Social Attitudes Regarding Disabilities and Suicidal Ideation - PowerPoint Presentation

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Social Attitudes Regarding Disabilities and Suicidal Ideation

EMILY M. LUND, PHD, CRC

UNIVERSITY OF ALABAMA

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Brief introduction

I’m currently an Assistant Professor of Rehabilitation Counseling and Counselor Education at the University of Alabama.

I graduated with my PhD in Rehabilitation Counseling and Special Education from Utah State University in 2016.

My primary research interests are suicide and trauma as they relate to disability.

I’m a Certified Rehabilitation Counselor (CRC) and have worked with people with disabilities and their families in a variety of education, rehabilitation, and clinical settings.

I have a severe, non-progressive(-

ish

) physical disability and have my entire life.

If you need anything rephrased or repeated, just ask!

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What do we mean by “disability”?

Broad term referring to chronic physical or mental health conditions that impair someone’s ability to perform activities of daily living (e.g., eating, breathing, walking, thinking, working)

People with disabilities are one of the largest minority groups in the United States, making up about 20%-25% of the population (Okoro, Hollis, Cyrus, & Griffin-Blake, 2018).

Disabilities may be congenital (something someone is born with) or acquired at any point during the lifespan.

Disabilities may be episodic (waxing and waning) or consistent, progressive or static, visible or invisible….

People can—and often do—have more than one disability or type of disability.

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Some common examples of disabilities

Developmental: Autism, intellectual disabilities, cerebral palsy

Physical/orthopedic disabilities: Spinal cord injury, limb loss or difference, cerebral palsy

Sensory: Blindness or visual impairment, Deafness or hearing impairment

Chronic health: Lupus, multiple sclerosis, cancer (including post-treatment effects)

Psychiatric/mental health: Major depressive disorder, bipolar disorder, schizophrenia, personality disorders

Cognitive: Traumatic brain injury, dementia

Learning: Dyslexia, dyscalculia

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Key things to remember

People with disabilities may or may not “look” or “seem” disabled at a given point of time.

People’s functional limitations, symptoms, experiences, and responses to treatment can vary widely even for people with the same diagnosis.

Increasingly, disability is being viewed and treated by people with disabilities as a positive and important aspect of one’s identity—even a source of pride—instead of a solely harmful or negative factor.

Disability identity development can protect against negative psychological outcomes in people with chronic health conditions.

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Disability and suicide

People with disabilities have been consistently shown to have higher rates of suicidal thoughts, plans, behaviors, and deaths than people without disabilities.

This persists across countries and types of disabilities.

One interesting exception: lower rates of suicide deaths in people with intellectual disabilities despite a high rate of suicide risk factors

As researchers, clinicians, and suicide prevention workers, the first question we ask is “why is suicidality so much higher in people with disabilities?”

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Disability and suicide

First thought: Is it simply the higher rates of depression, which are well-documented in people with disabilities?

However, researchers have consistently found that the increased suicidality in people with disabilities is still evident even when statistically accounting for the increases rates of depression diagnoses or symptoms.

Second thought: Is it due to the higher rates of some sociodemographic risk factors for suicide, such as unemployment and lack of a romantic partner, among people with disabilities?

Again, researchers have found that disability generally remains a significant predictor of suicidality even when controlling for other risk factors as well as mental health concerns, particularly depression!

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Disability and suicide

This leads us to the important question of: what else could be contributing to this increased risk of suicide?

One concern is that the general, continuous stress of having a disability—both in terms of symptoms as well as social and attitudinal barriers (e.g., social exclusion or harassment, difficulty receiving accommodations, discrimination in education and employment), combined with internalized self-stigma, may lead to greater suicidality.

This is known as the “minority stress model” and has been researched and validated in other marginalized groups, especially in LGBTQ+ populations.

Another possible factor is that social attitudes towards disability, particularly disability and suicide, may be contributing.

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Disability and suicide

Much of the discussion about disability and suicide centers around physician-assisted suicide or euthanasia.

This is an important conversation, but it is largely a different one than the conversation about

suicide and disability.

In most places where PAS is legal (including the U.S. states where it is available), it is restricted to people who have both a terminal diagnosis and a brief (usually 6 months or less) expected remaining lifespan.

This is a different population than the broader population of people with disabilities, although there is some overlap.

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Attitudes towards suicide and disability: A study

We conducted a study on attitudes towards suicide in people with non-terminal but non-curable disabilities.

Participants read 5 pairs of vignettes about individuals who were suicidal. Each vignette pair consisted of one vignette where the suicidal individual was not stated to have a disability and a vignette in which the individual was experiencing a similar life stressor but was stated to have a disability.

Disabilities were varied and included: acquired brain injury, acquired spinal cord injury, chronic health condition, congenital blindness, and mental illness.

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Sample vignettes

Disability:

Maddy is a 22 year-old college student who worked hard to prepare for medical school applications. She has been blind since a young age and has always wanted to be a doctor. Recently, Maddy was told that because she is blind, medical school will probably not be an option for her. She has looked into other majors and careers, but cannot think of one that she is interested in where her blindness would not be an issue. Because of this, Maddy has felt very hopeless and sad. She has begun to think of killing herself, as she can’t do anything due to her disability.

No disability:

Jill is a 22 year-old college student. She has wanted to be a lawyer since she was a child and has worked hard to achieve that goal. She recently took the LSAT, a law school admissions test, and received a poor score. Her score will make it very difficult to get in the law school. Because Jill studied hard for the test, she does not feel like she can raise her score and cannot find any other careers that she is interested in pursuing. Because of this, she feels hopeless and has begun to think of killing herself, as she feels like she can no longer pursue a good career.

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Attitudes towards suicide and disability: A study

After each vignette, participants completed rating scales about how they viewed the individual’s situation, whether they would feel the same way in that situation, and if the hypothetical individual should have the right to kill him- or herself.

Approximately 500 participants (American adults) completed the study,

For all five vignette pairs, both overall scores on the measures and scores on the “right to kill oneself” item specifically were significantly higher for the disability vignette than the no-disability vignette.

Overall, 91.8% had a mean score difference that indicated more negative attitudes/suicide permissiveness in the disability condition.

Overall, about half of participants (44.4%) had a mean score that indicated higher endorsement of one’s right to kill themselves for the disability vignettes versus the no-disability vignettes, with most of the remaining participants (49.8%) having essentially no difference in the belief in one’s right to kill themselves between the conditions.

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Attitudes towards suicide and disability: A study

This difference was not related to one’s own disability status, depression, or suicidality nor to having a friend or family member with a disability or having had a friend or loved one attempt or die by suicide.

With very few exceptions, demographic or exposure variables did not significantly relate to the differences in scores between the disability and no-disability conditions, for either the overall measure or the right to kill oneself item specifically.

Conclusions? The idea that life is inherently much worse when you have a disability and that disability confers a greater right to

pr

justification for suicide appears very pervasive in our culture, even with non-terminal disabilities.

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Attitudes towards disability and suicide: Implications for practice

Coming from this study, the obvious question is: what does this mean for understanding suicide prevention in people with disabilities?

Broader social messaging about disability and (not) having a “life worth living” is a concern.

This is oftentimes reflected in popular media, such as

Million Dollar Baby

and

Me Before You

, in which characters with permanent but non-terminal disabilities choose suicide over life with a disability.

May also be reflected in phrases such as “life [or death] with dignity”—what constitutes a “dignified” life? (e.g., can you have a “dignified” life if you cannot feed yourself or use the bathroom without assistance?)

May unintentionally encourage or be taken as “support” for suicidal thinking or behavior in depressed or suicidal people with disabilities.

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Attitudes towards disability and suicide: Implications for practice

Video clip,

Me Before You:

https://www.youtube.com/watch?v=7Fc_LSiyD7s

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Attitudes towards disability and suicide: Implications for practice

On a more individual level, there is also the question of what responses people with disabilities receive when they disclose suicidal thoughts: Are they being told “No, your life has meaning; it is important to me that you live?” or “Yes, given your circumstances that makes sense, and it would be okay if you chose that?”

Currently, there is no good research on this, although there is some discussion of the issue concerning well-publicized clinical cases where this issue has come up.

We are planning to do research on this in the near future!

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What can we do?

We need to have counselors and other health and mental health professionals who are culturally competent in disability-affirmative therapy and medical practice.

We need to promote positive disability identity development in people with disabilities and research the most effective strategies of how to do this.

We also need to promote broader social acceptance of people with disabilities and reduce barriers to help-seeking for suicidality as well as general engagement in an active, rich, and personally meaningful life.

We need to develop and evaluate suicide preventions programs specifically in and concerning people with disabilities.

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Best practices for suicide intervention and prevention in people with disabilities: what can we say?

In general, the core gatekeeping and counseling competencies we teach are still critical (e.g., compassion and empathy, direct questioning about suicide, assessing risk and protective factors, developing a safety plan).

Effective, evidence-based treatment for any underlying mental health concerns or psychiatric conditions (e.g., ACT or CBT for depression and anxiety, DBT for borderline personality disorder, PE or CPT for PTSD,

etc

) is also critical.

It is important to acknowledge the difficulties and oppression associated with disability but also to encourage hope and the ability for other things to change for the better (“The life you create may be different and difficult at times, but it can still have great meaning and joy.”)

Peer support and mentorship from others with similar disabilities may be critical in developing this sense of hope and community.

Consultation with experts in the psychology of disability, such as rehabilitation psychologists and rehabilitation counselors, is potentially valuable.

“Be on the side of life” and remind them that they are valued by and valuable to you and others.

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Questions and comments?

Contact information:

emlund@ua.edu

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Reference/reading list

Suicide prevalence and disability:

Giannini, M. J.,

Bergmark

, B.,

Kreshover

, S., Elias, E., Plummer, C., & O’Keefe, E. (2010). Understanding suicide and disability through three major disabling conditions: Intellectual disability, spinal cord injury, and multiple sclerosis.

Disability and Health Journal

, 

3

(2), 74-78.

Lund, E. M., Nadorff, M. R., Galbraith, K., & Thomas, K. B. (2019). Comparing internal consistency, overall scores, and response patterns on the Suicidal Behavior Questionnaire-Revised (SBQ-R) in people with and without disabilities.

Rehabilitation Counseling Bulletin, 62,

108-120.

Lunsky

, Y., Raina, P., & Burge, P. (2012). Suicidality among adults with intellectual disability. 

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Pompili

, M., Forte, A., Palermo, M., Stefani, H.,

Lamis

, D. A., Serafini, G., ... Girardi, P. (2012). Suicide risk in multiple sclerosis: A systematic review of current literature. 

Journal of Psychosomatic Research

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Segers

, M., &

Rawana

, J. (2014). What do we know about suicidality in autism spectrum disorders? A systematic review. 

Autism Research

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Wetzel, H. H., Gehl, C. R.,

Dellefave

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Psychiatry Research

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Reading list

Suicide and disability in the context of other risk and protective factors:

Dennis, M.,

Baillon

, S.,

Brugha

, T., Lindesay, J., Stewart, R., & Meltzer, H. (2009). The influence of limitation in activity of daily living and physical health on suicidal ideation: Results from a population survey of Great Britain. 

Social Psychiatry and Psychiatric Epidemiology

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, 608-613.

Lund, E. M., Nadorff, M. R., &

Seader

, K. (2016). The relationship between suicidality and disability when accounting for depressive symptomology.

Rehabilitation Counseling Bulletin

,

59

, 185-188.

Lund, E. M., Nadorff, M. R., Thomas, K. B., & Galbraith, K. (in press). Examining the contributions of disability to suicidality in the context of depression symptoms and other sociodemographic factors.

OMEGA: Journal of Death and Dying

.

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Dubé

, C., & Park, E. (2015). Suicidal ideation among adults with disability in western Canada: A brief report. 

Community Mental Health Journal

, 519-526. doi:10.1007/s10597-015-9911-3

Russell, D., Turner, R. J., & Joiner, T. E. (2009). Physical disability and suicidal ideation: A community-based study of risk/protective factors for suicidal thoughts. 

Suicide and Life-Threatening Behavior

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, 440-451. doi:10.1521/suli.2009.39.4.440

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Reading list

Attitudes towards suicide and disability:

Achille , M. A., &

Ogloff

, J. R. (2003). Attitudes toward and desire for assisted suicide among persons with amyotrophic lateral sclerosis. 

OMEGA--Journal of Death and Dying

, 

48

(1), 1-21.

Amundson, R., &

Taira

, G. (2005). Our lives and ideologies: The effect of life experience on the perceived morality of the policy of physician-assisted suicide. 

Journal of Disability Policy Studies

, 

16

(1), 53-57.

Emanuel, E., Fairclough, D., Daniels, E., &

Clarridge

, B. (1996). Euthanasia and physician-assisted suicide: Attitudes and experiences of oncology patients, oncologists, and the public. 

Lancet

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347

, 1805-1810.

Fadem

, P.,

Minkler

, M., Perry, M., Blum, K., Moore, L. F., Rogers, J., & Williams, L. (2003). Attitudes of people with disabilities toward physician-assisted suicide legislation: broadening the dialogue. 

Journal of Health Politics, Policy and Law

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, 977-1002.

Lund, E. M., Nadorff, M. R., Winer, E. S., &

Seader

, K. (2016). Is suicide an option?: The impact of disability on suicide acceptability in the context of depression, suicidality, and demographic factors.

Journal of Affective Disorders

,

189

, 25-35.

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Reading list

Disability culture and identity:

Andrews. E. E.,

Forber

-Pratt. A. J., Mona, L. R., Lund, E. M.,

Pilarski

, C. R., &

Balter

, R. (2019). #

SaytheWord

: A disability culture commentary on the erasure of ‘disability’.

Rehabilitation Psychology,  64,

111-118

.

Bogart, K. R., Lund, E. M., &

Rottenstein

, A. (2018). Disability pride buffers self-esteem through the Rejection-Identification Model.

Rehabilitation Psychology

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63

, 155-159.

Forber

-Pratt, A. J.,

Lyew

, D. A., Mueller, C., & Samples, L. B. (2017). Disability identity development: A systematic review of the literature. Rehabilitation psychology, 62(2), 198-207.

Gill, C. J. (1997). Four types of integration in disability identity development. 

Journal of Vocational Rehabilitation

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(1), 39-46.

Nario

-Redmond, M. R., Noel, J. G., & Fern, E. (2013). Redefining disability, re-imagining the self: Disability identification predicts self-esteem and strategic responses to stigma. 

Self and Identity

, 

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, 468-488.

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Reading list

Minority stress model:

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence.

Psychological bulletin

, 

129

, 674-679.

Michaels, M. S., Parent, M. C., & Torrey, C. L. (2015). A minority stress model for suicidal ideation in gay men. 

Suicide and Life-Threatening Behavior

. doi:10.1111/sltb.12169 (online ahead of print).

Plöderl

, M.,

Sellmeier

, M.,

Fartacek

, C., Pichler, E.,

Fartacek

, R., &

Kralovec

, K. (2014). Explaining the suicide risk of sexual minority individuals by contrasting the minority stress model with suicide models. 

Archives of Sexual Behavior

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, 1559-1570.