The Neuroscience of Suicidal Ideation: Why the Brain Can't See a Way Out

[00:00:00] What's going on in somebody's brain when they get to the point where they've actually decided to kill themselves? And what can we do to intervene along the way and keep them from getting to that catastrophic point? Last week, we spoke to Zach, a Marine Corps veteran who tried to take his own life after getting out of service and has done some incredible things after that thankfully failed attempt. You should all really go check out that story.

[00:00:22] But today, we're going to be looking at it from a more clinical point of view. What's actually going on inside the brain? Where do these suicidal ideations and thoughts come from? And what effective interventions might there be that folks in a veteran's community can provide to keep them from getting to that catastrophic place? We will be speaking to Lindsey from the Wounded Warrior Project who is a suicide prevention manager.

[00:00:47] Now, if you or somebody you know is in crisis, please reach out to the National Suicide and Crisis Hotline at 988. Thank you for joining us for this very important, if not very pleasant series of content. With that, let's get to Lindsey. All right, Lindsey, welcome to the podcast. How are you doing today? Lindsey I am. Fantastic. Thanks for having me. Pleasure. For folks who aren't familiar with you and what you do, could you please introduce yourself in your own words for the audience?

[00:01:14] Yeah, sure. So my name is Lindsey. I am the suicide prevention manager at Wounded Warrior Project. And we have a pretty audacious goal to end veteran suicide. And so my team is really supporting the organizational's efforts to do that through building suicide safer communities, offering training, building connections and partnerships in our communities and all that. So, yeah.

[00:01:41] Cool. So what is a suicide safer community? Yeah, I love that question. Is there bubble wrap on everything? Like, what is this? Well, the idea, right, is that people are safer from suicide in those communities because we're talking openly about it. There's less stigma, there's less barriers to care. And so, you know, what we know is that suicide doesn't discriminate. It doesn't have a face. Anybody at any given time can be at risk. And so we want everybody in the community to know that there are people who care about you and resources available.

[00:02:10] And we can't do that if we're not talking about it. Gotcha. Now, suicide's, you know, tragedy in a lot of different, well, really in every way, but impacts all sorts of segments of society. There's this very famous, you know, 22 a day veterans campaign that's been going on for forever and a day on social media. But what's actually going on in somebody's head when they get to the point where they decide to check out a life?

[00:02:34] Yeah. You know, I think it's a really important question because what we know is that people aren't necessarily seeking death, right? More often than not, they're seeking relief from an overwhelming amount of pain that is happening in their lives. And so we're learning from neuroscience that there are disruptions that are happening in a lot of different brain areas.

[00:02:55] So those systems that are responsible for things like managing our emotions and decision making and impulse control or problem solving sort of go offline in the way that they're intended to. And so the brain really shifts into this kind of threat based survival mode and it becomes this sort of all encompassing chaos where the brain becomes overwhelmed by that pain.

[00:03:21] Right. Studies show that parts of the brain involved in those things like the prefrontal cortex and the amygdala are changed in how they're working. So the amygdala is saying danger, danger, danger. And the prefrontal cortex is kind of going offline. It's becoming less active. And so when that happens, it can be really hard to manage strong feelings or manage that pain that we're experiencing.

[00:03:45] And so it can start to feel so intense that it actually becomes physical in the brain's perception of it. And people are really just desperately looking for a way to end that pain. So, you know, suicide is commonly understood as, you know, either to put it somewhat disparagingly, a weak-willed person checking out a life or someone who's been exposed to just tremendous trauma and tragedy.

[00:04:14] You know, someone post miscarriage or, you know, stillbirth or a veteran coming home from war after an IED strike, you know, insert terrible tragedy here, whatever you're most afraid of. And it's overwhelming and they check out. But how much of this, I guess, is a poor response to trauma? And how much is this a cascading effect of someone's brain not working right? Is it an event or is it a breakdown in the brain that primarily drives this?

[00:04:41] Yeah, it's really a breakdown in the brain, right? Because what we also know to be true, I think it's easy to assume it's that trauma or those bad experiences. But what we often see or hear anecdotally, right, is the people who say, gosh, I never saw this coming, right? This person was, had just gotten a promotion, had just gotten married, had just had a baby, all these things that we typically attribute to being really positive. But in the end, there is some form of loss and pain that come with those. And those might not be as obvious, right?

[00:05:09] But when we think of, okay, what am I losing? Or, you know, where's the pain when I get married? It's like, okay, I now have this other person I'm considerate of and making decisions with. And it's not just kind of all about me. And so the brain is trying to figure out ways to just manage those pieces. And so, yeah, I think historically that has been, especially in the military community, right, where we think of being strong, resilient, mission-focused people, it's that stigma has unfortunately been that you're just weak.

[00:05:37] But again, there are structural and chemical differences even that are happening in a person's brain when they shift into kind of a suicide crisis, where we're seeing all kinds of hormones dump into that system and overriding it, essentially. Yeah. So, you know, as a junior officer in the infantry, you know, 23 years old and responsible for other human beings, which is a very interesting position to find yourself in. Very common in the military, very interesting in society. Sure. We, I know my battalion at the time, had a massive spike in suicidal ideations.

[00:06:08] It was very interesting to experience firsthand. But there was, we were, you know, educated, quote unquote, about the difference between suicidal ideation and suicidal attempt as we're filling out paperwork involving incidents because it's the military that they have to have paperwork for these things.

[00:06:24] But what happens in this time and space between someone has a suicidal ideation, which I think is them thinking I might try to kill myself at some point or that might be a better alternative to living versus actually going through with a plan? What happens between those two? Yeah. And we typically think of suicide as kind of a gradient, right? Where to your point, some people are maybe more passively thinking about suicide.

[00:06:50] And that's where we might find people in a place of just feeling hopeless or helpless and kind of moving into the thought process. Gosh, if like I went to sleep tonight and didn't wake up, maybe it wouldn't be the worst thing. We see that, right, if not addressed, that can move into progressively more active or intrusive thoughts of suicide, where we might start seeing people think about plans.

[00:07:11] But an interesting question in kind of the world of suicide science, if you will, is why not only why do people think about suicide, but what increases the likelihood that they'll actually act on those thoughts, right? And I think that's kind of what you're getting to. And we know that that progression can typically happen because, again, of a convergence of a number of things. So, again, emotional pain increases. Hope for change or improvement or betterment in my situation decreases.

[00:07:40] And then thinking becomes much more rigid or less flexible. So we talk about that as being what we call cognitive constriction or like tunnel vision, right? And I can't really think through the left or right of just this really narrow space of live with this overwhelming amount of pain or die and end the pain, really.

[00:08:00] And so, you know, I think when that kind of overwhelming psychological pain combines with, again, that hopelessness, cognitive constriction and the ability to overcome sort of this like naturally self-preserving instinct that we might have, risk really increases significantly. And that's where we typically see people's capacity to act increase. Gotcha.

[00:08:28] You mentioned, you know, the cultural stigma around not being resilient in the military. And, you know, a lot of folks will assume that, you know, we hear about 22 veterans killing themselves a day. People debate the exact figure, but it certainly seems to be higher than the general population. You know, how much of this is the fact that just being in the military, you happen to be exposed to more traumatic events at a younger age than the general population? So it's just a natural occurrence that there's higher rates.

[00:08:57] And how much of this might be there are other aspects about military life and culture that, especially once you leave service, impact your likelihood to want to kill yourself, not even just immediately after, but, you know, a decade plus later? Sure. Yeah. I mean, again, I think one of the biggest misconceptions in veteran suicide is that it's simply a consequence of combat trauma. Because, again, as we've just discussed, it's so much more complex than that. It's never going to just be one thing, right?

[00:09:24] It might be the one thing that you hear about, but for so many veterans who are struggling, right, it's that transition out of the military and I no longer have a sense of purpose. I don't have a community. I don't know what my mission is every day when I get up. I might be struggling to figure out, OK, how am I paying bills? How am I putting a roof over my head? How am I managing some of these, you know, challenges that I might be facing either because of something like post-traumatic stress or traumatic brain injury? And so and then you add to that, right, maybe not sleeping well or chronic pain.

[00:09:54] It just becomes, again, a really complex situation that leads people to feel like they're a burden on everybody around them. And there's no hope that those things are really going to change.

[00:10:03] And so I think, you know, what makes the veteran experience sort of unique or their military service unique when we think about comparing veteran suicide rates to the civilian is that, again, there is really a strong sense of purpose, identity, structure and belonging that might not exist in the civilian world in the same way.

[00:10:26] So, again, you know, when you think of it and you might have experienced this right when you left the military, but for many veterans, transitioning out of that environment means not only losing a job, but losing an entire community of people. And I think that's something that we spend a lot of time focusing on at Wounded Warrior Project, because biologically, we know that there is power in connection. There's power in a sense of belonging. And unfortunately, so many veterans leave the military and start to isolate. And so it's just a really challenging experience for a veteran.

[00:10:56] Yeah. Is there any sense of does the rate of suicide in the veteran population, how much of that is actually correlated to experiencing combat or what people would traditionally assume are the traumatic events of being in service? You know, do folks who have experienced direct combat action actually have a statistically significantly higher rate of suicide than folks who just spent time in service and then left?

[00:11:21] No. Well, and I don't want to misquote, but I believe that one of the more recent studies that I read actually said it's the opposite, right? It's actually the people who have had higher exposure to combat who tend to have a greater sense of resilience. And again, maybe it's a greater connection to the people in their unit than folks who maybe haven't been downraged or haven't seen as much of that exposure.

[00:11:43] But again, it's hard to say it's a one size fits all because there's so many other things we know, you know, but I guess just looking back, you know, a lot of people join the military because they don't have a great childhood. And we know those adverse childhood experiences can increase risk for suicide. So, again, there's a lot of risk factors that need to be considered from a health historical and kind of environmental factor perspective that isn't as easy as just I've seen combat or I haven't.

[00:12:09] Yeah, that brings up a really interesting point that I'm thinking back and this is, God, I was a lieutenant at Fort Trump 2013 to 2016-ish time frame, somewhere in there. And the battalion chaplain, I was having a conversation with him about, you know, why are we having all the suicidal ideations? It was a huge thing in the chain of command. And he pointed out that, well, actually, one of the biggest problems that look at the population that the infantry primarily recruits from for a variety of reasons.

[00:12:35] You've got young men from poor white families and you stack up all these risk factors of economic situation growing up, plus what race they are, mostly white, and this, this, this, this, this, and this. It actually correlates very directly to a suicide crisis that we're seeing in the nation more broadly. You know, that was over 10 years ago now.

[00:12:56] But I do wonder, do we have any sense of how much the veteran community problem with suicide is similar or dissimilar to the larger epidemic we've seen with suicide and mental health in the broader population? Yeah, I mean, I think it's tricky, right?

[00:13:15] We know that the veteran population definitely has a higher rate of suicide, and especially when you look at the VA's most recent annual report on suicide said a female veteran in particular is 103% more likely to die by suicide than a non-veteran woman. And so when you look at those things, it's staggering, right? But I think you have to look at things like access to lethal means and proficiency with access to certain lethal means, right?

[00:13:41] And, you know, it's not to say that people can't or shouldn't have certain things, whether that's medication or weapons or whatever, right? We know there's a time and a place for all of those things. And so I think one of the things that we have to be doing a better job is really talking about how are we safe with access to, you know, for some of our veterans, right? Large quantities of medicine from the VA because it's more convenient to have a 90-day supply than to have to go every 30 days or you're well-trained to use that weapon, right?

[00:14:10] And so we're seeing veterans lean towards much more lethal means of suicide that, again, they're very proficient already just because of their training in the military. Gotcha. Gotcha. You mentioned before, you know, suicide-safe communities and part of that is talking about it and destigmatizing access to care and this, that, and the other thing.

[00:14:33] But are there preventative steps that we've identified over the past several years that can actually make a meaningful difference in preventing someone if they've reached the point of suicidal ideation from going to suicidal act or even preventing them from getting to suicidal ideation if they're experiencing whatever they got going on? Yeah, I mean, I think the hope in any of these communities is that we're getting further upstream of those things right before a suicide crisis happens. And so one of the things that we talk about a lot are risk factors.

[00:15:02] And we know, again, certain conditions can create environments where suicide is much more likely to start or at least suicide thoughts are more likely to occur than not. But I think one of the things that we maybe don't spend as much time on but should be is what are the protective factors, right? And how can we be making sure that people are connected to their strengths, their resources, before the point that suicide becomes, start of, excuse me, begins to become part of the thought process, right? And so again, that does mean who is my community?

[00:15:31] Who are my people that I feel safe and trusted around and can talk openly about without fear of repercussions or some kind of negative consequence, right? How am I connecting to things that I enjoy or like doing or that gives me meaning and purpose, whether that's employment or hobbies, right? How am I sleeping? Am I, do I have a routine that allows me to get nice restorative sleep every night?

[00:15:57] Or am I kind of in that bucket where I'm sleeping, you know, two to three hours and it's really disturbed and I wake up feeling awful again? So I think it's how do we get further to those things and connect people to things, finding ways to reduce barriers to care that people need and deserve, whether that's mental health or behavioral health treatment, physical health, right? Just giving people the basic to things that are going to help with that goes so far in terms of helping create those suicide saver communities.

[00:16:27] And again, ideally getting as far upstream to this risk as we can. What are the first signs someone might see that, you know, someone in their life is contemplating doing this? And are those signs different if it's a veteran versus the general population? I think suicide warming signs, right, are unfortunately as unique as the person that you might be talking to, which makes it really tricky.

[00:16:52] But I think one of the things that we often try to talk about is taking the approach of just being curious with people, right? It's really easy to sort of make assumptions or kind of project that we know what people are going through because maybe we've lived through the same experience. And so I think, you know, when we hear people start to say they're suicidal, for example, we want to lead into that persuasion and sort of immediately argue against that of like, no, no, no, you don't want to do that, right? Like things are going to get better.

[00:17:22] You have so much to live for you. People that care about you. And while those responses are typically pretty well intended from the person delivering them, they really miss what people need the most, which is just to be kind of seen and understood. And so when we think about, you know, warning signs, I always just tell people, right, we want to pay attention to things that might look or sound different than this person's typical approach with us, right?

[00:17:49] So if we notice that there's changes in hygiene, if people are talking about changes in sleep or appetite, right? It doesn't have to be anything more than just like, hey, is that different? What's going on, right? Tell me what's been happening in your life and just sort of being curious about it.

[00:18:07] Because, again, we know that that connection and that more collaborative approach, if suicide is part of what they're considering, is going to be so much more impactful than us lecturing people or arguing with them or trying to just tell people what to do. Because at the end of the day, I don't know many adults who like to be told you have to do this and see that for a while. It seems like there's a real disconnect there from some of the stuff you were describing earlier. Someone's gotten locked in their brain where they can't see a way out of this terrible situation.

[00:18:36] They, for whatever reason, have gone to the point where they have rationally reached the conclusion based off a constrained set of variables that suicide might actually be the best option for them. Yeah. Somebody else showing up and say, oh, no, no, no, no. This thing you've been thinking about for a long time and this conclusion that you reached is completely wrong. Your life's going to be great. Stick it out. It'll get better. Give people time. And that's what you'll hear a lot. Time and distance saves lives, right?

[00:19:02] So what we are finding with science is if we can give people an opportunity to kind of share a little bit about what's happening, it really allows that prefrontal cortex time to kind of reboot, if you will, or come back online.

[00:19:14] So it does expand our thought processes and we do, or we start to be able to move outside of that very rigid thinking of, you know, suicide or don't suicide to say, okay, maybe there is a lot happening, but I can take bite-sized pieces of some of this and it's not going to resolve itself immediately. But I don't really want to die. I just don't know what to do with all of this.

[00:19:36] And so, again, we can kind of give the brain the opportunity to come back online in the way that it should be functioning, you know, but again, we have to slow ourselves down. And most of us like to fix, right? So some of this is just about us being aware of our tendencies there. To say this isn't my story to share. You know, I'm thinking through this because, yeah, I got back from Afghanistan in 2021.

[00:20:02] And, you know, while we were there, company supply clerk, I was the company because I worked really closely with this guy. And, you know, we were doing the withdrawal from Northern Afghanistan. And so this guy comes over mid-tour. His name's Dan. He absolutely crushed the deployment. He wants to be a green brain when he comes back. So we're talking about, you know, train up and stuff. He had tried before we left. We're going to get him ready to go again. Everything you'd want to see in a guy. We get home. He's a rock star. He, I go to his promotion ceremony a couple months after we get back, you know.

[00:20:31] Dude's crushing it. And then I get the phone call that he killed himself the night before. And I was like, well, fuck. Like, you're actually mad at the guy for doing this. But, you know, he was, he was my soldier. I completely missed anything that was going on with him. And I thought through this too, like, okay, if he had come to me, what my playbook would have been like, oh, soldier, suicidal ideation. Put in POV, drive to behavioral health, drop off, walk him into the building.

[00:20:59] Whatever, whatever meetings I'm going to are canceled, like, get him there. But, like, that's my checklist for solving the problem as his leader in the military. I don't actually think that'd be a very good checklist. I don't actually think that's a very effective approach. And I'm not sure what's better. But what are your thoughts on that? Because that's what a junior officer or NCO in the Army understands to be what they should do.

[00:21:20] Yeah, well, I guess my first point would be, right, I would say within the veteran community, people or the active duty community, in your example, right, people get really good at putting on the mask and kind of showing the world of the face that they want to see because there's fear there, right? There's fear that if I'm open and honest about some of the challenges that I'm facing, right, it's going to impact my security clearance or my ability to promote or do these things that I'm looking to do as part of my career.

[00:21:46] Right. But to your point, what we also know to be true because of that progression, not everybody who is thinking about suicide needs inpatient stabilization or 24-hour monitoring, right? Sometimes they really just need someone to say, like, gosh, tell me what you're going through. How long have you been carrying this, right? Again, just asking those kind of open, really curious questions. One of the trainings that we provide to our staff and our partners is called ASSIST or the Applied Suicide Intervention Skills Training.

[00:22:13] And it's kind of the global gold standard for intervention. And that model is really, again, sort of about buying time so that people can walk you through, here's what's been happening. What we are doing as potential helpers in that situation is really listening for, like, why might this person be willing to even entertain a conversation about safety with me? And so by the time we get there, they're kind of active participants in their own safety. So it's not me saying, hey, Scott, I want you to do this, this and this.

[00:22:42] It's really you saying, OK, I have this resource available or I have this person I can talk to or, hey, I know access to this thing probably isn't really safe for me right now. Here's what I'm going to do to kind of create a little space for those things. And in those cases, people are so much more willing to follow through with their plan for safety than, to your point, right, being grabbed to go to behavioral health for a couple of. Yeah.

[00:23:10] Who does seem to be in the best position to intervene with a veteran once they're out? Is it another veteran who maybe they serve with or just from another area who's in the area? Is it a spouse? Is it a parent? Who are the effective interveners for a person? Yeah. You know, I think there's not a simple solution here or a simple answer. I really think it is whoever that person feels most comfortable talking with, right?

[00:23:35] There are definitely scenarios where a friend or a family member might kind of see things happening more real time because they are engaged with that person on a more regular basis than somebody like a clinician might be. But I think, you know, we just have to remember that everybody's going to see a different part of this picture or have a different piece of this puzzle. And so, again, a spouse may notice some changes at home. A friend might hear them saying things that, again, just don't track for how this person would normally engage with us.

[00:24:05] Another veteran, right, in many cases might have a level of credibility or understanding that can kind of create space for an open conversation. But really what we always encourage people to do is to help a well-rounded system of support. And so when we talk to our warriors, we always say, hey, my challenge to you, right, is I want you to have five people on a good day that you think if you reached out to talk to that are there.

[00:24:29] And it doesn't even have to be about suicide, but ideally this should include friends and family and, right, if you are a spiritual, a faith community, your providers, again, whether that's behavioral health or your primary care physician, and a 24-hour crisis line. Because what we know to be true, again, is people are well-intended, but sometimes I'm not available to everybody 24 hours a day, right?

[00:24:51] And so if you're in a crisis and I'm the person that you're reaching out to and I'm on an airplane and can't answer my phone, right, we don't want to leave you kind of shit out of luck to say like, okay, well, she didn't answer, so I don't have anything else. We want you to know that there are other people around. And so I think effective suicide prevention isn't about finding the perfect person to intervene.

[00:25:13] And if you're someone trying to help, it's not necessarily about having the perfect words for this, but it's really just about, again, building a network of people that you trust and can have open conversations about this with in a situation that's not judgmental to you, because that's another layer of complexity when we think about who those people in our lives might be. Yeah. You know, one thing that comes up in a lot of veteran stories about this is at some point, alcohol seems to be a primary driver of action.

[00:25:42] What's going on with alcohol in these situations? Why do so many veterans seem to be self-medicating with that prior to committing suicide? Yeah, it's a hard question, right? Whether it's drugs or alcohol, I think we know, again, going back to so many people are experiencing overwhelming amounts of pain. And so those substances are a way to kind of like numb the pain that I might be experiencing or avoid them.

[00:26:06] But unfortunately, what we also know to be true is that alcohol sort of impacts all of those brain systems that we talked about right earlier. So it reduces inhibition. It's going to increase levels of impulsivity. It's going to impair judgment. We can also narrow attention and judgment. It makes it harder for people to think through consequences and easier to just kind of act on that like emotional brain that's happening.

[00:26:34] And so, you know, I don't think we can say drugs or alcohol create suicide thoughts, but it definitely lowers the barriers that would, you know, otherwise kind of protect us from acting on thoughts when we are having them. Gotcha.

[00:26:48] Now, if someone's out there listening to this and they realize like, I might have a friend or family member in my life that maybe was going through some stuff I didn't realize, you know, how would you want them to approach someone in their circle if they think that they're starting to contemplate either suicidal ideations or a suicidal plan? Yeah, I think, you know, a couple of things. One, remember that you're not responsible for fixing any of their problems.

[00:27:11] I think we often assume that if we're asking this, we have to be prepared with a lot of solutions and that prohibits a lot of people from engaging in this conversation to begin with. But again, I think it's really about just being curious to want to understand what's happening for people. So, again, questions about like, how are you feeling or how long have you been feeling this way? If we think that we need to ask about suicide, right, being really direct in that question of either asking, right, are you thinking about suicide?

[00:27:41] Are you thinking about ending your life? Or are you thinking about killing yourself? And that's a little bit of a shift. You know, it used to be. So don't beat around the bush. If you have a concern, ask them directly if they're at that point. Yeah, right. And again, when we think about what's happening in a person's brain, if I don't have the ability to kind of decode what you're asking me, those questions of are you thinking about hurting or harming yourself that we used to be told to ask, right, we might be getting the answer to a different question than what we think we're asking. Gotcha.

[00:28:09] And if someone's out there listening to this and they realize that, you know, they might be further along the spectrum towards considering hurting themselves, you know, what would they, what should they do? Where would you point them for help? Yeah, I think, again, there are lots of organizations that are available should you not feel like you have a friend or a family member who is available for you to have these conversations. So organizations like the National Suicide Prevention Lifeline, 988.

[00:28:37] If you are someone who prefers, you know, texting because it's a really hard conversation to have, there's the crisis text lines. You can text 741-741. One, there's lots of different organizations that are available to help and assist, even if you're not in a point of crisis, right, but you're just kind of feeling overwhelmed and don't know where to go. Those organizations can be incredibly helpful. Awesome. Well, this is the end of the prayer programming for today.

[00:29:04] But, you know, is there anything that I should have asked you while we're together that I haven't asked you yet? No, I, you know, I just, I appreciate the conversation, right? I think the more that we're talking about this, the better. It's a really important way to decrease stigma, to know that it's okay not to be okay, and it's okay to reach out for help. It doesn't, to your earlier point, right, make anybody weak or less than. We all struggle.

[00:29:29] And so, I guess for those who are listening, it's also to know you can help just by being curious and open to the conversation. Awesome. Well, thank you so much for taking the time to speak with us today. Really appreciate the work you're doing out there. Yeah, I appreciate your time. Thank you for watching part two. For part three, we're speaking to Sam, another veteran who found herself in a crisis situation. If you or someone you know needs help, please reach out to the National Suicide and Crisis Hotline at 988.