The crisis of suicide

That cry for help may come anytime. The pastor needs to he ready.

Vern R. Andress, Ph.D., is professor of psychology at La Sierra University, Riverside, California.

The phone call interrupted my dinner. The voice on the other end was desperate. "I'm at my wit's end, and you are the only one I can turn to. If you can't give me one good reason to live, I've made up my mind to end it all."

The words were slow, deliberate, and almost imperceptible; the voice unforgettable and bone-chilling. Such calls come hundreds of times each year. A minister's chance of getting such a call is greater than that of almost any other professional, including physicians and psychologists. Each year between 25,000 and 30,000 people kill themselves. It is estimated that 10 times that many attempt suicide.

Suicide is a major problem today. Pastors need to have a proper understanding of the issues involved. They need a clear insight into the mind of the suicidal individual in order to be better prepared to face that desperate cry for help.

The mind of the suicidal person

In the late 1950s psychologists Edwin Shneidman and Norman Farberow coined the phrase "the cry for help" to describe the generally ambivalent feelings of the suicidal person. The suicide threatener is not simply a manipulative person capriciously trying to get attention, but rather is someone who is in so much pain that they have concluded there is no other solution to their problem except a permanent end to pain---death.1 The interesting point is this: Such persons are ambivalent about life and are looking for a reason to live. In their desperation they are willing to gamble with life. If they find some hope that the future will be better, they will opt for life. If they sense no future hope, they will opt for death.

The suicidal person: a profile

Shneidman and Farberow suggested that suicidal people generally fall into one of three categories: the threatener, the attempter, and the committer.

The threateners tend to be young women between the ages of 15 and 25. They make their threats known to parents, teachers, pastors, and significant others either vocally or by leaving notes where they can be found. Their level of ambivalence is the greatest, leaning in the direction of wanting to live rather than wanting to die. They want to get the attention of significant others and the concomitant commitment to help them end their painful existence in a life-supporting way.

The suicide attempter is often a single woman, who is usually somewhere between 19 and 30. Three out of four people who attempt suicide are female. Again, the level of ambivalence is high, leaning in the direction of wanting to live. This is shown by the fact that the suicidal gestures of attempters usually involve a method with a relatively safe margin that allows for rescue before death actually takes place. Taking medication (sometimes prescribed, but often over-the-counter) is the preferred method. The slow action of medication helps to reveal the attitude "If I am rescued, it was meant to be; if I'm not rescued, then my time has come." Attempters frequently commit their act in the presence of others, or in locations where they expect others to be so they can be rescued. It is not unusual for them to take the medication and then telephone a friend, a pastor, or a suicide hot line, explaining what they have done and asking for help. Their notes are often left in conspicuous places and frequently explain the reason behind their attempt and the seriousness of their intent. It is not uncommon for a person to make several attempts, leading significant others to feel that they are being manipulated and therefore to become calloused and indifferent. Unfortunately, their attempts can become unintentionally fatal.

Three out of four suicide committers are male. Typically, the male is older and shows his lethality by selecting a method with little room for rescue or change of heart. Guns, especially handguns, are the most common means of suicidal death, with hanging and jumping close seconds. Unlike the act of taking a medication, with its fairly long margin of safety, the methods typically chosen by the suicide committer are precipitously fast-acting. Once the trigger is pulled, there is no opportunity to reverse the action.

Typically, suicide committers may be single, separated, divorced, or widowed. Marriage seems to act as a buffer against suicidal death, perhaps because it represents a readily available support system. Separated or widowed males are considered to be highly lethal to themselves, while single or divorced females pose a similar high risk.

Alcohol also plays an important, if somewhat vague, role in the lethality of the committer. About one third of those who commit suicide have a detectable amount of alcohol in their blood at the time of their autopsy. Alcohol's exact role in suicidal behavior is not clear. Does it reduce the person's inhibitions toward self-destruction, does it enhance their hopeless feelings, or does it merely cloud their mind and make it hard for them to perceive any other alternatives that may be available to them?

Why Suicide?

The most common question asked following a suicide threat, attempt, or an actual death is "why?" In the case of threateners and attempters, the individual can be asked that question directly. The answers are often vague and inconclusive. In the case of committers, we can only speculate. Suicide notes are rarely a good source of information. First of all, only about one third of suicide committers leave a note.2 Most of the note writers are female,3 and the notes rarely give any indication as to motive. Such notes often contain directions as to how to close out a person's estate or how to dispose of their body. Frequently they are requests for forgiveness either from significant others or from God. When they do give an indication about motive, they reveal unbearable and unending mental or physical anguish and pain. The major themes of these notes are hopelessness, helplessness, and loneliness.

Researchers usually turn to those closest to the deceased to find out why the person may have resorted to the extreme step. Unfortunately, the inner thoughts and feelings of people are highly guarded secrets of life, I and more often than not, the survivor-victims of suicide are caught off guard 1 and left perplexed as to motive. In I looking back over the life of their loved one or friend, especially the last few I days, they suddenly become aware of I "clues" that the deceased dropped here and there encoding their hopelessness and I their tendency toward self-destruction. But § these indicators were either missed, or they 1 were taken to be less than serious.

Suicidologists believe that the leading I motives for suicide are a sense of helplessness and hopelessness over some event I in the person's life over which they feel I they have no control, such as irreversible j physical illness and pain, or an anguishing disruption in personal relationships with no perceivable positive outcome.

Suicide is not an impulsive act with little forethought or planning. In fact, it is well designed and thought out. Research suggests that most suicides evolve over at least a 90-day period preceding the attempt, the planning process being quite orderly and methodical, with three distinct stages.

Stages in suicide planning

The first stage is called the resolution phase. This is usually the longest phase and is accompanied by a great deal of agitation and restlessness. During this time the individual is struggling with the moral and ethical issues of suicide. They are asking themselves whether or not suicide is a sin or what effect it will have on loved ones and friends. The deep significance of these questions accounts for the high degree of edginess and agitation felt by the individual. Their significant others experience this as a time of extreme moodiness and impatience.

The second stage, the initiation phase, involves less time than the first and produces a milder form of agitation. In this phase the individual formulates actual plans for the act. The person wrestles with what means should be used: shooting, hanging, jumping, drug overdose, etc. The person also plans on where to do it: at home or off in some remote region. If at home, which place: the garage, the living room, a bedroom? The person also thinks about who might find their body: family members, friends, police, or a maid in a motel. Once they have resolved these issues, they begin to gather the means for carrying out their suicidal act, usually collecting an overabundance of the items they plan to use.

When the first two phases of the plan are in place, the individual often becomes very calm as he or she enters the third stage or postponement. Knowing that they are capable of solving their problem, they relax and bide their time until they fulfill their plan. This serenity often catches the family and friends off guard, so that when their loved one finally commits the suicidal act, they are surprised. People close to the victim often say such things as "I can't believe he actually killed himself. If he had done it a few months ago I would not have been shocked ... he was so anxious and agitated back then. But recently it seemed as if things were going so much better. He seemed so relaxed."

Clues to suicide

Identifying clues to suicidal tendencies is important, particularly for family members and significant others so that they can be of help to the person concerned. Such clues include the following:

1. Unusual periods of sleeplessness. Because individuals are so burdened in the first stage of the suicide plan, they find it difficult to sleep. They wrestle with thoughts that may affect them for eternity, and these thoughts aren't easily turned on and off. Such insomnia is frequently accompanied by periods of general sadness.

2. Sudden changes in appetite, weight, or sexual drive. These could include either an increase or a loss in appetite, an intensification or loss of interest in sex, or an unusual preoccupation with and consumption of drugs and alcohol.

3. Loss of interest in family, friends, and familiar pursuits. Suicidal individuals often become so preoccupied with their own thoughts that they begin to neglect their friends and family. They do not participate in family functions or discussions. To a noticeable extent they lose interest in such things as sports, hobbies, and work.

4. Frequent discussions of death, the wish to die, or feelings of worthlessness. Such comments as "You'd be better off without me," or "I can't take much more of this," or "I wonder where people go when they die, and if they feel any pain after they are dead" should be taken as possible indicators of a contemplated suicide. This is especially true if these comments are made along with other types of clue behavior.

5. Sudden, unusual interest in death and death rituals. When individuals uncharacteristically begin to discuss making or changing a will or insurance policy, or when they show excessive concern about making funeral arrangements, it may indicate some suicidal intention.

6. Unexplainable or illogical giving away of prized possessions. When an individual begins to give away things they have spent a lifetime accumulating, especially to casual acquaintances, such behavior should alert family members to the possibility of suicide.

7. Collecting information and means for suicide. This could include a sudden interest in guns, the collecting and hoarding of medications, or a surprising interest in news accounts of other people's suicidal deaths.

When that call comes

When you get that urgent call in the middle of your dinner or in the middle of the night, what should you as a pastor do? Here are a few basic points.

1. Remain calm and don't act surprised, frightened, or overwhelmed by what the person is telling you.

2. Take seriously anyone's talk of suicide. Don't get caught in the "boy who cried wolf" syndrome. Remember, everyone who talks about suicide is a potential danger to themselves.

3. Be genuine and honest in expressing your interest, concern, and support for the person with whom you are talking. Often they will say something like "Why should you care about me? You hardly know me; even the people who are closest to me don't care." Give an honest answer, something like "It's true, I don't know you very well, but I want to hear about your pain; I care about your wellbeing, and how you deal with that pain."

4. Don't be judgmental or moralistic. Telling them that they are committing a horrible sin or reminding them of how selfish suicide is will only add to the guilt that has led them to contemplate suicide.

5. Don't argue. Don't tell them they can't commit suicide. They really can, and nobody can stop them if they are intent on such an act. They may go ahead just to prove they are in control.

6. Listen carefully, especially to the hidden meanings behind the words. Often the one thing the person most lacks in life is another person who is genuinely willing to listen. Never rush in with platitudes or suggestions. Let them have their say. Many times they won't come right out and say they are going to kill themselves. Instead they will make such statements as "I'm thinking about checking out. .." or "My time has come . . ." Get them to clarify these vague statements by asking a direct question, such as "Are you telling me that you are thinking about killing yourself?" Such a question tells them that you are listening and that you are actually hearing their message. By listening carefully, you may hear something that will significantly help you in giving them aid.

7. Get them to seek professional help from someone trained in dealing with suicidal behavior. To do this, you should maintain a current list of professional counselors in the area. A good source of information is the local suicide-prevention hot line, if there is one in your area.

8. Act quickly. After you have established a strong rapport with them by your genuine concern, gently insist that they immediately see someone for counseling. If necessary, encourage them to get into a hospital setting.

9. Don't assume guilt for things over which you have no control. If you deal with suicidal people long enough, the chances are high that you will eventually be involved with one who refuses your intervention and commits suicide. At times like this it is easy to torture oneself with feelings of guilt. Remember that no one is ever responsible for someone else's actions. If you feel burdened by your feelings, don't be too proud to seek professional help yourself.

Be ready for that cry for help

Suicide is a unique kind of death. Almost without exception it leaves people behind who will have a complicated process of grieving because of the unanswered questions surrounding the death and the assumption of guilt for the person's actions. As a pastor-counselor, it is important to understand these burdens felt by the survivor-victims of suicide. Pastors should know the process of referral and the process of grief recovery. They should also be alert to minister to the bereaved ones, especially at times such as the loved one's birthdays, special holidays, wedding anniversaries, and the bereavement anniversary when memory has a way of bringing back the tortured past. As a pastor-friend you may want to send survivor-victims a little note of concern and encouragement at these special times to let them know you care. Survivors generally receive a great deal of concern and caring right after the death of their loved one, but soon after, their special needs and pains are forgotten as people rush on with their busy lives. As a minister, you should always be ready for the cry for help and for the cry of the grieving.

1. Edwin S. Shneidman and Norman L. Farberow, eds., The Cry for Help (New York: McGraw-Hill, 1958).

2 Vern R. Andress and David M. Corey, The Demographic Distribution of Suicide in Riverside Country Between 1965 and 1969 (Loma Linda, Calif.: Loma Linda University, 1976).

3 L. B. Borque, B. Cosand, and J. Kraus, "Comparison of Male and Female Suicide in a Defined Community," Journal of Community Health 9 (1983): 7-17.

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Vern R. Andress, Ph.D., is professor of psychology at La Sierra University, Riverside, California.

July 1996

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