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.
- 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.
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/
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