http://www.hbacademy.org.uk

1. FEATURE
Gently tipping the balance
By Dr Leow Chee Seng, Certified Stress Consultant Professional (US)
When contemplating suicide, the individual is attempting to take back control
of a situation they feel they have no control over. Thus, the best cure is helping
them regain this control.
N obody can ever predict how another person
will react to the more troubling or difficult
things in life. Different people handle different
situations in different ways – this is an undeniable
fact of life, no matter how old you are.
But there are usually some clear advance warning
signs that a friend may be in trouble and that
suicide may be something he is considering. Since
suicidal wishes could become a prevalent and
potentially lethal problem in depressed patients, it
is important for therapists to understand why the
patient is considering such a drastic action in the
first place.
The therapist will then be in a better position to
select appropriate and effective techniques to deal
with the particular problem. However, no anti-
suicidal strategy is of any use unless the therapist is
first able to detect and assess the degree of suicidal
intention.
Risk indicators
Clues to suicide plans may be detected in overt
behaviour such as secretiveness, a sudden decision
to make a will or verbal statements. For example,
a suicidal individual may say, “I don’t want to go on
living” or “I want to end it all.”
Other statements suggestive of suicidal intent
include: “I’m not going to put up with it anymore”, “I’m
a burden to everyone”, “things will never get better”
and “my intent is indirect and may be pieced together
only in retrospect”. Other indications are: “I guess I
won’t be seeing you again” or “I want to thank you for
trying so hard to help me.”
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2. FEATURE
A depressed patient leaving on a weekend pass
from a hospital or upon retiring for the night, may
say “goodbye” instead of “goodnight”.
According to the Diagnostic and Statistical Manual
of Mental Disorder (DSM-IV-TR), mental disorders
that could lead to suicidal impulses include
conduct disorder among children, delirium,
dementia, substance-induced mental disorders,
amphetamine-induced disorders, schizophrenia,
a major depressive or manic episode, anxiety
disorders, dissociative disorder, sexual and gender
identity disorders, borderline personality disorder
and premenstrual dysphoric disorder.
Researchers have noted that some individuals lean
towards suicide more than others. The characteristics
associated with such at-risk adolescents include the
following:
• 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 for
The most common external causes – or more having driven the person to take his own life. In this
accurately, external catalysts – of suicidal behaviour type of suicide (or suicide attempt), the individual
include bullying, peer pressure incidents, family is attempting to take back control of a situation he
crises 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, getting
escalating history that leads the individual to feel he in the last word. And, if the real life situation has left
has no other way out. In their minds, the situations the individual feeling totally helpless, the idea of
had reached breaking point and they see no other going out of control and teaching other people a
way out except death, or the threat of death. lesson in the process can be strangely appealing.
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3. 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 external
circumstances include an unwanted pregnancy Some people suffer from depression because of
without a support system, abuse in the family or chemical imbalances and to outsiders, their lives
relationship, sexual assault, sexual harassment, seem great – or at the very least average – with
bullying, 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 he
would be getting back at somebody whom he feels Tipping to positive
has hurt him – and that this other person will see It is important for friends and therapists to “play for
the 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 himself
Because such impulses are often fleeting in nature in the therapy process such that he decides to stick
and 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 his
be repeated and escalate in severity with each therapeutic approach.
repeated attempt.
Involvement of patients in the treatment plan helps to
Under these circumstances, the suicide attempts treat the decision to commit suicide as the outcome
are often dismissed as cries for attention, which can of the struggle between the patient’s wishes to live
be a fatal mistake on the part of the people close to versus his wishes to die. As in a declaration of war, an
the 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 wounding
sense of helplessness – being ignored or having Initially, therefore, the therapist’s efforts should
others 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 maintain
taking his own life. continuity between sessions.
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4. FEATURE
Once the patient has agreed to weigh the pros have to go through another period of turmoil and
and cons of suicide, the therapist would elicit the prolong his plan.
“reasons for living” and “reasons for dying.” Although
patients might forget their reason for living, we Being alert
can guide them by asking them to think of happy When dealing with depression, hopelessness and
moments. fear, it is difficult to know where the bad feelings
end and the real risk begins. If your friend exhibits
The next step is to draw two columns on a sheet of two or more of these warning signs in a short period
paper. 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. The
therapist proceeds to ascertain which of the “past” This does not mean you should take the weight of
reasons for living are valid in the present or, at the their world upon your shoulders, but it does mean
very 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, a
often nullified these positive factors in his life which trusted teacher or counselor. Just like your friend – who
he has either forgotten, ignored or discounted their does not have to go through a difficult time alone – you
value. 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 seems
be quite painful for the patient to reconsider his sad or who has changed for the worse is at a real risk
decision to kill himself. The patient may have of committing suicide. If you fear your friend may
undergone enormous turmoil before arriving at attempt suicide, you should get some outside help
his decision to terminate his suffering by suicide; and guidance from people who are better able to get
and reopening the question may mean that he will your friend the help he or she really needs. OH!
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