FEATUREGently tipping the balance By Dr Leow Chee Seng, Certified Stress Consultant Professional (US)When contemplating suicide, the individual is attempting to take back controlof a situation they feel they have no control over. Thus, the best cure is helpingthem regain this control.N obody can ever predict how another person will react to the more troubling or difficultthings in life. Different people handle differentsituations in different ways – this is an undeniablefact of life, no matter how old you are.But there are usually some clear advance warningsigns that a friend may be in trouble and thatsuicide may be something he is considering. Sincesuicidal wishes could become a prevalent andpotentially lethal problem in depressed patients, itis important for therapists to understand why thepatient is considering such a drastic action in thefirst place.The therapist will then be in a better position toselect appropriate and effective techniques to dealwith the particular problem. However, no anti-suicidal strategy is of any use unless the therapist isfirst able to detect and assess the degree of suicidalintention.Risk indicatorsClues to suicide plans may be detected in overtbehaviour such as secretiveness, a sudden decisionto make a will or verbal statements. For example,a suicidal individual may say, “I don’t want to go onliving” or “I want to end it all.”Other statements suggestive of suicidal intentinclude: “I’m not going to put up with it anymore”, “I’ma burden to everyone”, “things will never get better”and “my intent is indirect and may be pieced togetheronly in retrospect”. Other indications are: “I guess Iwon’t be seeing you again” or “I want to thank you fortrying so hard to help me.”44 SEPT/OCT 2009 • OH!
FEATUREA depressed patient leaving on a weekend passfrom a hospital or upon retiring for the night, maysay “goodbye” instead of “goodnight”.According to the Diagnostic and Statistical Manualof Mental Disorder (DSM-IV-TR), mental disordersthat could lead to suicidal impulses includeconduct disorder among children, delirium,dementia, substance-induced mental disorders,amphetamine-induced disorders, schizophrenia,a major depressive or manic episode, anxietydisorders, dissociative disorder, sexual and genderidentity disorders, borderline personality disorderand premenstrual dysphoric disorder.Researchers have noted that some individuals leantowards suicide more than others. The characteristicsassociated with such at-risk adolescents include thefollowing:• A previous suicide attempt;• Suicidal gestures (cutting off one’s hair, self- inflicted cigarette burns, other forms of self- abuse); Depressive fantasy• A tendency to be socially isolated (having no When external forces become unbearable enough friends or only one friend); for a person to contemplate suicide, depression of• A record of school failure or truancy; some sort is always involved. The depression causes• A broken home or a broken relationship with a the individual to make irrational decisions based on significant other (family member, boy/girlfriend); unstable emotions.• Talk of suicide, either one’s own or that of others;• A close friend or relative who was a suicide victim; This type of suicidal tendency is often accompanied• Not living at home; by “after-death” fantasies in which the now dead• Preoccupation with death or dying; individual, after taking his or her own life, gets to• A recent significant loss or the anniversary of one; view the reactions and grief of those left behind.• Sudden disruptive or violent behaviour; or• Being more withdrawn or uncommunicative and In these fantasies, the people who have caused the more isolated from others than usual psychological pain feel punished by the suicide. While grieving, they demonstrate great remorse forThe most common external causes – or more having driven the person to take his own life. In thisaccurately, external catalysts – of suicidal behaviour type of suicide (or suicide attempt), the individualinclude bullying, peer pressure incidents, family is attempting to take back control of a situation hecrises and health problems. feels he has no control over.Usually, these are situational in nature and have an In killing himself, he is taking back control, gettingescalating history that leads the individual to feel he in the last word. And, if the real life situation has lefthas no other way out. In their minds, the situations the individual feeling totally helpless, the idea ofhad reached breaking point and they see no other going out of control and teaching other people away out except death, or the threat of death. lesson in the process can be strangely appealing. SEPT/OCT 2009 • OH! 45
FEATURE When the external causes are addressed and dealt with, and the person’s sense of helplessness is overcome, the suicidal urges all but disappear. Biological causes Internal causes of suicidal behaviour are much more complex and harder for the average person to see than external causes. The most common internal causes of suicide or suicidal behaviour include clinical depression, psychiatric disorders or chemical imbalances. Essentially, all suicide attempts come down to something inside the suicidal person but those without external catalysts are often biological in nature. Severe depression, which is believed to be caused by a combination of external factors and internal chemistry, is one thing that almost every suicide or suicide attempt has in common – how that depression came to be is the only difference.Suicidal urges that are brought on by externalcircumstances include an unwanted pregnancy Some people suffer from depression because ofwithout a support system, abuse in the family or chemical imbalances and to outsiders, their livesrelationship, sexual assault, sexual harassment, seem great – or at the very least average – withbullying, peer rejection and romantic rejection. nothing outstanding that would indicate a reason for this person wanting to die.The individual is intrigued by the fantasy that hewould be getting back at somebody whom he feels Tipping to positivehas hurt him – and that this other person will see It is important for friends and therapists to “play forthe error of his ways and feel tremendous guilt as a time” until the dangerous period has passed.result of the suicide. The strategy used is to involve the patient himselfBecause such impulses are often fleeting in nature in the therapy process such that he decides to stickand happen in a moment of extreme emotional it out until he sees where the therapy is going.stress, the suicide attempts are more likely to fail, This can be done by stimulating an interest in hisbe repeated and escalate in severity with each therapeutic approach.repeated attempt. Involvement of patients in the treatment plan helps toUnder these circumstances, the suicide attempts treat the decision to commit suicide as the outcomeare often dismissed as cries for attention, which can of the struggle between the patient’s wishes to livebe a fatal mistake on the part of the people close to versus his wishes to die. As in a declaration of war, anthe suicidal individual. irrevocable decision may be made on the basis of a margin of a single vote, as it were.Since the root cause here is a deep and woundingsense of helplessness – being ignored or having Initially, therefore, the therapist’s efforts shouldothers dismiss the attempts as attention-seeking be directed towards shifting the votes in favour of– it can ultimately lead to the person successfully living. On top of it, the therapist should maintaintaking his own life. continuity between sessions.46 SEPT/OCT 2009 • OH!
FEATUREOnce the patient has agreed to weigh the pros have to go through another period of turmoil andand cons of suicide, the therapist would elicit the prolong his plan.“reasons for living” and “reasons for dying.” Althoughpatients might forget their reason for living, we Being alertcan guide them by asking them to think of happy When dealing with depression, hopelessness andmoments. fear, it is difficult to know where the bad feelings end and the real risk begins. If your friend exhibitsThe next step is to draw two columns on a sheet of two or more of these warning signs in a short periodpaper. The therapist and patent can then list reasons of time, it is best that you try to help.in favour of living that were valid in the past. Thetherapist proceeds to ascertain which of the “past” This does not mean you should take the weight ofreasons for living are valid in the present or, at the their world upon your shoulders, but it does meanvery least, might be valid in the future. you should alert other people to the possible risk.It is interesting to note that the suicidal patient has Go to your other friends, your at-risk-friend’s family, aoften nullified these positive factors in his life which trusted teacher or counselor. Just like your friend – whohe has either forgotten, ignored or discounted their does not have to go through a difficult time alone – youvalue. do not need to try to save your friend on your own.The therapist should also recognise that it may It is impossible to know for sure if a person who seemsbe quite painful for the patient to reconsider his sad or who has changed for the worse is at a real riskdecision to kill himself. The patient may have of committing suicide. If you fear your friend mayundergone enormous turmoil before arriving at attempt suicide, you should get some outside helphis decision to terminate his suffering by suicide; and guidance from people who are better able to getand reopening the question may mean that he will your friend the help he or she really needs. OH! SEPT/OCT 2009 • OH! 47