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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.

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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 antisuicidal 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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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, selfinflicted cigarette burns, other forms of selfabuse); • A tendency to be socially isolated (having no friends or only one friend); • A record of school failure or truancy; • A broken home or a broken relationship with a significant other (family member, boy/girlfriend); • Talk of suicide, either one’s own or that of others; • A close friend or relative who was a suicide victim; • Not living at home; • Preoccupation with death or dying; • A recent significant loss or the anniversary of one; • Sudden disruptive or violent behaviour; or • Being more withdrawn or uncommunicative and more isolated from others than usual The most common external causes – or more accurately, external catalysts – of suicidal behaviour include bullying, peer pressure incidents, family crises and health problems. Usually, these are situational in nature and have an escalating history that leads the individual to feel he has no other way out. In their minds, the situations had reached breaking point and they see no other way out except death, or the threat of death.

Depressive fantasy When external forces become unbearable enough for a person to contemplate suicide, depression of some sort is always involved. The depression causes the individual to make irrational decisions based on unstable emotions. This type of suicidal tendency is often accompanied by “after-death” fantasies in which the now dead individual, after taking his or her own life, gets to view the reactions and grief of those left behind. In these fantasies, the people who have caused the psychological pain feel punished by the suicide. While grieving, they demonstrate great remorse for having driven the person to take his own life. In this type of suicide (or suicide attempt), the individual is attempting to take back control of a situation he feels he has no control over. In killing himself, he is taking back control, getting in the last word. And, if the real life situation has left the individual feeling totally helpless, the idea of going out of control and teaching other people a lesson in the process can be strangely appealing.
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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. Some people suffer from depression because of chemical imbalances and to outsiders, their lives seem great – or at the very least average – with nothing outstanding that would indicate a reason for this person wanting to die. Tipping to positive It is important for friends and therapists to “play for time” until the dangerous period has passed. The strategy used is to involve the patient himself in the therapy process such that he decides to stick it out until he sees where the therapy is going. This can be done by stimulating an interest in his therapeutic approach. Involvement of patients in the treatment plan helps to treat the decision to commit suicide as the outcome of the struggle between the patient’s wishes to live versus his wishes to die. As in a declaration of war, an irrevocable decision may be made on the basis of a margin of a single vote, as it were. Initially, therefore, the therapist’s efforts should be directed towards shifting the votes in favour of living. On top of it, the therapist should maintain continuity between sessions.

Suicidal urges that are brought on by external circumstances include an unwanted pregnancy without a support system, abuse in the family or relationship, sexual assault, sexual harassment, bullying, peer rejection and romantic rejection. The individual is intrigued by the fantasy that he would be getting back at somebody whom he feels has hurt him – and that this other person will see the error of his ways and feel tremendous guilt as a result of the suicide. Because such impulses are often fleeting in nature and happen in a moment of extreme emotional stress, the suicide attempts are more likely to fail, be repeated and escalate in severity with each repeated attempt. Under these circumstances, the suicide attempts are often dismissed as cries for attention, which can be a fatal mistake on the part of the people close to the suicidal individual. Since the root cause here is a deep and wounding sense of helplessness – being ignored or having others dismiss the attempts as attention-seeking – it can ultimately lead to the person successfully taking his own life.
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Once the patient has agreed to weigh the pros and cons of suicide, the therapist would elicit the “reasons for living” and “reasons for dying.” Although patients might forget their reason for living, we can guide them by asking them to think of happy moments. The next step is to draw two columns on a sheet of paper. The therapist and patent can then list reasons in favour of living that were valid in the past. The therapist proceeds to ascertain which of the “past” reasons for living are valid in the present or, at the very least, might be valid in the future. It is interesting to note that the suicidal patient has often nullified these positive factors in his life which he has either forgotten, ignored or discounted their value. The therapist should also recognise that it may be quite painful for the patient to reconsider his decision to kill himself. The patient may have undergone enormous turmoil before arriving at his decision to terminate his suffering by suicide; and reopening the question may mean that he will

have to go through another period of turmoil and prolong his plan. Being alert When dealing with depression, hopelessness and fear, it is difficult to know where the bad feelings end and the real risk begins. If your friend exhibits two or more of these warning signs in a short period of time, it is best that you try to help. This does not mean you should take the weight of their world upon your shoulders, but it does mean you should alert other people to the possible risk. Go to your other friends, your at-risk-friend’s family, a trusted teacher or counselor. Just like your friend – who does not have to go through a difficult time alone – you do not need to try to save your friend on your own. It is impossible to know for sure if a person who seems sad or who has changed for the worse is at a real risk of committing suicide. If you fear your friend may attempt suicide, you should get some outside help and guidance from people who are better able to get your friend the help he or she really needs. OH!

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