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Gently tipping the balance

by
Datuk Dr Leow Chee Seng
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
“I lost everything! I invested all my money in my business. intent is indirect and may be pieced together only in
During COVID-19, I lost everything! I don’t even have retrospect”. Other indications are: “I guess I won’t be
money to feed my family.” This is a confess of a businessman. seeing you again” or “I want to thank you for trying so
The person has even had the attempt of suicidal. hard to help me.”

When contemplating suicide, the individual is attempt- A depressed patient leaving on a weekend pass from a
ing to take back control of a situation they feel they hospital or upon retiring for the night may say “goodbye”
have no control over. Thus, the best cure is helping instead of “goodnight”.
them regain this control.
According to the Diagnostic and Statistical Manual of
Nobody can ever predict how another person will react Mental Disorders (DSM-IV-TR), mental disorders that
to more troubling or difficult things in life. Different could lead to suicidal impulses include conduct disorder
people handle different situations in different ways – among children, delirium, dementia, substance-induced
this is an undeniable fact of life, no matter how old you mental disorders, amphetamine-induced disorders,
are. schizophrenia, a major depressive or manic episode,
anxiety disorders, dissociative disorder, sexual and gender
But there are usually some clear advance warning signs identity disorders, borderline personality disorder and
that a friend may be in trouble and that suicide may be premenstrual dysphoric disorder.
something he is considering. Since suicidal wishes could
become a prevalent and potentially lethal problem in Researchers have noted that some individuals lean towards
depressed patients, therapists need to understand why suicide more than others. The characteristics associated
the patient is considering such drastic action in the first with such at-risk adolescents include the following:
place.
• A previous suicide attempt;
The therapist will then be in a better position to select • Suicidal gestures (cutting off one’s hair, self- i flicted
appropriate and effective techniques to deal with a particular cigarette burns, other forms of self- abuse)
problem. However, no anti- suicidal strategy is of any
• A tendency to be socially isolated (having no
use unless the therapist is first able to detect and assess
friends or only one friend)
the degree of suicidal intention.
• A record of school failure or truancy

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• A broken home or a broken relationship with a In these fantasies, the people who have caused the
significant other (family member, boy/girlfriend) psychological pain feel punished by suicide. While
• Talk of suicide, either one’s own or that of others grieving, they demonstrate great remorse for having
• A close friend or relative who was a suicide victim driven the person to take his own life. In this type of
suicide (or suicide attempt), the individual is attempting
• Not living at home
to take back control of a situation he feels he has no
• Preoccupation with death or dying control over.
• A recent significant loss or the anniversary of one
• Sudden disruptive or violent behaviour In killing himself, he is taking back control, getting in
• Being more withdrawn or uncommunicative the last word. And, if the real life situation has left the
and more isolated from others than usual individual feeling totally helpless, the idea of going out
of control and teaching other people a lesson in the
The most common external causes – or more accurately, process can be strangely appealing.
external catalysts – of suicidal behaviour include Suicidal urges that are brought on by external
bullying, peer pressure incidents, family crises and circumstances include an unwanted pregnancy without
health problems. a support system, abuse in the family or relationship,
sexual assault, sexual harassment, bullying, peer rejection
Usually, these are situational in nature and have an and romantic rejection.
escalating history that leads the individual to feel he
has no other way out. In their minds, the situations had The individual is intrigued by the fantasy that he would
reached a breaking point, and they see no other way out be getting back at somebody whom he feels has hurt
except death or the threat of death. 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

Depressive fantasy of helplessness – being ignored or having others dismiss
the attempts as attention-seeking– it can ultimately lead
When external forces become unbearable enough for to the person successfully taking his own life. When the
a person to contemplate suicide, depression of some external causes are addressed and dealt with, and the
sort is always involved. The depression causes the person’s sense of helplessness is overcome, the suicidal
individual to make irrational decisions based on urges all but disappear.
unstable emotions.
Biological causes
This type of suicidal tendency is often accompanied by
“after-death” fantasies in which the now dead individual, Internal causes of suicidal behaviour are much more
after taking his or her own life, gets to view the reactions complex and more laborious for the average person to
and grief of those left behind. see than external causes. The most common internal

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causes of suicide or suicidal behaviour include clinical The next step is to draw two columns on a sheet of
depression, psychiatric disorders or chemical imbalances. paper. The therapist and patent can then list reasons in
favour of living that was valid in the past. The therapist
Essentially, all suicide attempts come down to something proceeds to ascertain which of the “past” reasons for
inside the suicidal person, but those without external living are valid in the present or, at the very least, might
catalysts are often biological in nature. Severe depression, be valid in the future.
which is believed to be caused by a combination of
external factors and internal chemistry, is one thing that It is interesting to note that the suicidal patient has
almost every suicide or suicide attempt has in common often nullified these positive factors in his life, which he
– how that depression came to be is the only difference. has either forgotten, ignored or discounted their value.

Some people suffer from depression because of chemical The therapist should also recognise that it may be quite
imbalances and to outsiders, their lives seem high – or painful for the patient to reconsider his decision to kill
at the very least average – with nothing outstanding, himself. The patient may have undergone enormous
that would indicate a reason for this person wanting to turmoil before arriving at his decision to terminate his
die. suffering by suicide, and reopening the question may
mean that he will have to go through another period of
Tipping to positive turmoil and prolong his plan.

It is important for friends and therapists to “play for Being alert

time” until the dangerous period has passed.
When dealing with depression, hopelessness and fear, it
The strategy used is to involve the patient himself in is difficult to know where the bad feelings end and the
the therapy process such that he decides to stick it out real risk begins. If your friend exhibits two or more of
until he sees where the therapy is going. This can be these warning signs in a short time, it is best that you
done by stimulating an interest in his therapeutic try to help.
approach.
This does not mean you should take the weight of
Involvement of patients in the treatment plan helps to their world upon your shoulders, but it does mean you
treat the decision to commit suicide as the outcome of should alert other people to the possible risk.
the struggle between the patient’s wishes to live versus
his wishes to die. As in a declaration of war, an Go to your other friends, your at-risk friends family,
irrevocable decision may be made based on a margin of a trusted teacher or counsellor. Just like your friend –
a single vote, as it were. who does not have to go through a difficult time alone
– you do not need to try to save your friend on your
Initially, therefore, the therapist’s efforts should be directed own.
towards shifting the votes in favour of living. On top
of it, the therapist should maintain continuity between It is impossible to know for sure if a person who seems
sessions. sad or who has changed for the worse is at a real risk of
committing suicide. If you fear your friend may attempt
Once the patient has agreed to weigh the pros and suicide, you should get some outside help and guidance
cons of suicide, the therapist would elicit the “reasons from people who are better able to get your friend the
for living” and “reasons for dying.”Although patients help he or she really needs.
might forget their reason for living, we can guide them
by asking them to think of happy moments. Nothing in this world cannot be solved. Face it and
tomorrow would a better day.

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