Talking About Suicide
Talking About Suicide
Laura Graham examines the recognised causes of suicide and outlines strategies for helping people deal with suicidal ideation
The sad death of Robin Williams recently sparked a wide debate about suicide. Generally, the media handled the subject sensitively; a positive development amidst a deeply tragic situation, as suicide stills remains a taboo subject.
Suicide is a much misunderstood subject, yet there is a whole and mature science (suicidology) dedicated to trying to understand it so that we may be able to prevent it. An estimated one million people complete suicide world- wide each year, ranking suicide as the world’s tenth leading cause of death. World Health Organisation figures show that globally, suicide is the third leading cause of death amongst 15 to 44 year olds, and the second amongst 10 to 24 year olds.
The reasons for suicide are complex. However, there are increased risks in people with conditions such as depression, schizophrenia, eating disorders, Borderline Personality Disorder, OCD, insomnia, anxiety and addiction (and partners of addicts – spouses of gambling addicts have a risk of suicide three times greater than the average population). There is an increased risk of suicide in people who have experienced trauma (as a one off event or over a long-term period), and suicide has strong links to the ending of a significant relationship (the death of a loved one, the ending of a relationship). A history of previous attempts of suicide is a risk of completed suicide, as is a family history of suicide (possibly as the result of a “normalisation” of suicide, or as the result of the trauma associated with losing someone to suicide). The presence of a physical condition such as a brain injury or a serious illness can increase risk – a diagnosis of cancer can double the risk of suicide to that of the general population. There is a strong link between suicide and the experience of being bullied (with an increased risk amongst young people, and in a prison environment).
Suicides without warning are rare. The science of suicide has found some features that may indicate suicidal ideation. In no particular order they are:
- Making a will – “getting their affairs in order”
- Suddenly visiting or contacting loved ones (to say goodbye)
- Writing a suicide note
- Acquiring the means to end their life (stock-piling medication, or making a ligature)
- Giving prized possessions away
- Anhedonia – a loss of interest in activities previously enjoyed
- Persistent thoughts of future problems – “something bad is going to happen”
- Expressing feelings of being “trapped”, “seeking revenge” or being “a burden to others”
- A preoccupation with death
- A peek in mood – suddenly becoming calmer or happier following a period of despair – this is a stark warning sign as the individual has gone from feeling hopeless about the future and without a solution to the current crisis, to having a sensation of relief once they believe suicide to be the answer. Similarly:
- An increase in energy is a danger sign as suicidal thoughts transfer into action.
It is important to understand that people who are considering suicide rarely confide in their therapist about this. If they are to initiate a discussion about their thoughts, it will more likely be with a family member or friend. When working with people who may be at risk of suicide, it is vital to have an open line of communication with the individual’s family and friends to ensure that their concerns about the individual are known by the therapist. Many people are uncomfortable about opening a dialogue about a person’s intention to kill themselves. However, asking the question, “Do you ever feel so bad, that you have thoughts about suicide?” is entirely appropriate if there are signs that they are. People who are not considering suicide will be horrified by the question. Asking the question will not “trigger” suicidal ideation in a person who is not already having thoughts about suicide, but provides space for discussion about how they might go about it, and when, in people who are considering suicide. Asking the question could save a person’s life. However, there is little point in asking the question if you do not know how to respond to a “yes” reply.
Obviously, if someone is in imminent danger of attempting suicide, the response should be to call the emergency services. If someone has expressed current or recent thoughts of suicide, there are several things to consider.
Firstly, look at protective factors against suicide. These can include the absence of current mental illness (they are sad in response to a recent life event rather than clinically depressed); they are drug-free and sober – alcohol and other drugs can act as a dis-inhibitor during suicidal ideation; the presence of a strong social support system; and having children under the age of eighteen. A previous history of suicidal ideation is a risk factor for completed suicide, but is also an asset to work with, as this person has experience of what helped them before – having overcome previous episodes of suicidal ideation suggests that this person has a history of being hopeful rather than hopeless.
Medications may be considered in helping through an immediate crisis, but talking therapy is considerably beneficial. CBT and DBT (the latter in particular with people who have Borderline Personality Disorder) have been found to be useful in helping people to understand how their thoughts and behaviours affect each other during a period of crisis, and that thoughts are not permanent. This can be supported with a compact or contract between the individual and their therapist. Some people who are considering suicide are “bargaining” with themselves and their immediate concerns – “If this happens (or doesn’t happen), I’ll kill myself” – and may respond well to an agreement with their therapist which can be incorporated into care-planning. Within any care plan, it is important that there is an agreement about who else should know about the suicidal thoughts. One person is not enough to support someone through a suicidal crisis – other health/care professionals may need to be informed, friends and family also – suicide in the company of others is rare – the more people who can keep this person active and engaged, the fewer opportunities there are for this person to kill themselves. Safety planning is important to preventing suicidal thoughts becoming actions. This can include distraction techniques but a list of contacts to be able to reach-out to during a period of crisis will enhance this security. Having a safe place to stay will also help – though it is not advisable to stay in an unfamiliar environment (such as a hotel room) alone during this time. A stay in a residential facility may be appropriate.
Supporting someone through a suicidal crisis is hard and not all attempts to prevent suicide will be successful. However, keeping an open dialogue about the subject helps. Talking helps. Keep talking.
World Suicide Prevention Day – 10th September.
For more information visit: http://www.iasp.info/
Laura Graham is an Independent Consultant/ Researcher in addiction, mental health and offender management. She spent three years developing suicide prevention policy in prisons. (firstname.lastname@example.org)