The game of life is hard to play
I’m gonna lose it anyway
The losing card of some delay
So this is all I have to say
Suicide is painless
It brings on many changes
I can take it or leave it if I please
And you can do the same thing if you please.

The theme from MASH

As a teenager I loved the programme MASH.

The adventures of the staff of a mobile army surgical hospital in the Korean War.

I particularly liked the theme tune and used to hum and sing it to myself. 

One day my mother heard me singing the words of the chorus, and became angry with me. It wasn’t for several years afterwards that I fully understood why.

Suicide is far from painless. It is the end result of a great deal of emotional and psychic pain for the individual concerned, and the start of pain for their families, while they try to make sense of what has happened.

There seems to be a rise in suicide among young people, and because of this it is becoming increasingly important to try and prevent situations arising where suicide seems like the only option.

Although there is evidence that suicide is currently on the increase amongst all age groups, completed suicide remains a rare event.

Much of the analysis of risk has been undertaken on older populations. This is partly explained by the reluctance of juries and coroners to reach a verdict of suicide in the young, and they will often return an open verdict or a verdict of accidental death instead. For research into an event to be undertaken it has to be thought possible in the first place. Unfortunately, suicide is becoming a much more common cause of death in young people, and prevention is increasingly seen as a vital part of any community.

In Australia the incidence of suicide is at a ten year high.

• In 2012. 11 people out of every 100,000 killed themselves compared with 9.9 the previous year.
• 1901 men and 634 women killed themselves in 2012.
• For the indigenous populations, the rate of suicide is 2.5 times higher for men and 3.4 times higher for women.
• To put the total numbers into perspective, this means that nearly twice as many people died by suicide as died from road traffic accidents.
• For every person who succeeds in killing themselves about 30 others will try.
• This is about 200 attempts every day or roughly one every 10 minutes.
• 250 people formulate a suicide plan every day.
• 1000 contemplate ending their life.

Much of the research into suicide and its prevention has been on older populations.  This has implications for accurate assessment in younger people, who may not fit neatly into the traditional “at risk” groups. Suicide risk assessment is an imperfect science. It is often based on a quantitative rather than a qualitative process. Factors that are associated with completed suicide are clustered together and used to try and predict and quantify risk. More attention tends to be paid to the total number of factors rather than to the quality of the risks.

Screening tools look at the various biological, psychological, social and environmental risks.  They use cut off points, based on the number of symptoms present, to determine whether risk is high, medium, or low.

While many people with diagnosed mental illness die at their own hand, many of those who kill themselves do not have a diagnosis. Similarly, while more people who kill themselves have a history of self harming, the vast majority of those who self harm do not kill themselves. The obvious risk factors interact with other, more imponderable, factors such as resilience or personality.

Reaching the point of suicide is often a gradual process, in which multiple events play a part. However, this is not always so, and sometimes suicide is an impulsive act occurring when a trigger event, and lethal means, are in close proximity, both physically and temporally.

The outcome is even more likely to be unwanted when drugs or alcohol have further reduced the young person’s ability to resist the urge to die. Young people who have had a relationship break up have been known to shoot themselves, or walk in front of an inconveniently passing train, under such circumstances.

Edwin Shneidman, who was Professor of Thanatology at UCLA, outlined ten psychological characteristics that go some way to explaining the suicidal mind.

• Solution seeking.  Suicide represents the answer to psychological distress or some other predicament. An absolute way out of dealing with our problems, even though they may only be short lived.
• An end to conscious awareness.  A way to overcome the burden of both the awareness of our problems, and of having to deal with an unhappy world. To deal with a sense of overwhelming guilt about things that have happened, even if through no fault of our own.
• The pain of feeling pain. Unbearable psychological pain can be ended by being dead. This may be the one symptom that is present in all suicide attempts.
• Hopelessness.  Along with helplessness, this can contribute to completed suicide when the sufferer can see no way for anything to change, or no way in which they can influence things to change. This is frequently when bullying is a major stressor from which the young person cannot escape.
• Frustrated needs.  Rejection in love is often a contributing factor.
• Ambivalence.  The 50:50 phenomenon. There may be extreme feelings of conflict about life and relationships. Love/hate. Life/death. To be/Not to be. Suicide may represent a way to end this unbearable conflict rather than a desire to be dead. I often ask the young people that I work with “What would be so good about being dead?” and then use their answers to help them find other ways to solve their difficulties without ending their life.
• Escape.  There is nothing worse than feeling trapped on the horns of an insolvable dilemma. Suicide is the final step in a series of causally related events. Failure at something, this is my fault, I am useless and become depressed, we ruminate – to try and find a solution – but only exacerbate our negative emotions, this leads to reduced resistance to impulses to die. Suicide then seems like an acceptable path.
• A sense of constriction. Our world narrows down, reducing our options and problem solving skills.
• Communication.   To let others know about our unbearable psychic pain. The intent to die has often been communicated in some way before hand.
• Consistency with our lifestyle.  How someone chooses to kill themselves often bears a relationship to their lifelong coping strategies or way of living. This is also true where writing a note, or tidying up our affairs to leave a neat ending is concerned.

 

There is a thinking triangle that many suicidal people demonstrate. This involves negative thinking about the self, the future and the world around us.

• The self.  Perceptions about the self are usually negative. “I am worthless”, “useless”, “nothing I do ever works out”. We tend to blame ourselves for thinking such thoughts, and become trapped in self perpetuating, negative cognitive cycles. Rumination that is so very destructive.
• The future.  Life is bad, has always been bad, and will always be bad. There is no end to it, ever. Up to 15% of those with depression kill themselves, and negative ruminations play a significant role.
• The world at large.  A world that constantly makes unreasonable demands upon us. Everyone hates us. Despite this we still feel it is all our fault, and that we ought to be able to cope.

Such models highlight a different way to think about risk. They can suggest better ways to assess and manage risk.

Risk is not absolute and is ever changing, sometimes quite rapidly.

Things that increase risk.

• Intrusive negative memories about the self and the world.
• Distorted perceptions and interpretations about the world.
• Rigid thinking processes, with little flexibility.
• Lack of any positive view of the future.
• Negative thinking style, pessimistic, self blaming, black and white.
• Personal perfectionism or feeling it is socially prescribed.

Factors reducing risk.

• Good problem solving skills.
• Reasons for living.
• Good communication skills.
• Strong social support networks that create a sense of belonging.
• Optimistic, empowered outlook on life.
• Hope.

These factors highlight areas where early interventions can be made that should make a difference.

Some early intervention strategies.

• Early diagnosis of mental health problems.
• Prompt treatment.
• Training in problem solving skills.
• Social networking to foster a sense of belonging to a community.  Particularly around immigrant or disadvantaged populations.
• Early interventions around attachment.
• Stopping bullying.
• Early social support to families when required.
• Bringing up our children to like themselves, and to be connected to their world directly.

All of these provide useful pathways to help reduce risk in the longer term.  they all act to increase resilience and self worth.

Contrary to coomon belief, asking about suicide makes it less rather than more likely. So, in the very short term, and probably most importantly, if we see someone who appears to be struggling, we can just ask how they are.

In the words of one current Australian mental health campaign:

“Are you OK mate?”

 

 

 

If you, or someone you know, has been affected by suicide the following links may be helpful

• http://www.lifeline.org.au
• http://www.headspace.org.au
• http://www.youthbeyondblue.com
• http://www.blackdoginstitute.org.au

If you, or someone else that you know, is feeling down and is contemplating suicide, please seek help from a mental health professional as soon as possible.
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