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.”

44 SEPT/OCT 2009 • OH!

 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);
• 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.
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.

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.
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.

SEPT/OCT 2009 • OH! 45

FEATURE
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.
46 SEPT/OCT 2009 • OH!
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.

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
FEATURE
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!
SEPT/OCT 2009 • OH! 47