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Part 1
Understanding Suicide
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Chapter 1
Introduction
The statistics
The statistics on suicide are clear and unequivocal. The World Health Organization (2009) notes that every year almost one million people die from suicide. Hawton and Heeringen (2009) agree with this, stating that this equates to one suicide every 40 seconds. They also note that suicide is the tenth leading cause of death, accounting for 1.5 percent of all deaths worldwide. In the last 45 years, suicide rates have increased 60 percent worldwide. Suicide is now one of the three leading causes of death among those aged between 15 and 44 years. These figures do not include suicide attempts which are 20ā40 times more frequent than a completed suicide.
A major factor in suicide is mental health problems; it is estimated that 90 percent of people who end their life by their own hand have some degree of psychiatric disorder. Depression is one particular mental health problem that is correlated with suicide, particularly when the depressed person shows symptoms of previous self-harm, hopelessness, suicidal urges and thoughts. Other common mental health problems are bipolar disorder, schizophrenia, anorexia nervosa and body dismorphic disorder. This last disorder may partly explain why suicide risk increases in females after breast augmentation surgery. Other causes of increased suicide risk can be physical and sexual abuse throughout childhood, as well as world eventsāfor example, natural disasters and sudden deaths of high-profile people such as Michael Jackson.
In Europe, Serbiaāand especially its northern province of Vojvodinaāhas the highest rate of suicide in Europe, with 19 out of 100,000 people opting to kill themselves, compared to a European average of 13 per 100,000. Interestingly enough, a number of sources have noted that suicide rates tend to drop during wars but jump in times of crisis. For example, in Serbia the highest rate of suicides recorded was during the hyper-inflation period and the lowest during the NATO bombing in 1999. It is hypothesized that, during times of war, suicide rates decrease due to the social cohesion that war can create in communities.
Hawton and Heeringen (2009) also state of the statistics, it is āsuspected [that] under-reporting in many countries means this is probably a big under-estimateā (p.1372). Governments tend to put the statistics of suicide lower than they actually are. High rates of suicide do not look good for a country as they imply the population is very unhappy, dissatisfied and not being properly governed. The recording of suicides for statistical purposes can be oriented so that the rates of suicide are likely to be lowered. A prime example of this is with fatal car accidents. I have had clients report directly to me that, should they attempt a suicide, they intend to make it look like an accident, and one of the easiest ways of doing that is with a car accident. Not uncommonly, they plan to drink a bottle of alcohol and then drive at very high speed into a tree, bridge or similar structure. It is highly likely that official statistics will record this as a car accident due to alcohol and high speed, rather than a suicide.
The usual reasons given by suicidal people for making it look like an accident are threefold. First, they do not want to leave behind a stigma for their loved ones. There is less stigma attached to a person who dies by accident than one who dies by suicide. Second, they do not want their loved ones to be guilt-ridden and questioning of self as to whether they should have done more or seen the suicide coming. Third, they may be concerned that their insurance company may not pay out on the life insurance policy if their death is deemed to be suicidal.
Goal of the book
Statistics like these obviously show there is a great need to study and understand why so many people choose to die by their own hand. This book seeks to add to the field in the assessment, management and understanding of the suicidal person. A problem with the study of suicide in recent years has been a distinct lack of new material. For the past twenty years the literature has essentially been picture-straightening, with theorists and practitioners restating or reorganizing what has been said before. This book offers considerable new material on both the theory of suicidal behavior and the treatment of such individuals. For example, the assessment of suicide risk has been discussed in many books over the years, but these studies tend to be one-dimensional in that they only look at the quantitative methods of risk assessment. This book will introduce qualitative methods of suicide risk assessment which isolate the crucial factor of the suicidal person and provide a much more complete assessment of suicide risk.
The overall structure of the book is threefold. First, it offers a theoretical understanding of the suicidal individual and an explanation of why some people are suicidal and others do not consider suicide. It will examine the different motivations of suicidal behavior, even by those who are not suicidal in the first instance. Second, this book will provide a comprehensive system for the assessment of suicide risk, including both quantitative and qualitative approaches. This provides a much more robust framework by which to make assessments of suicide risk. Third, once the assessment has been made and those who are potentially suicidal have been identified, this book will cover ways in which these people can be managedāfor example, with a no-suicide contractāand how they can be treated so that suicide is no longer seen as an option for them. Case studies will be provided in all three sections of this book to demonstrate the theory and practice described.
The authorās background
I have worked for 30 years as a counselor and psychologist in private practice, in drug rehabilitation, with the chronically mentally ill and in a prison. In that time I have come across many suicidal people, including some who have been at considerable risk. At the time of writing this book, I have never had a client complete a suicide, at least that I am aware of. However, as I remain working in the helping professions, it is a possibility that one day such an event will occur.
While working in the prison system, in particular, I learned a great deal about the suicidal individual. I got to speak with and know literally hundreds of suicidal and pseudo-suicidal individuals. My principal task was to coordinate and oversee the system used by the prison to identify and manage suicidal and self-harming inmates. This provided an exponential learning curve as I was dealing with suicidal people day in and day out. I truly learned how they think and operate. I have also been touched personally by suicide. As a teenager, I attempted suicide twice. That personal experience has afforded me a more profound understanding of the area of suicide, particularly in the area of teenage suicide.
Terminology
Sometimes one hears the phrase āHe successfully committed suicideā. Generally, in the field one does not use the word āsuccessā as to kill oneself is hardly a successful act. Also it is generally a misnomer to say that a person has committed suicide. In Australia, suicide and attempted suicide are no longer a crime in all states except one. This is also the case in most westernized societies. The term ācommittedā goes back to the days when suicide was illegal. To complete a suicide was an illegal act, just as it is to commit a robbery. In most countries, it is no longer illegal to attempt suicide or to complete a suicide, so the term ācommitā is a misnomer as it carries the connotation of an illegal act where there is none. The more correct terminology used in this book will be: the person attempted suicide, the person completed a suicide attempt or the person completed a suicide.
The personal level for practitioners
It is hoped that this book will also assist practitioners and others who deal with suicidal people to gain some understanding of their own attitudes to suicide. Suicide is a instance of death that usually elicits a stronger emotional response. If a loved one dies through illness or by accident, that can effect us profoundly. However, if a loved one dies by killing self, that usually creates more of an emotional reaction. Death through illness or by accident is in some ways more understandable and acceptable than a death by suicide. Indeed, if a loved one dies by suicide, perhaps that also reminds us that we are all capable of taking our own lives and it may be this that frightens us all at some level. A death by illness or accident requires some level of bad luck, but a death through suicide requires no such bad luck. It demonstrates that we are all in control of whether we live or die and that some choose to die. If they can do that, it shows to each of us that we also can.
The statistics cited above mean that suicide is an event that can easily come into our own personal world. Many, if not most, people know someone who knows a person who has completed a suicide or has been seriously suicidal. Many even know such a person first-hand. Most people know someone who is in the higher risk groups, such as those with a mental illness, those with alcohol or drug problems, the prison population, the seriously depressed and so on. With regard to our very selves, 66 percent of the general population have at some time thought about suicide and 32 percent have considered suicide in a significant way (Steele and McLennan 1995). Suicide is something that touches us personally, either by knowing someone who is suicidal or by feeling that way ourselves, and therefore we need to be prepared for how to deal with that. This is especially so for those in the helping professions who tend to deal with emotionally unstable people. Sooner or later they will have to deal with someone who completes a suicide or makes a significant attempt.
Of course, there is no right way or wrong way to respond emotionally. There can be a variety of responses:
ā¢Some respond with anger and see the suicidal as selfish for hurting the ones they left behind.
ā¢Some feel sad and despondent at the waste of human life.
ā¢Some respond in a contemplative way and ask the question āwhyā?
ā¢Some take the philosophical view and say that everyone has the right to choose when to die.
ā¢Some find it frightening because the person seemed so happy and full of life.
ā¢Some see it as a courageous act.
Then there is the whole area of responsibility, which again is especially relevant to the healthcare practitioner. If a client suicides, some practitioners can start to feel they were in some way responsible. They may think their suicide risk assessment was poor or that they should have done more to help the person. I have known practitioners who have felt precisely these things and have been deeply affected. It is hoped that this book will assist readers to come to some understanding of themselves in these ways. It aims to give them information about the suicidal so that they can begin to define their personal view of the suicide act and how they view their responsibility while working with the suicidal individual.
Throughout the book, the word āchildā is used to describe children of both genders. For reasons of convenience, both boys and girls are referred to using the pronouns āheā and āhimā, as are adults of both genders.
Unless otherwise indicated, all case studies mentioned in this book are fictional composites created to highlight an issue.
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Chapter 2
What is Suicide?
This chapter seeks to define what constitutes suicide and suicidal actions. One can find a common definition of suicide as the act of intentionally taking oneās own life. The key part of this definition is the word āintentionallyā. This definition seems quite simple and clear. However, upon closer examination, one finds there are various aspects and permutations that leave us with less clarity. These are addressed below.
What constitutes a suicide?
A lot is said about suicide bombers in these turbulent days and one hears the term used regularly. However, is the suicide bomber actually suicidal? This is questionable if one considers the intent of the suicide bomber. To be suicidal, the suicide bomberās primary intent must be to kill self. However, one could reasonably argue that the primary intent of the suicide bomber is to kill others rather than to kill self. The death of the bomber in this sense is only a side effect of the primary intention to kill others, and thus one could say that the suicide bomber does not meet the definition of what constitutes suicide.
In historical accounts of the First World War, one hears of the horrifying trench warfare. In these battles there were very few significant victories, and the soldiers at times had to climb out of the trenches and simply run at the enemy. They knew as soon as they did so that there was a high probability they would be killed by gunfire. I think most would say that these young men were not suicida...
