psychological component, the social factors, what are those factors that are key or seem to be important? Characterize each one of those for us.
Sakina Rizvi: When we look at age as a factor, it is the second leading cause of death in youth, which is pretty alarming. However, if you look at overall in the lifespan, it tends to be people who are more in their middle age. But there is pockets where that is increasing in seniors as well, particularly, I think with COVID, it was really, really impactful for seniors. I don’t know what the situation was in the States, but in terms of the long term care homes here, people were really, really isolated. And we’ll talk about isolation as a really key factor, too, because that’s an important one.
When it comes to gender, typically it’s men die by suicide, more likely, and women are more likely to attempt. What that means is that men are using probably more violent methods. That is actually, though, starting to shift. There’s some research that shows that that’s actually starting to shift. You’re starting to get more women who are dying by a suicide.
Life stressors tend to be if there’s something that just happened, like a breakup or a divorce, if you just lost your job. Certain life stressors can create a space for these things to show up even more. But that social isolation piece, I feel like we need to spend a little bit of time on that because that’s a really big piece.
When we think about how suicidal ideation arises, according to some of the theories that we have out now. Social isolation, not feeling like you belong, feeling like you’re a burden on other people, are what creates the desire to die by suicide. It’s not enough to actually go on to make a suicide attempt, but that is a key piece in inciting those thoughts. You can just imagine how COVID was a terrible situation for people on that front because people were very, very isolated.
Phil Stieg: Did suicide go up during COVID? The incidence of it?
Sakina Rizvi: In some areas, it did. I still think that the jury is out on that. So even looking at this, even from our Canadian data set, if you look even just in our province, we didn’t see an increase in suicide. But what we did see an increase in, was accidental death by drug toxicity. So if you’re a coroner, I don’t know how you make that distinction because I do volunteer grief counseling for people who are bereaved by suicide. I remember treating this couple who’s son had died from an overdose. They don’t know if it was a suicide or not. So I don’t know if it’s the case that what we’re seeing is that there was actually a displacement where actually the suicide deaths are actually being represented in drug overdoses.
Phil Stieg: A lot of people worry, is the tendency towards suicide genetic. Is it suicide that’s genetic, or is it more the genetic component seen with behavioral disorders, schizophrenia, different psychological challenges that an individual might have.
Sakina Rizvi: This is such a curious thing because there is a heritability. You do see things run in family, but you can’t inherit a behavior. It doesn’t really make sense. You can’t inherit. What you’re inheriting maybe is some of the predispositions to other aspects of suicide risk that might make it more likely that someone has that predisposition.
Phil Stieg: I was also fascinated by how much you state pain plays a role in suicide attempts. You also break it down into physical pain and also psychological pain. Can you characterize that for us more fully?
Sakina Rizvi: Going back to what suicide is, with the clients that I work with, we’re thinking about, where are your suicidal thoughts coming from? Tell me about what that pain is, because suicide is not a feeling. You have suicidal thoughts, you have suicidal behaviors. So tell me, what’s the feeling that’s actually triggering these thoughts and behaviors?
It’s going to be different for different people. For some people, it’s this sense of abandonment or certain feelings of anger, but there’s certain feelings that tend to pop up that are like, “You know what? This feels really overwhelming and intolerable for me.”
So that’s where, in terms of treatment, what we really want to target, we want to target those underlying feelings that really feel intolerable. The ability to endure those intense feelings is going to be really challenging. Psychological pain is actually a better predictor of suicide risk than things like depression or anxiety.
The majority of people with depression, are not going to actually attempt suicide. Maybe 20% will. Now of that 20%, maybe 3 to 4% will actually die by suicide. So what is different about that 20%? How do we characterize this group of people?
So one way, in the theory, is call capability for suicide. And that reflects being able to have a low fear of death by suicide, as well as a higher pain tolerance, which makes sense because you need these things in order to override that instinct to survive. We work with a lot of people who have childhood trauma, and that’s a big trigger for that high pain tolerance.
Phil Stieg: I would think not only that, but also the social factors from the childhood trauma would play into the ideation.
Sakina Rizvi: Yes, it does. Because if you have this certain experience of the world at such a young age. I often tell my clients that it’s the ultimate unfairness, that at the time of life when your brain is consolidating and sorting itself out and you’re getting these neural connections solidified, it’s the time in life you have the least control over your life. It’s really unfair.
Phil Stieg: When you’re dealing with a client, can you tell? You look at them – because what I’m thinking is, how can the listeners say, that’s a person that I need to be worried about? Short of, obviously, if you ask them a question, have you had suicide ideation? And they say yes, and they’ve planned it out. That’s clearly a warning sign. But are there other things that you just, boom, you know.
Sakina Rizvi: This is the biggest challenge, I would say with suicide assessment risk, is that when I mention that 20% who are actually going to go on to make an attempt, it’s very difficult to figure out who those people are. It’s very, very challenging.
That’s why we’re trying to do the biological research and the psychological research, to try to characterize this 20% and make it easier for clinicians to say, “You know what? I think it’s you.” So as part of the research that I’m doing is to look at that physical pain response to see, can we use that clinically? Well, can we actually translate that into a clinical tool that would be useful for clinicians.
Phil Stieg: I’m glad you brought it up because this is where I wanted to go with this next is the neurobiological basis of suicide. Now, I don’t want this to end up being a deep conversation. But like you said, there’s hope in that arena.
Sakina Rizvi: Yeah, it’s an exciting time for neuroscience in suicide research, I would say, because it’s still quite emerging. There has been advances in terms of we know that things like serotonin, which is important for mood, is going to be impacted in suicide risk.
When it comes to brain areas, we see that areas that are important for emotion regulation, areas that are important for decision making, that front of the brain that’s really important for controlling our behavior, paying attention to things, and experiencing rewarding things in our environment, learning that there’s a reward in your environment, learning that something was positive, oh, actually, I enjoyed that. All of that can be impaired with suicide risk.
Phil Stieg: What about the fight and flight part of the brain? Do individuals that tend towards suicide, is that a more active region in their brain? Do they get more startled, and are they more frightened?
Sakina Rizvi: I would say some people, probably for sure. That’s definitely going to play a role in people who’ve had child trauma, because they’ve grown up in an environment of high stress and high threat. So their nervous system has learned to be in overdrive. It’s not necessarily going to be the case, I think, with everybody, though, in terms of that startle response or the anxiety.
Phil Stieg: Let’s focus on the social component of it. You referred to it earlier about social isolation. I think it’s obvious, but can you state the obvious about how isolation plays into attempts at suicide, but also the community-based strategies that you’re using to effectively reduce the risk?
Sakina Rizvi: I think that as humans, it doesn’t matter if you’re an introvert or if you’re an extrovert, you’re a social animal. You just socialize differently. You still have those needs.
When we are not in connection with another, our brains aren’t evolved for that, actually. We’re evolved to exist together. When we are isolated, it has a pretty dramatic impact on the brain and how we behave, how we see the world. It happens pretty quickly. If you think of instances of, say, solitary confinement, it happens pretty quickly in terms of how it impacts people pretty severely. We really need to be in connection with each other.
Community is such an important suicide prevention strategy. It’s really about getting people more social, getting people connected. Just that can have an impact. So we don’t necessarily have to think about the most complicated treatment. It starts with connection.
Interstitial theme music
Narrator: A suicide prevention telephone hotline seems to make sense. Intervening at the right time, with compassionate listening and usable coping strategies, is now considered one of the most effective tools in preventing suicide. It wasn’t that long ago that lonely, isolated people struggling with thoughts of suicide had no place to find that sympathetic ear. That is, until 1962.
That was the year that Bernard Mayes, a British born Episcopal priest, established the San Francisco Suicide Prevention Hotline – the first of its kind anywhere in the country.
Motivated by the memory of a beloved teacher who had died by suicide, Mayes was alarmed by the high rate of suicide in the Bay area. He realized that what was really needed was a compassionate ear, someone to talk to. He proposed a service that would offer unconditional listening, and that he would be this anonymous ear.
Renting office space for this new service was more challenging than he expected. Many potential landlords across the city turned him down.
He would say “I’m looking for a room where I’m going to start a service where we talk to people who might be considering suicide. I’m a priest, and I’m going to talk to them.’ Finally one sympathetic landlord responded by saying ‘You mean like this?’ and rolled up his sleeves to reveal slash marks across both wrists.”
Mayes got the space at half price.
Fliers were handed out around the city, and ads were posted on the sides of city busses that read “thinking of ending it all? Call “Bruce” (the pseudonym that Mayes adopted as the hotline’s only volunteer). That first night the San Francisco Suicide Prevention got just one call. By the end of the first week it had gotten ten.
Within a few years the program had grown to fielding hundreds of calls a week.
Conscious of the dangers of compassion fatigue and burnout, Mayes stepped away from the program after 10 years, moving on to a pioneering career as a gay rights activist and becoming a founding executive in the National Public Radio System. But his lasting legacy after more than half a century will always be the team of “compassionate listeners” who continue to save lives every day – now partnering with the nationwide network that can be reached with a short easy to remember number – 988.
If you or a loved one are experiencing suicidal thoughts, help is always available – dial 988 – the national suicide prevention hotline that has grown from a single priest in a rented room into a network that fields more than 5 million calls a year.
Interstitial closing music.
Phil Stieg: So you’re talking with a friend or a family member, and they specifically start talking about their ideas regarding suicide, what are you recommending to the listeners that they should do – or don’t do?
Sakina Rizvi: If you have a loved one that has suicide risks or having suicidal thoughts, how do you know what to do? So often people can feel cut off at the knees with not knowing how to manage that. When I do some public talks, I talk about do’s and don’ts of how to deal with suicide risk. For one person, she raised her hand, she’s like, “Oh, my gosh, all the things on your don’t list would have been the things I would have thought to do.”
I’m going to use an analogy here. If someone comes to you with a broken leg and like, “Oh, I’m in pain. I’ve got this broken leg.” And you’re like, Oh, so do you want to go shopping? How can we make this feel better for you? You want to watch a movie? That’s not what they’re asking for.
They’re basically like, I’m in pain right now. Can you acknowledge this? Please acknowledge. It’s asking for attention.
There’s two steps here. One is recognize that you’re scared, understandably, that’s allowed. And you can also try to stay present with the fact that they’re trying to tell you that they’re in a lot of pain. And just validate it. Listen to it. You’d be surprised how much this helps to just say, “Wow, it sounds like you’re in a lot of pain. Tell me more.” I cannot even tell you how important that intervention is.
Phil Stieg: Can you give us examples of the “do’s” that should be “don’ts”
Sakina Rizvi: Do you want examples off the don’s or the dos or both?
Phil Stieg: Both.
Sakina Rizvi: So some of those don’ts would be things like, “you’ve got so much to live for. This is going to hurt your family.” Things like that you don’t want to do. You don’t want to lecture on the value of life. It’s so important. You’ve got a whole future ahead of you. It’s not going to land at all. That person is going to feel very, very isolated. And that’s the something that people often do. So these are some of those don’ts that became dos in someone’s life.
Don’t promise confidentiality because you can’t guarantee that. So if someone says they’re in imminent danger of harming themselves, you cannot keep that to yourself. You can’t. Getting into problem fixing doesn’t work as well because this is the more complicated scenario. So that’s not something that you can actually fix. It’s something that’s going to take more time to break down and support someone. And also, don’t blame yourself, right? So I think especially, it’s especially important for families where there’s a loved one. I work with a lot of families, and there can be a lot of like, what should I do? There’s something that I did. So trying to avoid that space, too.
So, the things that you’re looking for, so certain warning signs, where people are not feeling like they’re hopeful anymore. They’re starting to withdraw socially. They have access to means. So one of the best suicide prevention strategies is getting rid of means. When I’m working with clients, we always have different strategies, and sometimes very creative strategies for getting rid of access to means.
Phil Stieg: What specifically are you talking about there? Taking away the object that could result in a death?
Sakina Rizvi: Absolutely. Yeah. That’s really as simple as it is. It’s like whatever that person’s method happens to be. I had one client, without naming the method, she was someone who actually had a disability, so she had difficulty reaching. We’re like, Okay, can we get your friend to put this method up on your shelf? When she’s in that moment and she’s feeling really distraught, she can’t get to it.
The thing is, again, is that we’re trying to buy time because when you’re in that midst of that suicidal crisis, when your frontal cortex is offline, it’s difficult to process information. It’s difficult to process information. We’re just trying to buy some time for that to come down, because it does. We’re basically just trying to buy time for someone’s nervous system and brain response to calm down so they can actually make an informed decision about what they want to do or don’t do.
Phil Stieg: My feeling is if you take away the guns, then they’re just going to start hanging themselves.
Sakina Rizvi: What’s interesting is there’s some research that if you get rid of access to, say, a bridge, they actually don’t necessarily go to another one. That’s why we’re saying that means restriction is actually a really important suicide prevention strategy. Just get rid of it.
Phil Stieg: I see. If you get rid of the bridge, they’re not going to commit suicide.
Sakina Rizvi: Well, they’re not going to do it on that bridge.
Phil Stieg: Yeah. But I mean, so what I’m saying is, are they going to find some other means?
Sakina Rizvi: I think that there has been decreases in suicide deaths after certain means restriction. I think it does actually help to save lives.
Phil Stieg: So earlier you stated that childhood and adolescent suicide is now the second most common cause for death. For the parents that are listening, and for that matter, for the adolescents that are listening, what preventive measures can we take to try to reduce this? I guess an ancillary question is, how much is social media playing a part in all of this?
Sakina Rizvi: Those are big questions, Phil. I have a complicated relationship with social media just because I think it can be used for so much good. But I don’t see any research that suggests that it’s actually doing that. It actually can be quite harmful especially in girls.
I think it’s a big challenge here where I think that there’s a lot of things that are playing into this in youth. I’m really glad that we have a generation that’s more willing to talk about their mental health. My challenge has been, okay, as a therapist, if we’re going to talk about your mental health challenges, we’re going to develop some coping strategies first to have those conversations. That’s not happening in parallel.
So what ends up happening is you’re talking about your sadness and your deep anxiety, and you’re going into it and you’re feeling it, your nervous system is getting activated, but how do you soothe it? Do you know what I mean? You’re not developing the coping strategy at the same time to actually manage that.
Before I even go into someone’s trauma, we’re working on coping strategies so that we can actually have those conversations. I think that’s my worry around adolescents, and I think that we do see an increase in depression. We’re seeing an increase in anxiety.
It’s difficult to say how social media is playing a role as a key factor in this, but I do I think that there is a role here overall in coming back to that idea of community.
Phil Stieg: This brings me back to the question I asked earlier is, how do you, in your profession, how do I just sit and talking with a friend, pick up on that individual, that isolation is a bad sign for that individual? Is there just a sign that we need to be more sensitive about so we can pick up on this and help our fellow person?
Sakina Rizvi: Yeah. I think that if we’re around each other, we learn how to be attuned to each other. So as a couples therapists, I try to teach couples, how do you become attuned to each other?
70% of our communication is nonverbal. You have to say nothing. I just know. Especially couples who’ve known each other for a long time, they know the slightest hint that something is wrong. Being able to be attuned to, if you have a friend, are they behaving in certain ways that are different? Look for what’s different is, I think, the key thing to explore.
Phil Stieg: There has to be a willingness to talk about it then. You can’t just observe it. Which takes me to the next question then. What are the intervention strategies? What do you recommend?
Sakina Rizvi: Typically the way suicide has been treated is you treat the depression, you treat the anxiety, and then the suicide risk goes away. Well, we know that that’s not true. It might be true for some people, but it’s not true all the time. We really do need targeted suicide interventions where this is what we’re working with. I’m not working with your depression. I’m working with your suicide risk.
What we’re trying to do is help people understand where your suicide risk is coming from. First, we need to create that story around your suicide risk so it’s not this amorphous bubble. It’s just this one big feeling.
Let’s break this down. What’s the pain? Where does it start? How does it fluctuate in duration and intensity during the day, during the things that you’re interacting with? Then let’s start to build some skill set so you can recognize when that ideation is starting to escalate. Because when you get to a certain point and your frontal cortex is offline — any of us in distress, our frontal cortex just goes on vacation — see you later. I’m going to survival mode.
When you’re in survival mode, it’s very difficult to process information.
Phil Stieg: It sounds a little bit to me like the therapy that is being used for post-traumatic stress disorder. It’s confrontation of the issue, just putting it on the table and having an open, hopefully rational, conversation about what it is and then moving on from there. Is that a good summary?
Sakina Rizvi: I think that you have to understand how this is presenting in your life. To have suicidal thoughts is very distressing. If someone’s holding that and they’re not talking about that specific thing, what’s that doing to you? How do you manage that? How do you work with that? How does it show up in your life? Because it’s showing up some way.
Phil Stieg: So is it a sense that, number one, they recognize it, the light bulb moment, but also, is it the sense of forgiveness? Like, oh, my God, I’m not responsible for this?
Sakina Rizvi: Yeah. I love that you use the word forgiveness. Compassion, right? That self-compassion that like, oh, okay. This isn’t just something that’s wrong with me. I would say that suicidal thoughts in and of themselves are not…They’re distressing, but they’re not bad, right? It’s like any other symptom. It’s basically when I talk about feelings to people, to clients, particularly clients who don’t like to feel feelings, it’s like, emotions are really just your brain telling you, please pay attention to something in my environment. Something’s wrong. Just look at it.
The suicidal thought is doing the same thing. It’s saying, please check something in my environment. Something doesn’t feel right.
Phil Stieg: It’s exceedingly important at this time in the conversation to say, okay, this is a huge problem throughout the world. Give me a couple resources where the listeners could go to learn more about this subject.
Sakina Rizvi: Yeah. American Foundation for Suicide Prevention is a great resource. If you want education, if you’re looking for local programming in your respective cities, because suicide intervention program will vary quite a bit. That’s a great resource. Canadian Association for Suicide Prevention, Beyond Blue, which is a website that’s based in Australia. Those are websites that will have a lot more information about suicide risk, what you can do if you’re a caregiver, what you can do if you’re experiencing it yourself, and give people a little bit more understanding around that. We’ll also have some links to where you can get support.
Phil Stieg: In one word, can you characterize for me as a person listening to somebody that says, I’m in pain, I hurt, and I’m thinking about this, haven’t specifically come up with a pathway that I’m going to achieve it, but I’m thinking about this. What is the word you would describe that I should apply if I’m in that listening position?
Sakina Rizvi: I would say compassion for yourself and for the person in front of you. Compassion is different from empathy. Because empathy is trying to put yourself in the position that someone…what they’re experiencing. Compassion takes a step back. There’s a line there where it’s like, I’m not in this with you, but I’m hearing what you’re going through. As caregivers, that’s a very important place to inhabit.
If you’re always in an empathic space, it can be very, very draining. You might take on more. You might take on the responsibility of what they’re feeling. I would say compassion for yourself, because it’s scary to have these conversations. So if you’re activated, I get it. And also, compassion for the other, that they’re also in this pain and you’re trying to help them understand that there’s someone out there who cares and who wants to listen to them and hear their story.
Phil Stieg: Dr. Sakeena Rizvi, thank you so much for spending this time with us, going through the biological, psychological, and social factors involved with suicidal ideation. I think it’s really important for us to understand the complexity of the issue, but also the hopefulness of how we can be helpful to a friend or family member that might be having these issues. So thank you for being with us and taking the time.
Sakina Rizvi: Thank you so much. It’s just such an important conversation. So I’m so happy that we’re having it.