How to recognize the risks for suicide, with Wendy G. Lichtenthal, PhD, FT

A breast cancer diagnosis is a major disruption to your life, and it’s common to have feelings of sadness or to feel overwhelmed at times. But for some people, these feelings persist or grow more intense, making it difficult to function in day-to-day life.

Talking about mental health, emotional health, and suicidal thoughts can be difficult, but the best hope for finding help is to connect with others and find support. As hard as that may feel, it is possible. As the COVID-19 pandemic continues to affect the way we interact, it is more difficult, but also more important, to stay connected with people, especially those who may be going through a difficult time.

Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke to Wendy G. Lichtenthal, PhD, FT, about warning signs that someone may be experiencing depression or having suicidal thoughts. They discuss some of the ways to reach out to someone who may be in distress and resources available.

If you are feeling hopeless and helpless and think you are in danger of hurting yourself, please contact the National Suicide Prevention Lifeline at (800) 273-8255. This hotline provides free and confidential emotional support 24 hours a day, 7 days a week. Reasons we encourage you to call are that you:

• Have thoughts of wanting to hurt or kill yourself
• Are looking for ways to kill yourself

Also call if you have these symptoms that lead some people to want to end their lives and increase the risk for suicide:

• You feel hopeless, can’t control your anger, or feel as if there is no way out.
• You are doing more risky things.
• You are using alcohol or drugs more often and too much.
• You have extreme mood changes.
• You tend to isolate yourself from friends and loved ones.
• You lose your sense of purpose in life.

Resources discussed in this episode:

• National Suicide Prevention Lifeline: (800) 273-8255
• COVID Cancer Care, by Blue Note Theraputics
• American Foundation for Suicide Prevention
• National Association on Mental Illness
• IMAlive
• Crisis Text Line
• Stop It Now! List of crisis hotlines
• Look for local resources, such as NYC Well in New York

Wendy G. Lichtenthal, PhD, FT

Wendy G. Lichtenthal, PhD, FT is an associate attending psychologist and director of the bereavement clinic in the department of psychiatry and behavioral sciences at Memorial Sloan Kettering Cancer Center and assistant professor of psychology in psychiatry at Weill Cornell Medicine. Read more.

 

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

Jean Sachs (00:00):

Hi, everyone. It is Jean Sachs. I'm the CEO of Living Beyond Breast Cancer. And today we're talking about an issue that is really difficult to talk about, but we know really needs to be discussed, and that is the possible signs and risks for suicide.

Suicide is among the top 10 causes of death in the United States, and there is an incredible stigma around it. And I think a lot of it is because people are afraid and they just don't understand. So today, in honor of Suicide Prevention Month, we are going to have a very open discussion and break down some of the stigma and hopefully really help people in our community that may be suffering.

For anyone watching today who might want to reach out and talk to someone directly right away, I want to let you know that I have this number, which is 1-800-273-8255. And that is the National Suicide Prevention Lifeline. You'll also see it on the screen. But if anyone needs help immediately, please consider calling that number.

For now I'm excited to introduce Dr. Wendy Lichtenthal. She's a psychologist at Memorial Sloan Kettering with a clinical expertise in counseling patients with breast cancer. Welcome!

Wendy Lichtenthal (01:25):

Thank you so much for having me.

Jean Sachs (01:27):

We really appreciate you being with us this morning and anyone who would like to read Dr. Lichtenthal’s full bio, just go to LBBC.ORG, and you can learn more.

We're going to jump right in because we do have a fair number of questions. The first one is: When you're thinking about suicide risk, what are some of the issues that might make a person at higher risk for suicidal thinking, or actual attempts?

Wendy Lichtenthal (01:56):

Sure. There are a number of risk factors that have been well established in the general population. So we'll speak about the general population first and those include having a mental health challenges — particularly depression — having a family history of suicide, previous suicide attempts are a predictor, a history of substance abuse, alcohol abuse, or anything that might increase impulsivity on acting on something. Uncontrolled pain is another one that's really important, and physical illness, which I think is what we're here today to talk about.

Those are among, among the many, many risk factors, but those are some important ones that people keep in mind.

I do want to mention one more. I apologize, which is isolation, and that's a big one. I'm sure we're going to talk more about that today, particularly in the context of, of COVID, but that that's a big one and something we're really mindful of right now

Jean Sachs (02:55):

Yeah. And that's a good point and it's really great to have some things for people to think about. Let's talk specifically about someone who has been diagnosed with breast cancer. Is their risk different for suicide or anything specific you want to call out?

Wendy Lichtenthal (03:12):

Sure. That's a great question. I think when we think about cancer in general, there is a literature pointing to an elevated risk for suicide, but the literature on breast cancer specifically is a little more mixed. There does appear to be of some literature pointing to an elevated rate. One study in 2006 found that breast cancer patients were 37 percent more likely to [die by suicide] then a general population of women — 37 percent more at risk, but again, a mixed literature.

And there was a really interesting study done in 2011, a Swiss study that said it's really important in these population studies that we do to look at the nuances, to look at the specific cases and what actually led to the suicide. And when they took a look at this, they found that really the contributing factor for a couple of the cases where it was really a mental health history that you couldn't point directly to the breast cancer experience itself. For others, it was advanced disease and learning of a poor prognosis that seemed to be connected to it. And then for others, something that's not talked about as much, is physician-assisted suicide.

When you do an epidemiological study and you look at the rates without that information of even something like physician-assisted suicide we're missing some information, so that's important to know.

That being said, I think we want to be mindful of the vulnerable points along the breast cancer trajectory where people should be attentive to the different kinds of psychosocial challenges that patients face. I can say a little bit more about that.

Certainly there's the initial diagnosis. And with that initial diagnosis comes a surge of fear, potentially a threat to one's life, depending on how they take that. That all depends on what they know about cancer, what has happened maybe in their own families, specifically for breast cancer patients, what they've witnessed, what they've seen. So that can be a vulnerable time. However, the literature on that being a more vulnerable time for breast cancer patients is a little more mixed.

Another very difficult time to just be mindful of is, of course, during treatment. But people are often in kind of battle mode. They're just going.

When treatment ends — for those who complete treatment — and they're in that post-treatment phase, a lot of stuff can come up. A lot of existential issues can come up. And I think we want to be mindful of how hard those can be, because there's often somewhere in there, a [a feeling] that someone should be grateful or they should be celebrating. And yet for many women, that's not at all how they feel and they feel shook by the experience.

They feel like perhaps they've gotten that message that life is finite, that there's been a threat and it should be a wakeup call and yet reconfiguring their lives can leave them feeling lost. It can also have them taking stock of the life lived and feeling less than satisfied. So there might be some regrets, things like that. And there's anxiety. There is now: “So I have this message that maybe I want to change some things, but I'm scared and I don't have a roadmap of what my future looks like. I don't know how major of a change I want to make,” and that can leave people feeling paralyzed. Then when they're feeling paralyzed, they feel like, “but I should be living!”

All of that, all of those tensions, can be really challenging and really leave someone ultimately feeling more depressed, more dissatisfied, so we want to be mindful of that. And that stuckness that those in the post-treatment phase can feel. Yeah.

Jean Sachs (07:04):

Thank you for putting the statistic in perspective because 37 percent is an alarming number and really digging into that. And also thank you for acknowledging that once treatment ends I think most people think, “Oh, now you should be happy and celebrating.” But what we see at Living Beyond Breast Cancer is that's often a really, really tough time. And of course the popular media really loves to celebrate breast cancer survivors and everybody's running races and feeling happy. So if you are someone that just doesn't resonate with you, you're definitely not alone.

Let's get into a little bit more. Many people don't know how to recognize suicidal thinking in themselves or others. So what might suicidal ideation look like or feel like to someone who has a cancer diagnosis or to a loved one or a caregiver?

Wendy Lichtenthal (07:57):

Yeah. I think it's important because suicidality and suicidal ideation often does go hand in hand with depression and signs of depression. Some symptoms of depression have a lot of overlap with cancer symptoms and cancer treatment side effects that we just be mindful to disentangle the two or at least recognize their overlap. Fatigue and sleep disturbances, appetite, disturbances, those kinds of physical symptoms that are signs of depression are also side effects that so many women report.

So where we look for signs of depression, which again is such a correlate of suicidal ideation, might be more in thinking patterns and emotional symptoms. Are people sad more days than not? Have they lost interest in things that they're normally interested in? Are they having feelings of guilt or worthlessness?

And then, to your question about the kinds of thoughts that come into one's mind, obviously, sometimes it's explicit. “I don't want to be here anymore. I feel like I want to kill myself.” But sometimes it is more subtle. It can be,

“I feel like I just want to go to bed and not wake up.”

“I wish it would just all end.”

“I don't want to feel this way anymore.”

And that is often connected to thoughts that someone can't handle something and that they won't be able to handle something in the future. The thoughts around “I just can't handle it,” while not directly connected to suicidality, certainly cause us concern. We want people to feel like they'll be able to handle what comes their way.

And hopelessness is another concerning [sign]. Thoughts of hopelessness, that whatever I feel right now is not going to change. “I don't see how it can change. I feel like I've lost meaning in my life. I feel lost. I feel scared. And I can't see beyond this moment.” Those are times where we get concerned as well.

Jean Sachs (09:47):

That is so helpful and again, really concrete, so thank you. So if there is someone in your life that you are concerned about how do you bring it up? How do you lead it? And start the conversation?

Wendy Lichtenthal (09:58):

Sure. Well, I think pointing to what you've seen, the observations. You talked about signs, so “I've heard you talk about saying things like you feel like things aren't going to change.” When you hear those kinds of things, when you're speaking to someone directly calling out what you heard or what you saw to explain where you're coming from is important. But when it comes to asking about it, being direct is often recommended and maintaining a stance of being nonjudgmental, validating. Whatever you come in with, we want to validate to anyone we're speaking with when they're going through something hard that what they're going through is hard. So couching it in validation.

“I know how hard this time is right now. I know, I've seen how much how much you've struggled, and I just want to ask, are you thinking of killing yourself? Has it gotten that bad?”

It's important to be direct because when you really are concerned in that regard, when it's indirect or when someone says something like, “You're not thinking of killing yourself, are you?” that's already couched in some judgment and makes it really hard to say “Yes, well, yes I am.”

We want to make it easy for someone to say yes by validating the circumstance, how hard the circumstances are, maintaining a stance of non-judgment. Not saying “You're not actually thinking of that, are you??” Which would communicate a judgment, maybe perpetuate shame. “I'm really just saying has it felt so hard that you've had those kinds of thoughts?” If you can follow that with, “I hear that's really common” or “I know that happens,” something like that to give the permission to share it. I think that that's even better yet.

Jean Sachs (11:47):

Right. So language is really important. And if you do discover that someone you love or is struggling, how can you encourage them to get help? Or how do you intervene?

Wendy Lichtenthal (12:01):

Communicating that help can be helpful. That professional support actually can work can be a star. Any stories that someone has about their own efforts to get professional support or someone they know explaining that it really can help when it comes to breast cancer specifically, I think a very important piece of this is that we need to continue to build the culture that mental health care, psychosocial care is part of the standard of care that this is hard. I think when we come at this with someone who's going through something as difficult as the breast cancer journey can be, we need to build into it that this is almost normal. It is normal to struggle that this can be part of it. That's why in many institutions and oncology practices, there is a direct pathway to mental health providers.

It's important to know that they're there. I always say to patients who I meet, “We're here because this is that hard.” And so the thoughts that you have about not wanting to feel this way, whatever this way is for you we understand where they're coming from and we want to give you hope that there's a way through it. And we can. For a lot for a lot of people, the coping strategies they've used in the past don't often apply in their breast cancer journey. And we want to kind of say, OK, we got to maybe find some new ways of addressing these kinds of new feelings of anxiety that you never experienced before. How do we equip you and make you feel empowered? And all of that can be communicated by the person, encouraging someone to get help to say this is possible. There's a reason that mental health providers are built into your cancer care, and let's get you someone to talk to. This is really hard.

Jean Sachs (13:50):

Yeah. And that is good to know because all these if you have breast cancer, you are connected to a medical oncologist or a surgeon. So it sounds like you could go talk to them and say, “I really do think I need to talk to someone” and there's a team to support you.

I know you probably know this, but many breast cancer patients are connected online. It's a big way we find community, particularly with the COVID-19 pandemic. If you're connected with someone online, which is different than sitting face-to-face, and you're sensing a real concern about them what are your thoughts about how to support them?

Wendy Lichtenthal (14:32):

Absolutely. I think, as in any friendship or relationship, letting someone know you are there and that they're not alone is huge. I think that is what draws so many people to online communities in breast cancer is feeling less alone in their journey and having someone else who gets it. Having someone who gets it is so important. Communicating that even if you're not someone who you yourself has had suicidal ideation that you get the struggle I think is really important.

“I know how hard this is. I want you to know I'm here. And I wonder, have you spoken to someone?”

Certainly sharing one's own experiences with speaking to professionals can be helpful or someone who giving that hope that this actually could be a pathway to getting help and feeling better is important.

And certainly again, validating the experience and saying this comes up and, and pointing to resources, like even something like this, where they are out there, where there's a naming of it and a de-stigmatizing effort I think is so important. This is, again, I don't want to call it common, but it's understandable to be in this position. And it does happen so much. Certainly the people I see it happens more than people who do present to counseling. This is often what we're talking about. We want to recognize that this happens because the struggle is real.

The other part about the online connections that I think we want to be mindful of, is that so many women are naturally caregivers and they want to take care of each other. So one of the major challenges we often see in self-care being part of what they contend with how to be in the receiving role of health. I think for the person receiving, sometimes it can be difficult to receive that kind of support for the person who's offering the support.

We want to be mindful of the limits of online connections. There's a sense of responsibility that someone might feel that might be disproportionate to what they can actually do because they don't know even know where that person lives. If there was an emergency they don't have contact with people in their world. But helping them, what you could do is help someone connect to other people in the world. Have you told your family member about what you're thinking? I wonder if that would be helpful just to get it out and so that they know, and they can help support you.”

So encouraging connections beyond that online community is important. We have to realize that sometimes there are things we can't control and can't do for the people we care about. I think that's one of the challenges of an online relationship where there are these limits and parameters that challenge how much someone can do. Even as mental health providers, there's sometimes only so much we can do. We don't want someone leaving a relationship where someone is struggling or in the event they even do complete suicide that the online supporter feels like they should have done something else, that they missed something or that the responsibility or the onus was on them. So that I think is just an important caveat to put in there. But there is a lot of support. We're going to talk about resources and you want to just normalize it and advocate for getting help. This should be a standard of cancer care and the cancer journey.

Jean Sachs (18:07):

Yeah. So as the final question, I'll just combine the last two, which is we would love any resources. Obviously Living Beyond Breast Cancer can be a resource, but there are others. And then also, because everyone is more isolated now, and you can't sort of do everything that might sort of feed you and rejuvenate you. if you have some tips for what people can do when they're starting to feel depressed or sad and they can't kind of do what is more natural to them?

Wendy Lichtenthal (18:40):

Absolutely, so I want to advocate for the hotlines that are out there, because one of the things that we I talked less about today is also this feeling that people don't want to burden one another. That's another risk factor when people feel like they're burdening others. That also stops people sometimes from reaching out or telling someone who cares about them, that they're struggling. While we want to build up capacity to share it with those in your life, we also want to recognize that sometimes that's not possible or sometimes something hits in the middle of the night and there are these hotlines.

There's the National Suicide Prevention Lifeline as a resource. And there are lots of great resources the American Foundation for Suicide Prevention, the National Alliance on Mental Illness, NAMI, all of these organizations offer mental health support.

There are also sometimesin certain areas, local hotlines that, that people can look up where there's 24/7 support in New York City, for example, there's NYC Well. You should look in your area for local provisions for 24/7 crisis management hotlines. Again, in those moments where those darker thoughts are happening, to remind you that these are transient thoughts, they pass. That this moment passes and to help someone locate more support to build up their coping strengths. So I think that's important.

And we recognize right now that all the rules have changed what we often advocate for and what we help those who have gone through breast cancer do, is to connect to what matters most to them, to coexist with the struggle that they have, whether it's anxiety or treatment side effects.

We want them living meaningfully and engaging in life. And COVID-19, and the pandemic has changed the way we do this, and it has limited it. And of course, for those who are maybe immunocompromised, what they feel comfortable doing, even as sometimes people are kind of phasing more into life, they don't feel comfortable doing that, and they're higher risk. So the challenges continue and we're now in a marathon mode. We want to really be creative in thinking about how to stay connected. That connectivity to others is huge. Make scheduling times with friends and family. I spoke to someone the other day who had literally made a spreadsheet and tracked them — this is one way of doing it — but track when the last time they reached out to someone was because they were having trouble remembering, and it just put, a list there, something for them to make the outreach.

Often we know that patients are disappointed when others aren't checking in on them and reaching out. We don't want that to be a barrier to connection. We understand that it stinks when people are disappointing but reaching out and building your network is important. I think we want to compassionately understand when people are disappointing you by not reaching out, but also be your own self advocate and connect to others in any way you can: video call socially distant visits or walks. Things like that that do feel comfortable and safe.

And taking advantage of the virtual world that has been built. There are so many lectures and classes and so on. We always say that while you cannot control what happens to you, you can choose how you respond and choosing to take this moment, this bizarre moment in time right now, and choosing to use it to build in more self-care practices that you've haven't been able to do, to take time that was otherwise spent in the out world and turn it, get into good health lifestyle practices and things like that can be great. Learning to cook things and new healthy recipes, fitness routines.

I'll say one more thing about that. If you don't do any of that, that's okay too. Because there has been this culture of “Let's use this time. I should be using this time. This should be a time that I'm getting into these lifestyle practices and new habits.” And yet there's a pandemic going on, so it's not easy. While we can remind ourselves that we can take control, we also have to remember that this is a very, very challenging time, offer ourselves that self-compassion offer that to the community you have and validate how challenging this is.

Jean Sachs (23:07):

Wow. That was a lot. Thank you so much. I have some new tips. I think your idea of keeping a list or a spreadsheet. I realized if I don't reach out to people, like it can be suddenly months that we haven't connected because there weren't the natural ways that we were seeing each other, so that is really great.

This has been a really informative discussion, and we so appreciate your time for joining us and, and sharing your expertise with our community. I just want to remind everyone that this national helpline, which is the National Suicide Prevention Lifeline, which is 800-273-8255. We'll also make sure it's posted on our website.

Thank you so much Dr. Lilienthal for joining us and for all you're doing to help the cancer community.

Wendy Lichtenthal (24:00):

Thank you for offering a platform and recognizing and giving one more chance to reduce the shame and the challenges that patients face. Thank you.

Jean Sachs (24:09):

Absolutely. So I want to wish everybody well, stay healthy, stay strong, and take care of yourselves.