Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.
They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.
Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.
Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.There is also a general tendency to not want the expressions to be true.In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.
Why should we want to pay attention to an addict’s cry for help?
In Singapore, we lose 1.1 lives every day to suicide.It is still the leading cause of death for youths aged 10 to 29.While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.
When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.
In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.
In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).
What Does This Mean In Practical Terms?
Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.
The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.
What Can We Look Out For?
How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?
Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.
Intense Emotional Outbursts
Extreme Isolation or Withdrawal
The feeling of Being a Misfit in Every Way
Researching or Procuring Means of Suicide.
Self-Harm, Including Risky Substance Use or Behaviours.
Planning of Affairs.
Presence of Trigger Events
Loss of Primary Relationship.
Physical or Mental Health Conditions That Debilitate.
Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?
Ask the Suicide Questions:
In the past few weeks, have you ever wished that you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you made plans about killing yourself?
Have you tried to kill yourself?
If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:
Be empathetic towards the suicidal wish.
The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
Find a genuine connection with the affected person.
However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
Make a safety plan.
Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.
Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.
6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Thanks to the Internet, a global communications network, thousands of host servers worldwide are connected, making instantaneous and interactive sharing of information effortless and uncomplicated. But is the ease of access to information necessarily a good thing? There is increasing evidence that the Internet and social media may influence suicide-related behaviour, and hence the freedom of information may do more harm than good.
The Internet and social media have become fundamental in the way many people communicate and share opinions, ideas, and knowledge – alongside a multitude of information on the topic of suicide that is readily available. Social media coverage of celebrity suicide, which is unfortunately on the rise in current times, increases the risk for prosuicide behaviour of vulnerable individuals. One concern is the contagion effect where people are triggered to act as a result of learning of the death or self-harm of others that they identify with or admire. The glamorising of such stories can normalise suicide and present it as acceptable and unproblematic, leading to a rise in imitational suicides. The Internet also provides a source of information for people to obtain how-to descriptions of suicide and lethal ways of killing themselves.
But that’s not all there is to it. As we dig deeper, we find that the Internet also allows for cyberbullying, the formation of suicide pacts, and even suicide challenges including the infamous ‘Blue Whale Challenge’ – the Internet’s deadliest suicide game. Youths, in particular, are the ones most vulnerable and susceptible to caving into such pitholes – the very generation that is possibly the most in touch with the Internet. Suicide is the shortcut that a large proportion of people with mental health conditions (e.g. depression) succumb to if they aren’t able to cope well – yet, it isn’t an issue that we address much. To look out for one another, we should try to understand how these pro-suiciders think and act, to help them through their difficulties as fast and as much as possible.
There are mainly two categories of suicidal internet users – “Lower Severity Use” and “Higher Severity Use”. These categorial names refer to the extent to which these individuals use the Internet to find out about the act of self-harm or suicide. People that fall under the “Lower Severity Use” category are usually just conducting “pessimistic browsing” – a stage in which they are still uncertain about suicide, but are distressed enough to want to know more. They mostly navigate through the web haphazardly, trying to find stories or others to whom they can relate. They enter broad search terms, and randomly click on whatever appears at the top of their newsfeed. In summary, these people are still struggling to make sense of their feelings. However, a critical distinction between this group of individuals and the other is that people under “Lower Severity Use” actually flit between prosuicide content and online sources of help. Their uncertainty regarding suicide enables them to be more open to rethinking their actions, be it joining online peer support forums or attaining self-help resources. Perhaps the broad search terms they enter on Google could have also played a part in uncovering various methods of treatment.
Unfortunately, this has been proven otherwise for those who fall under the “Higher Severity Use” category. Individuals in this group are much more troubled and perturbed – so much so that they conduct “purposeful researching”, and are no longer as open to receiving online help. These people turn to the Internet to identify, evaluate and choose suicide methods. They research and learn about the effective implementation of each plan, and subsequently acquire the means to carry out the suicide attempt. Part of their research also includes evaluating different factors such as the speed, effectiveness, pain level and technical instructions for them to carry the suicide method. What types of household items can be used for suicide? How much drug constitutes an overdose? What would be the appropriate height to jump to death? Such thoughts fill the heads of these individuals, and the same things are searched up online for them to make a successful suicide attempt. Regrettably, a handful of them also makes use of websites that were never meant to encourage suicide, some of which include professional websites such as WebMD. The published notes on symptoms of overdosage etcetera on such sites could lead some individuals to deduce the amount needed for a successful suicide attempt. This, coupled with the ease of purchasing medications over-the-counter or online, could very well lead to undesirable consequences.
You might wonder, is there a link between the two categories? The answer is yes. Many a time, people start with “pessimistic browsing” before they move on to “purposeful researching”. The decision and will to pursue the act of suicide comes during the transition from former to the latter. The haphazard online navigation, or what was once considered rather “purposeless”, could become addictive. These sensitive and vulnerable individuals could find themselves roped into a cult of negativity, being enticed and increasingly drawn to the provoking and graphic content online. Subconsciously, they will start searching things up more frequently, and their suicidal thoughts and motive escalate. Eventually, they will find themselves under the “Higher Severity Use” category.
Above all, we should be concerned with protecting our loved ones. If we sense that a friend or family member is contemplating suicide or is vulnerable to the suicide-promoting influences of the Internet, seek help from a professional i.e. a counsellor, a psychotherapist or psychologist, immediately. As time passes, there is a higher chance that their initial help-seeking thoughts will be displaced. They will start validating their self-harm and suicidal thoughts and will expose themselves to more suicide content. Suicide isn’t okay, and should not be portrayed as an acceptable response to distress or difficulties. Never downplay the seriousness of suicide and delay help. Trust me; You will be doing anyone at-risk a vital service by persuading them to seek professional assistance.
The Samaritans of Singapore (SOS) reports that the number of suicides in Singapore rose 10 per cent in 2018, with suicides among boys aged 10 to 19 at a record high. Suicide mortality among youths and males is a “significant societal concern”, SOS said, highlighting that for every 10 suicides in 2018, at least 7 involved males. Among boys aged between 10 and 19 years old, there were 19 suicides last year – the highest since records began in 1991 and almost triple the seven cases recorded in 2017.
Suicide does affect children and adolescents, and avoiding the topic does nobody any favours – burying your head in the sand won’t help them learn how to get help if they find themselves needing it. One common misconception about the discussion of suicide is that talking about it plants the idea in people’s heads, causing children and adolescents to think about it. The simple truth is that parents won’t ever know if their child harbours suicidal thinking if they are too afraid to broach the topic. Suicidal behavior in children is complicated. It can be impulsive and associated with feelings of confusion, sadness, or anger. The so-called “red flags” people are cautioned to look for can be subtle in young children. While a young adult might say something along the lines of, “You’ll be better off when I’m gone,” in contrast, a child might say some something similar to, “No one cares if I’m here.”
While the warning signs in children can be subtle, learning to identify potential red flags plays a crucial role in intervention.
Changes in baseline behaviour:
Take note of behavioural changes that aren’t short-lived. While suicidal behaviour is often associated with symptoms of depression, you might also notice the following changes in your child:
Changes in sleeping habits (too much, too little, insomnia)
Changes in eating habits (overeating or eating too little)
Withdrawing from family and friends (social isolation)
Psychosomatic symptoms: headaches, stomach-aches, other aches and pains that can’t be explained
Changes at school:
It’s perfectly normal for children to experience ups and downs during the learning process, but a pattern of negative change can be a red flag that a child needs help. Make a note of the following:
Drop in academic performance
Decreased interaction with teachers and kids at school
Lack of interest in school
Refusal to attend school
Loss of interest in normal daily activities (playing, sports, co-curricular activities)
Preoccupation with death:
It’s natural for children to think about death at times, particularly when they are coping with loss or hear about tragic events in the news. Preoccupation with death, researching ways to die, and/or talking about their own death can be red flags. Watch for the following warning signs that involve thoughts about death:
Frequent questions about or looking up ways to die
Statements about dying or what will happen if the child dies (Examples: “You won’t miss me when I die, I wish I was dead, I won’t bother you anymore when I’m gone.”)
Feelings of hopelessness:
Children who have suicidal thoughts might communicate feelings of hopelessness for the future. They might also make statements about helplessness. These kinds of statements indicate that the child feels as if there is nothing to be done to improve their outcome, and no one can help.
Some children give away their favourite possessions or tell parents, siblings, or friends who should get their favourite possessions. While talk of dividing up possessions might seem like fantasy play to parents, it can signal thoughts of suicide when combined with other changes in behaviour.
Writing or drawing about death or suicide:
Young children often struggle to verbalize intense emotions, but they are likely to take to the diary or drawing block to explore these emotions. Poems, stories, or artwork depicting suicide or, frequent writings and drawings about death should be evaluated.
Significant changes in mood:
Kids experience changes in mood as they grow and work through stressors, but significant changes in mood signal a problem. If your child suddenly shifts from calm and relatively happy to aggressive, completely withdrawn, or very anxious, it’s important to get help.
In addition to the warning signs that a child might experience suicidal ideation, there are also certain factors that can elevate the risk.
Previous suicide attempt (regardless of how serious)
Experiencing a loss (this can include grief and the loss of a relationship due to divorce or family discord or break-up)
Family history of suicide or suicide attempts
Violence or witnessing violence
Feelings of hopelessness
Feeling like a burden
Communication Tips with your Child
Any signs of suicidal ideation or behaviour should be taken seriously.
Parents should ask specific, direct questions about suicidal thoughts – “Are you thinking about hurting or killing yourself?”
Parents should also talk openly about depression by asking questions like, “Are you feeling depressed or very sad lately?” These questions show your child that you understand and that you care. Conveying empathy in a time of emotional crisis is crucial. You may be concerned about saying the “right” thing. But the truth is that just having an open and honest discussion with your child can provide them with much-needed support.
Keep the Talk Age-Appropriate
Make sure that your child understands what you are saying and is not confused or bored by the discussion.
Use words that your child can understand. Words such as “depression” or “emotional reaction” are probably too complex for a younger child but may be appropriate for an older child or adolescent.
Try comparing your child’s depression to something that your child is already familiar with like a physical illness such as the flu or an ear infection.
Keep the Conversation Positive
Depression is a serious illness that causes emotional and physical pain, but try to keep the conversation focused on the positive.
By maintaining a positive and hopeful outlook in your discussions, you will avoid unnecessarily alarming your child.
Prioritize the Positive
Another important way to prevent suicidal behaviour is to prioritize interacting with your child in positive ways. Sometimes we get into a sort of vicious cycle with a child. The child does something concerning; the parent gets critical; the kid does something more concerning; the parents get more upset. All interactions turn contentious. Interacting in positive ways means doing fun things together, hanging out and chatting about things that aren’t controversial, that aren’t difficult.
Don’t make promises you cannot keep.
Don’t go into detail about topics that you are not certain of.
Do tell your child what you do know.
Make a list of questions to discuss with your child’s mental health professional.
Your child needs to know that you recognize and respect their feelings.
Even if you do not quite understand their thoughts, don’t dismiss their feelings.
Avoid comments like “What do you have to be depressed about?” or “Don’t be ridiculous.”
Dismissive comments can cause a child to hide their feelings or become defensive.
It may seem obvious to you that you love your children, and that they know you love them. But when they’re having a hard time, children need to hear over and over again from you how much you love them, and how much you care about them. It’s not good enough to just say, “You know I love you.” You need to convey that in small and big ways. These days, we all have so many things we’re juggling that our children can end up unsure of where they fit in, and whether you really have time for them. Let them know how important they are to you.
Be a Good Listener
Allow your child to talk openly and express their opinions and thoughts.
Avoid interrupting, judging or punishing them for their feelings.
Listening demonstrates that they have someone they can confide in help to sort out their feelings.
If there are any safety concerns, do not provide judgment or discipline; simply remove your child from immediate danger, do not leave them alone, and get them immediate help.
Never dismiss suicidal thoughts in a child and any suicidal thought or behaviour should be brought to the attention of your mental health provider immediately. If needed, bring the child to an emergency room or call an ambulance.
If for some reason the above options are not available, make a referral to the Samaritans of Singapore (SOS) by writing to firstname.lastname@example.org, or calling its 24-hour hotline at 1800-221 4444.
The author hopes that the suicide prevention/awareness workshops he conducts at schools and corporations are doing some good.