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Suicide Risks for Persons with Addictions

Suicide Risks for Persons with Addictions

Written by: Juliana Pang, Therapist

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.

  • Mood
    • Intense Emotional Outbursts
    • Extreme Isolation or Withdrawal
    • The feeling of Being a Misfit in Every Way
  • Speech
    • Hopelessness
    • Helplessness
    • Worthlessness
  • Behaviour
    • 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.

In these situations, working with professional therapists can help the affected person build up their sense of self, adjust unhelpful beliefs towards the whole life experience, reignite their sense of being a valued part of humanity and community, develop skills to cope with life’s stresses and build a treatment and recovery plan for any inter-connected problems such as their addiction problems.

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.


1 Glendon.org. 2021. Understanding & Preventing Suicide – DVD « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/understanding-preventing-suicide-dvd0/

2 Sos.org.sg. 2021. Suicide Facts and Figures | Samaritans of Singapore (SOS). [online] Available at: https://www.sos.org.sg/learn-about-suicide/quick-facts

3 Addiction Center. 2021. Addiction and Suicide – Addiction Center. [online] Available at: https://www.addictioncenter.com/addiction/addiction-and-suicide/

4 Goeders, N., 2003. The impact of stress on addiction. European Neuropsychopharmacology, 13.

5 Glendon.org. 2021. Understanding & Preventing Suicide – DVD « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/understanding-preventing-suicide-dvd0/

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

7 Glendon.org. 2021. Dynamics of Suicide: An Interview with Dr. Israel Orbach « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/dynamics-of-suicide-an-interview-with-israel-orbach/

8 Glendon.org. 2021. Understanding & Preventing Suicide – DVD « The Glendon Association. [online] Available at: https://www.glendon.org/product-post/understanding-preventing-suicide-dvd0/

9 Glendon.org. 2021. Firestone, R.W. – The “inner voice” and suicide « The Glendon Association. [online] Available at: https://www.glendon.org/resource/firestone-r-w-the-inner-voice-and-suicide/

Photo by Francisco Moreno on Unsplash

The Online Environment (Internet) and Suicide

The Online Environment (Internet) and Suicide

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.

 


 

References:

Dr Lucy Biddle, 2019, Tackling Challenges of the Online Environment and Suicide-related Internet Use, video recording, Mental Health Academy <https://www.mentalhealthacademy.co.uk/dashboard/catalogue/tackling-challenges-of-the-online-environment-and-suicide-related-internet-use>.   (Accessed 16/06/2020)

Photo by Oleg Magni on Unsplash

 

Myth Busting Teen Mental Health – Self-Harm

Debunking myths about adolescent mental healthviolence-self-harm

Although society has made some headway in reducing the stigma and misinformation about general mental health issues, the public’s understanding of self-harm remains decades behind. Let’s debunk some common myths about adolescent self-harm.

Myth: ‘Self-harm means cutting right? Only emos and goths do that.’

Self-harm refers to a range of behaviours that are purposely inflicted to cause damage to the body. It can include cutting, but also refers to scratching, picking at wounds, burning, pinching, hitting, head banging, and minor overdosing. Self-harm can also be in the form of excessive risk-taking that is above and beyond typical adolescent risk-taking.

It is a misconception that only ’emos’ and ‘goths’ self-harm. Although self-harm can be part of adolescent subculture experimentation, it is more often a sign that a teenager is experiencing unmanageable distress. Self-harm becomes a way of coping with distress that provides temporary relief from emotional pain.

Myth: ‘Self-harm is all about attention-seeking. If a person was really depressed enough to cut themselves then they would probably just commit suicide.’

Self-harm is not about attention-seeking. It is often a secretive and private behaviour. For a teenager, self-harm is a way of coping with unmanageable distress, and can be a medium to communicate that distress to others. Self-harm should never be dismissed as attention-seeking.

A person who cuts themselves is not necessarily suicidal. Cutting behaviour can be suicidal, non-suicidal, or a mix of both. It is important to remember that suicide risk is not static. A teenager who displays non-suicidal self-harm can become suicidal at another point in time.

Any teen who self-harms should undergo a thorough and comprehensive suicide risk assessment by a registered mental health professional. Their suicide risk should be closely monitored and assessed at regular intervals.

Myth: ‘I can punish my teen so that they stop self-harming. That will solve the problem.’

Punishing a teen for self-harming does not solve the problem. Cutting is a symptom of a deeper issue – unmanageable distress. Stopping the cutting via punishment may actually worsen their distress, especially if the teen lacks healthy and effective coping strategies.

Here are some suggestions for what you can do instead of punishing your teen:

  • Be an active listener
  • Validating their feelings
  • Be emotionally and physically present for them
  • Engage in joint problem solving

Always seek advice from a registered child psychologist if you suspect that your teen may be self-harming.

Written by Leeran Gold, Psychologist in our Forensic Service.

At Promises Healthcare, we are committed to helping you through your journey to recovery. Discover a new life and find renewed hope. If you or someone you know needs mental health support, please contact our clinic for inquiries and consultations.

For after-hours crisis support contact your local mental health service or emergency services.

In Singapore: IMH 24-hour helpline +65 6389 2222, Ambulance 995.

Myth Busting Mental Health – Youth Suicide

Myth Busting Mental Health – Youth Suicide

youth-suicideLet’s take a look at some common mental health myths about youth suicide and set the record straight.

Attempted suicides are just a cry for attention.

A suicide attempt should never be dismissed as ‘just a cry for attention’. A young person is highlighting that their level of internal distress is unmanageable and unbearable. They need help, not judgement. A young person can feel even more isolated and misunderstood if those around them fail to take their actions seriously. Never ignore or minimise suicidal behaviours and seek professional help as soon as possible.

Teens who cut their wrists must be suicidal.

Cutting is a form of self-injury that can either be suicidal or non-suicidal. In both cases, the cutting is a sign that a young person is not managing their internal distress in a healthy way. Any young person who self-injures should undergo a full suicide risk assessment by a registered mental health professional.

If I ask a young person whether they are feeling suicidal, it might put the idea in their head.

This is a particularly dangerous myth as it discourages discussion of the issue at hand. Talking about suicidal feelings will not encourage a young person to commit suicide. When having the conversation try to stay calm and non-confrontational. Remain open and genuine, and remember the overall message – it is ok to talk about feelings, and there is help available. Show that you care and avoid judging the young person. If you are uncomfortable or unsure about having the conversation, get in touch with a mental health professional for some tips and guidance.

Written by Leeran Gold, Psychologist in our Forensic Service.

At Promises Healthcare, we are committed to helping you through your journey to recovery. Discover a new life, away from addiction and find renewed hope. If you or someone you know needs mental health support, please contact us today for inquiries and consultations.

For after-hours crisis support contact your local mental health service or emergency services.

In Singapore: IMH 24-hour helpline +65 6389 2222, Ambulance 995.

Self-Harm Series – Part 3 –

Self-Harm Series – Part 3 –

What can I do to help my teen?
In addition to regular professional mental health support, here are some things you can do to help your teen:
– Show that you care
– Be non-judgmental
– Accept your teen’s feelings
– Suggest distractions
– Learn basic first aid
– Encourage them to communicate their feelings
– Ensure an authoritative balance in your parenting style

Avoid:
– Guilt trips
– Punishing your teen for self-harm

What can the school do to support my teen?
Ask to see your school’s policy on self-harm management. If your school does not have a policy, get in touch with your treating psychologist who can provide the school with resources and psycho-education. Make sure the school counselor sees your teen regularly, and that they are aware of any safety and risk issues.

If you suspect that your teen is self-harming, seek professional help as soon as possible. Contact Promises Healthcare for a confidential enquiry today.

If your teen is in any danger, contact your local ambulance service on 995. You can contact the Institute for Mental Health 24-hour hotline on 6389-2222.

This is part 3, of a series of 3 posts        Click here for Part 1     Click here for Part 2

Written by: Leeran Gold – Psychologist, Forensic Services, Promises Healthcare