This post is written with the intent to express the importance of engaging in Self-Care behaviors during this time of crisis we are living in. When people are isolated within their homes they are physically cutoff from friends and loved ones (obviously), but more importantly they are cutoff from physical contact, which is one of the four basic human needs. This lack of physical contact significantly increases the probability of people engaging in maladaptive (problem) behaviors, including suicidal thoughts and attempts. In addition to discussing this concern, I will discuss options for coping with this stress.
The Problem – Needs/Functions Not Met
People are usually said to have 4 basic needs – food/water, sleep, human contact, and shelter. When people are unable to access one of the four needs, they go through a variety of emotions, including, but not limited to, anxiety, depression, and loneliness. The feelings people have that correlate to lacking one of these needs makes obtaining them more or less important, which affects the rest of your thoughts and emotions.
Behaviorally, we state that people have 4 functions (reasons) for behavior – Attention, Escape/Avoidance, Access to tangibles (items/activities), and Automatic (sensory stimulation, pain attenuation). Automatic simply means, “it just feels good”. As a result of 1 of these 4 functions, people will engage in a specific behavioral response. Each behavior becomes more and less rewarding (reinforcing) based on the environmental setting. This fluidity in significance of behavioral consequences is termed within ABA as Establishing Operations (EO’s). EO’s are broken into Motivating Operations (MO’s) and Abolishing Operations (AO’s). MO’s make a behavior/response more rewarding, and AO’s make a behavior/response less rewarding. Additionally, within ABA, thoughts and emotions are considered private behaviors, which follow the rules and functions of behavior; they are just behaviors that only the person experiencing them can describe.
Maslow’s Hierarchy of Human Needs
Abraham Maslow described humans’ needs with the terms “physiological”, “safety”, “belonging and love”, “social needs”/”esteem”, and “self-actualization”. They are often visually represented like a pyramid, as shown, with the most important needs being the base, and lesser important needs stacking on top. Their importance is defined as outranking each other. For example, people will care less about friendships if they have no food or water to survive. This correlates to MO’s, as behaviors will become more or less rewarding dependent on the environment. For example, water is more reinforcing when you have been exercising, versus when you are watching TV. Another example, food is less reinforcing when you have been snacking all day, versus if you haven’t eaten all day.
Suicide in the U.S.
Within the U.S., suicide had consistently become a growing concern before we had the necessity to live in self-isolation. The fear has now developed that suicide will become exponentially more concerning, as people fight to find ways to cope with the loss of leisure activities, jobs/careers, physical contact with family and friends, and general freedoms that were previously unnoticed and taken for granted. Data and statistics from the American Foundation for Suicide Prevention (AFSP) report, in 2018, there were approximately 1,400,000 suicide attempts, resulting in more than 48,000 deaths from suicide, and more than $69,000,000,000 in costs associated with suicide or the self-injury from suicide attempts. Additionally, the suicide rate is consistently and significantly increasing each year. 
During times of isolation and a lack of quality reinforcing stimuli, people have increased risks of self-harm and suicide. This correlates with population density in general, as the more likely people are to be around each other, the less likely they are to attempt/commit suicide. Behaviorally, Attention is 1 of the 4 functions that maintain behaviors, which can be simplified as social interactions with others. In Figure 1, we see a chart and graph displaying the HIGH suicide rates in states that commonly have large areas and low populations, decreasing the likelihood of social interactions and increasing the probability of its residents having behaviors associated with isolation. 
Data has shown that the highest suicide rates correlate to the states with the fewest big cities and more spread out citizens. For example, Montana is the 4th-largest state by area, and has the 3rd-lowest population density in the country. Alaska is the largest state, and has the lowest population.
In Figure 2, we see a chart and graph displaying the LOW suicide rates in states that commonly have high overall populations and population densities. New York, California, and Illinois make this list, containing the 1st, 2nd, and 3rd largest cities in the U.S. (respectively) by population, and have the 3rd, 1st, and 5th largest state populations (respectively). Additionally, 6 of the 8 states with the highest population densities, New Jersey (1st), Rhode Island (2nd), Massachuetts (3rd), Connecticut (4th), Maryland (5th), and New York (7th) are among the 8 states with the lowest suicide rates. While California has the 11th highest population density, it is home to another 6 of the 50 highest population cities – San Diego (8th), San Francisco (15th), Fresno (34th), Sacramento (36th), Long Beach (43rd), and Oakland (45th).
Data has shown that the lowest suicide rates correlate to the states with the biggest cities and highest population densities. For example, New Jersey and New York have the lowest and second-lowest suicide rates respectively. While Illinois is primarily rural, it is home to Chicago (3rd largest city in the U.S., and has many dense small cities/towns), and states like Massachusetts are home to Boston, and within short traveling distance to many other big cities due to the state’s small physical size.
“Suicidal thoughts and behaviors and social isolation”
In an article titled “Suicidal thoughts and behaviors and social isolation: A narrative review of the literature” (Calati et al., 2019), social isolation was studied in specific relation to sucidal behavior and thought. It summarized that social isolation is strongly associated with suicidal outcomes, that subjective feeling of loneliness has a major impact (including transculturally), and that objective and subjective social isolation should be added in suicide risk assessment.
Specific results reported the main social constructs associated with suicidal outcomes were marital status (being single, separated, divorced, or widowed), living alone, social isolation, loneliness, alienation, and belongingness. Both the objective condition (e.g., living alone) and the subjective feeling of being alone (i.e., loneliness) were strongly associated with suicidal outcomes, in particular with Suicide Attempts (SA) and Suicidal Ideation (SI). Specifically, loneliness (investigated in most studies) had a major impact on both SI and SA, and associations were transculturally consistent.
Data from the observational studies suggest that both objective social isolation and the subjective feeling of loneliness should be incorporated in the risk assessment of suicide. Interventional studies targeting social isolation for suicide prevention are needed.
Calati et al., 2019
Behavioral Impact & Self-Care
During this time of crisis, we need to make sure more than ever we are practicing appropriate self-care. While many people are out of work, and many people feel they have too much free time on their hands, people are actually at risk of depression (among other issues). During times of isolation and a lack of quality reinforcing stimuli, people have increased risks of self-harm and suicide. This is where the importance of taking care of yourself comes in. Everyone is dealing with so many stressors (e.g., job loss, inability to maintain physical health) that they are not focusing on keeping their mental health healthy. People are using social media as ways to satiate their behavioral necessity for Attention, but there’s only so much apps and the internet can help. People all have functional needs that were maintained by their physical interactions, which now require alternative behaviors. The following list will give examples of physical interactions that need to be replaced, and simple alternative behaviors that can be performed during this crisis.
- Social Interactions – whether its going to work or going to the club, the primary activity in our social interactions are talking to people, venting our lives, getting to know each other better, and just having basic conversations.
- Possible Replacements – these may give you the many of the sensory responses associated with physically talking to people in-person.
- Write a letter/postcard – this allows you to express your emotions in a long, uninterrupted form, which is especially good for people who tend to talk and ramble for long periods while others typically listen and attend to the speaker.
- Phone calls instead of text messages – being able to hear another person’s voice can help satiate your need to talk to co-workers and others.
- Video chat relatives you haven’t talked to in a while – letters and hearing your loved ones is fine, but the closest thing to replacing an in-person conversation is probably a video call; between Facebook, iPhones, Skye, etc., there are a plethora of options. And for family and fiends who are not tech savvy, at least one of the options should be easy enough to walk them through.
- Possible Replacements – these may give you the many of the sensory responses associated with physically talking to people in-person.
- Physical Interactions (Attention and Access to preferred activities) – some activities you miss go beyond talking.
- Virtual Workout Buddies – do you miss having a workout buddy or gym partner? I’ve been recommending to family members that they facetime their friends and usual workout partners while they hit their tredmills. You don’t have to actually look at the phone, but having the ability to talk and occasionally see each other is a great way to find adequate alternative.
- Virtual Workout Classes – dust of your workout tapes if you still have the DVD’s or VHS tapes! Richard Simmons didn’t become a millionaire because everyone feels comfortable going to the gym; he achieved his success because people want the feel of not being alone during a workout, while being alone in a judgement free setting. Plus, with apps like DDP Yoga, Peloton, and Beach Body, you can have actual classes with live instructors.
- Gaming – obviously people can game online, but instead of just logging on and playing random people, focus on playing your real-life friends. If you or them don’t log-on often, call each other up and set up gaming sessions. You can talk to them and enjoy playing a game without dealing with annoying online trolls.
- Sexual Contact (Attention & Sensory based) – let’s be honest, most people have either felt the deprivation of sexual contact, or have read/watched on social media people complain about their deprivation.
- Possible Replacements – these may help replace both the attention and sensory based responses associated with sexual behaviors, in addition to the intimacy and feelings/emotions (private behaviors/responses) that coincide with the physical responses (observable behaviors).
- Masturbation/Sex Toys – people may have recently joked or been upset by sex shops/toys continuing to be available while other businesses are not, but the use of toys is helping a lot of people cope in appropriate ways, without bothering anyone else.
- Phone Sex – knocking out two problems at once, people can use phone sex to have intimacy with a partner and relieve their sensory and attention based needs.
- Possible Replacements – these may help replace both the attention and sensory based responses associated with sexual behaviors, in addition to the intimacy and feelings/emotions (private behaviors/responses) that coincide with the physical responses (observable behaviors).
In Summary
Times are rough and we all have to make changes in our habits and behaviors to ensure our mental health. Find alternatives that will help fulfill the FUNCTION of the activities (behaviors) you miss engaging in. This means, take the time to think about, “what about (activity) do I miss?”. Typically, as we’re in a state of isolation, it’s the friendship, kinship, comradery, and closeness you shared with others while engaging in the activity. Then, focus on the best and easiest ways to bring people back into those shared experiences. Otherwise, you could fall into the dangers that isolation creates; specifically, the risks of depression, anxiety about having to leave your safe spaces, loneliness, and suicidal thoughts. The more isolated we are, the more suicide increases in numbers. Don’t be a statistic, and use the instinct of human survival to find ways to stay positive and make the best of this crisis.
Source Citations
Calati, R., , Ferrari, C., Brittner, M., Oasi, O., Olié, E., Carvalho, A. Courtet, P. (2019). Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. Journal of Affective Disorders, 245(15 February 2019), 653-667. https://doi.org/10.1016/j.jad.2018.11.022
Suicide statistics. (2020, March 1). American Foundation for Suicide Prevention. Retrieved April 9, 2020, from https://afsp.org/about-suicide/suicide-statistics/
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