Suicide is a significant cause of death in many western countries, in some cases exceeding deaths by motor vehicle accidents annually. Many countries spend vast amounts of money on safer roads, but very little on suicide awareness and prevention, or on educating people about how to make good life choices.

Attempts at suicide, and suicidal thoughts or feelings are usually a symptom indicating that a person isn't coping, often as a result of some event or series of events that they personally find overwhelmingly traumatic or distressing. In many cases, the events in question will pass, their impact can be mitigated, or their overwhelming nature will gradually fade if the person is able to make constructive choices about dealing with the crisis when it is at its worst. Since this can be extremely difficult, this article is an attempt to raise awareness about suicide, so that we may be better able to recognize and help other people in crisis, and also to find how to seek help or make better choices ourselves.

Here are a number of frequently asked questions to help raise awareness and dispel some of the common myths about suicide:

1. Why do people attempt suicide?
People usually attempt suicide to block unbearable emotional pain, which is caused by a wide variety of problems. It is often a cry for help. A person attempting suicide is often so distressed that they are unable to see that they have other options: we can help prevent a tragedy by endeavoring to understand how they feel and helping them to look for better choices that they could make. Suicidal people often feel terribly isolated; because of their distress, they may not think of anyone they can turn to, furthering this isolation. In the vast majority of cases a person who attempts suicide would choose differently if they were not in great distress and were able to evaluate their options objectively. Most suicidal people give warning signs in the hope that they will be rescued, because they are intent on stopping their emotional pain, not on dying.

2. Aren't all suicidal people crazy?
No, having suicidal thoughts does not imply that you are crazy or mentally ill. People who attempt suicide are often acutely distressed and the vast majority are depressed to some extent. This depression may be either a reactive depression which is an entirely normal reaction to difficult circumstances, or may be an endogenous depression which is the result of a diagnosable mental illness with other underlying causes. It may also be a combination of the two.

The question of mental illness is a difficult one because both these kinds of depression may have similar symptoms and effects. Furthermore, the exact definition of depression as a diagnosable mental illnesses (i.e. clinical depression) tends to be somewhat fluid and inexact, so whether a person who is distressed enough to attempt suicide would be diagnosed as suffering from clinical depression may vary in different peoples opinions, and may also vary between cultures.

It's probably more helpful to distinguish between these two types of depression and treat each accordingly than to simply diagnose all such depression as being a form of mental illness, even though a person suffering from a reactive depression might match the diagnostic criteria typically used to diagnose clinical depression. For example, Appleby and Condonis[1] write:

The majority of individuals who commit suicide do not have a diagnosable mental illness. They are people just like you and I who at a particular time are feeling isolated, desperately unhappy and alone. Suicidal thoughts and actions may be the result of life's stresses and losses that the individual feels they just can't cope with.

In a society where there is much stigma and ignorance regarding mental illness, a person who feels suicidal may fear that other people will think they are "crazy" if they tell them how they feel, and so may be reluctant to reach out for help in a crisis. In any case, describing someone as "crazy", which has strong negative connotations, isn't helpful and is more likely to dissuade someone from seeking help which may be very beneficial, whether they have a diagnosable mental illness or not.

People who are suffering from a mental illness such as schizophrenia or clinical depression do have significantly higher suicide rates than average, although they are still in the minority of those who attempt. For these people, having their illness correctly diagnosed can mean that an appropriate treatment can begin to address it.

3. Doesn't talking about suicide encourage it?
It depends what aspect you talk about. Talking about the feelings surrounding suicide promotes understanding and can greatly reduce the immediate distress of a suicidal person. In particular, it is OK to ask someone if they are considering suicide, if you suspect that they are not coping. If they are feeling suicidal, it can come as a great relief to see that someone else has some insight into how they feel. This can be a difficult question to ask, so here are some possible approaches:

• "Are you feeling so bad that you're considering suicide?"

• "That sounds like an awful lot for one person to take; has it made you think about killing yourself to escape?"

• "Has all that pain you're going through made you think about hurting yourself?"

• "Have you ever felt like just throwing it all away?"

The most appropriate way to raise the subject will differ according to the situation, and what the people involved feel comfortable with. It's also important to take the persons overall response into consideration when interpreting their answer, since a person in distress may initially say "no", even if they mean "yes". A person who isn't feeling suicidal will usually be able to give a comfortable "no" answer, and will often continue by talking about a specific reason they have for living. It can also be helpful to ask what they would do if they ever were in a situation where they were seriously considering killing themselves, in case they become suicidal at some point in the future, or they are suicidal but don't initially feel comfortable about telling you. Talking exclusively about how to commit suicide can give ideas to people who feel suicidal, but haven't thought about how they'd do it yet. Media reports that concentrate solely on the method used and ignore the emotional backdrop behind it can tend to encourage copy-cat suicides.

4. So what sort of things can contribute to someone feeling suicidal?
People can usually deal with isolated stressful or traumatic events and experiences reasonably well, but when there is an accumulation of such events over an extended period, our normal coping strategies can be pushed to the limit.

The stress or trauma generated by a given event will vary from person to person depending on their background and how they deal with that particular stressor. Some people are personally more or less vulnerable to particular stressful events, and some people may find certain events stressful which others would see as a positive experience. Furthermore, individuals deal with stress and trauma in different ways; the presence of multiple risk factors does not necessarily imply that a person will become suicidal.

Depending on a person's individual response, risk factors that may contribute to a person feeling suicidal include:

• Significant changes in Relationships.

• Well-being of self or family member.

• Body image.

• Job, school, university, house, locality.

• Financial situation.

• World environment.

Significant losses:

• Death of a loved one.

• Loss of a valued relationship.

• Loss of self esteem or personal expectations.

• Loss of employment.

Perceived abuse:

• Physical.

• Emotional/Psychological.

• Sexual.

• Social.

• Neglect.

5. How would I know if someone I care about was contemplating suicide?
Often suicidal people will give warning signs, consciously or unconsciously, indicating that they need help and often in the hope that they will be rescued. These usually occur in clusters, so often several warning signs will be apparent. The presence of one or more of these warning signs is not intended as a guarantee that the person is suicidal: the only way to know for sure is to ask them. In other cases, a suicidal person may not want to be rescued, and may avoid giving warning signs.

Typical warning signs which are often exhibited by people who are feeling suicidal include:

• Withdrawing from friends and family.

• Depression, broadly speaking; not necessarily a diagnosable mental illness such as clinical depression, but indicated by signs such as:

• Loss of interest in usual activities.

• Showing signs of sadness, hopelessness, irritability.

• Changes in appetite, weight, behavior, level of activity or sleep patterns.

• Loss of energy.

• Making negative comments about self.

• Recurring suicidal thoughts or fantasies.

• Sudden change from extreme depression to being `at peace' (may indicate that they have decided to attempt suicide).

• Talking, Writing or Hinting about suicide.

• Previous attempts.

• Feelings of hopelessness and helplessness.

• Purposefully putting personal affairs in order:

• Giving away possessions.

• Sudden intense interest in personal wills or life insurance.

• `Clearing the air' over personal incidents from the past.

This list is not definitive: some people may show no signs yet still feel suicidal, others may show many signs yet be coping OK; the only way to know for sure is to ask. In conjunction with the risk factors listed above, this list is intended to help people identify others who may be in need of support.

If a person is highly perturbed, has formed a potentially lethal plan to kill themselves and has the means to carry it out immediately available, they would be considered likely to attempt suicide.

6. I'm a bit uncomfortable about the topic; can't it just go away?
Suicide has traditionally been a taboo topic in western society, which has led to further alienation and only made the problem worse. Even after their deaths, suicide victims have often been alienated by not being buried near other people in the cemetery, as though they had committed some utterly unforgivable sin.

We could go a long way to reducing our suicide rate by accepting people as they are, removing the social taboo on talking about feeling suicidal, and telling people that it is OK to feel so bad that you'd think about suicide. A person simply talking about how they feel greatly reduces their distress; they also begin to see other options, and are much less likely to attempt suicide.

7. So what can I do about it?
There usually are people to whom a suicidal person can turn for help; if you ever know someone is feeling suicidal, or feel suicidal yourself, seek out people who could help, and keep seeking until you find someone who will listen. Once again, the only way to know if someone is feeling suicidal is if you ask them and they tell you.

Suicidal people, like all of us, need love, understanding and care. People usually don't ask "are you feeling so bad that you're thinking about suicide?" directly. Locking themselves away increases the isolation they feel and the likelihood that they may attempt suicide. Asking if they are feeling suicidal has the effect of giving them permission to feel the way they do, which reduces their isolation; if they are feeling suicidal, they may see that someone else is beginning to understand how they feel.

If someone you know tells you that they feel suicidal, above all, listen to them. Then listen some more. Tell them "I don't want you to die." Try to make yourself available to hear about how they feel, and try to form a "no-suicide contract": ask them to promise you that they won't suicide, and that if they feel that they want to hurt themselves again, they won't do anything until they can contact either you, or someone else that can support them. Take them seriously, and refer them to someone equipped to help them most effectively, such as a Doctor, Community Health Center, Counselor, Psychologist, Social Worker, Youth Worker, Minister, etc etc. If they appear acutely suicidal and won't talk, you may need to get them to a hospital emergency department.

Don't try to "rescue" them or to take their responsibilities on board yourself, or be a hero and try to handle the situation on your own. You can be the most help by referring them to someone equipped to offer them the help they need, while you continue to support them and remember that what happens is ultimately their responsibility. Get yourself some support too, as you try to get support for them; don't try to save the world on your own shoulders.

If you don't know where to turn, chances are there are a number of 24 Hour anonymous telephone counseling or suicide prevention services in your area that you can call, listed in your local telephone directory. This Web Site also lists a number of Internet resources which provide support for people in crisis.

8. Help? Counseling? But isn't counseling just a waste of time?
Certainly it is true that counseling is not a magic cure-all. It will be effective only if it empowers a person to build the sort of relationships they need for long-term support. It is not a "solution" in itself, but it can be a vital, effective and helpful step along the way.

9. Talk, talk, talk. It's all just talk. How's that going to help?
While it's not a long-term solution in itself, asking a person and having them talk about how they feel greatly reduces their feelings of isolation and distress, which in turn significantly reduces the immediate risk of suicide. People that do care may be reluctant to be direct in talking about suicide because it's something of a taboo subject.

In the medium and longer term, it's important to seek help to resolve the problems as soon as possible; be they emotional or psychological. Those who previously attempt are more likely to attempt suicide again, so it's very important to get unresolved issues sorted out with professional help or counseling as necessary.

Some issues may never be completely resolved by counseling, but a good counselor should be able to help a person deal with them constructively at present, and to teach them better coping skills and better methods of dealing with problems which arise in the future.

10. How do telephone counseling and suicide hot-line services work?
Different services vary in what they offer, but in general you can ring up and speak anonymously to a counselor about any sort of problem in a no-pressure context that's less threatening than a face-to-face session. Talking the situation over with a caring, independent person can be of great assistance whether you're in a crisis yourself, or worried about someone else who is, and they usually have connections with local services to refer you to if further help is required. You don't have to wait until the deepest point of crisis or until you have a life-threatening problem before you seek help.

Demand for telephone services vary, so the most important thing to remember is that if you can't get through on one, keep trying several until you do. You should usually get through straight away, but don't give up or pin your life on it. Many people that feel suicidal don't realize that help can be so close, or don't think to call at the time because their distress is so overwhelming.

11. What about me; am I at risk?
It's quite likely that some people that read this will one day attempt suicide, so here's a quick suicide prevention exercise: think of a list of 5 people who you might talk to if you had no-one else to turn to, starting with the most preferred person at the top of the list. Form a "no-suicide contract" with yourself promising that if you ever feel suicidal you will go to each of the people on this list in turn and simply tell them how you feel; and that if someone didn't listen, you'd just keep going until you found someone that would. Many people who attempt suicide are so distressed that they can't see anywhere to turn in the midst of a crisis, so having thought beforehand of several people to approach would help. This is extremely important for Suicide Survivors.

12. How does suicide affect friends and family members?
Suicide is extremely traumatic for the friends and family members that remain (the survivors), even though people that attempt suicide often think that no-one cares about them. In addition to the feelings of grief normally associated with a person's death, there may be guilt, anger, resentment, remorse, confusion and great distress over unresolved issues. The stigma surrounding suicide can make it extremely difficult for survivors to deal with their grief and can cause them also to feel terribly isolated.

Survivors often find that people relate differently to them after the suicide, and may be very reluctant to talk about what has happened for fear of condemnation. They often feel like a failure because someone they cared so much about has chosen to suicide, and may also be fearful of forming any new relationships because of the intense pain they have experienced through the relationship with the person who has completed suicide.

People who have experienced the suicide of someone they cared deeply about can benefit from "survivor groups", where they can relate to people who have been through a similar experience, and know they will be accepted without being judged or condemned. Most counseling services should be able to refer people to groups in their local area. Survivor groups, counseling and other appropriate help can be of tremendous assistance in easing the intense burden of unresolved feelings that suicide survivors often carry.

13. Hang on; isn't it illegal though? Doesn't that stop people?
Whether it is legal or not makes no difference to someone who is in such distress that they are trying to kill themselves. You can't legislate against emotional pain so making it illegal doesn't stop people in distress from feeling suicidal. It is likely to merely isolate them further, particularly since the vast majority of attempts are unsuccessful; leaving those who attempt in a worse state than before if they're now a criminal as well. In some countries and states it is still illegal, in other places it's not.

14. But don't people have the right to kill themselves if they want to?
Each of us is responsible for our own actions and life choices. In a sense then, an individual may have the right to do as they wish with their life, including to end it if they so desire. Western societies in particular tend to emphasize individual rights over communal rights and responsibilities.

However, every person exists as part of a larger network of relationships of various types which set the context in which an individual's rights and responsibilities exist. People who feel lonely, isolated, distressed and hopeless about their future can find it extremely difficult to recognize supportive relationships which may exist around them. This often causes them to grossly underestimate both the degree of support which could be gained from those around them, and the impact that their suicide would have should they complete it.

Discussions regarding rights can become emotive, particularly when there is a conflict between individual and communal rights and responsibilities. For example, people who have been emotionally devastated by the suicide of someone close to them could equally assert their right not to be as understanding by someone else's suicide attempt. It should be reiterated however that a person contemplating suicide is more likely to need understanding than a lecture on their responsibilities to other people.

Ultimately, helping people to deal with their problems better, see their options more clearly, make better choices for themselves and avoid choices that they would otherwise regret empowers people with their rights rather than taking their rights away.