Handling Someone Suicidal

Since I began talking publicly about my struggles with anxiety, depression, and borderline personality disorder, I’ve posted a lot about suicide prevention. I’ve been suicidal countless times and have often used the idea of suicide to calm myself after the worst days. With the help of my doctor and friends I’ve pulled myself back to live another day — and I’ve done this over and over again.

In the course of that time I’ve had people ask me how to help their friends who seem to be in trouble. I’ve also had people tell me that they’ve had friends use suicide as a threat to get what they wanted. It’s hard to tell the difference, so I asked my psychiatrist about the best way to react to someone talking about suicide. Here’s what he said.

Note: This was originally meant to be a podcast but due to sound issues I’m transcribing it. I’ve only made minor corrections for clarity. My psychiatrist’s credentials are here: https://www.practo.com/Bangalore/doctor/dr-ravi-prakash-neurosurgeon

Me: “So doc, the question that I got was, how do you tell the difference between someone who is threatening suicide in order to manipulate you vs someone who is genuinely suicidal and needs to be taken care of?”

Doc: “That’s a very interesting question. The thing is that, first of all, coming to suicide as a word and suicide as a phenomena, either of them we cannot take lightly for anyone. If someone is saying that “I am thinking or I want to commit suicide” he definitely needs mental help, in one way or the other. If he is really meaning that he wants to commit suicide he needs mental help. And if he is not meaning, and if there is something else, what we classify as secondary gains and tertiary gains, may be there.

Tertiary gains are completely materialistic. Secondary gains are not so materialistic. It is basically an emotional support that you’re deriving from other people. And then there is primary gain of doing something or saying something which is basically a resolution of subconscious emotional conflict. So these three kinds of gain a person can have. But suicide can be beyond these three gains also — Suicidal thoughts or activities. It might be an actual cry for help and an actual feeling of debilitation with no hope for the future of any change.

So a person can fall in any one of these categories. We don’t know. But what I suggest first of all is that any person who is talking about suicide in any way - he should seek, or he should get, or he should be taken for a mental health check up.

Now how will you tell? That’s a question that cannot be answered so easily because it is basically dependent on the person who is testing it. It’s like saying how will you differentiate between a fake diamond and a real diamond? For that you need to develop that kind of a skill. So in psychiatry and clinical psychology there is something known as mental status examination. It’s a very, very technical thing. I think mental status examination is the most technical part of psychiatry. At least the assessment of the psychiatry. In that, every small word, slip of the tongue, eye movement, blinking response, facial expressions, twitching movements of any muscle, the posture in which you’re sitting. Every verbal, non verbal communication is assigned a meaning and a value. And in my personal opinion, anyone who is trained in mental health, even a little bit, as a professional, he will come to know in a few minutes if the person is really meaning or not. Especially I would say that periocular response, the pupillary expansion, the way he starts crying, the way his words, his tone changes when he’s talking about the helplessness, it cannot be missed in any way.

So I have zero percent doubt that if a person really means to say that “my life is meaningless” or in any way is committed to doing this act, a trained professional will come to know. Other people may not come to know. But for other people, my suggestion is that your primary responsibility (if a person is talking to you that means you are related to that person) is to take him to a mental health professional. There should be no doubt in that. You may not be able to differentiate but don’t take it lightly for anyone.”

Me: “What were those gains you were talking about? Primary, secondary, tertiary.. What are some examples?”

Doc: “I’ll give you brief examples. Tertiary gain is the most common, people say that having health issues and they don’t go to office, they get away from work, they escape from things. Tertiary gains are very materialistic in nature.

Secondary gains usually happen between people who are related to each other. A person says I am sick because he wants attention. A person expresses a somatic symptom because he wants some emotional gain, he wants pampering, he wants sympathy. There’s a whole syndrome behind that, where people seek sympathy from doctors. Those kind of emotional gains are called as secondary gains.

Primary gains are a little difficult to define. It’s a release of an unconscious conflict. Sometimes some somatic symptoms like dissociative conditions, conversion disorders, they happen without the personal exactly knowing that it is happening with him. It is because the conflict is subconscious in nature. The conflict is getting resolved by doing that somatic activity. By expressing the somatic symptom. That is called is primary gain. Primary gain most difficult to explain, I myself had not understood it for a very long time. But yes, primary gain phenomena does exist.

But I am saying that suicidal thoughts may not fall in either of these three categories. It maybe a very realistic experience for the person where he feels … it’s called relief by death phenomena. The person feels that embracing death relieves him somehow. That’s a very dangerous phenomena. When you ask such a person “How do you feel? Do you imagine yourself in such the act?” The person will say “I imagine myself hanging. I imagine the consequence and I imagine how much relief I will get”. All these are very dangerous phenomena. We should immediately curb these psychological states which are there. It is the immediate duty of the near and dear person to take him to a mental health professional.”

I know this is a brief answer to a complicated question, but if you or someone you know feels this way, please please get help or urge them to get help. It gets better. A few years ago, ‘relief by death’ was the only way I could get myself to calm down. Today I practice meditation and mindfulness instead. It gets better, you can get better, help is available and there is no shame is asking for it.

If you’re in India, please check Practo.com or Lybrate.com to find a psychiatrist near you. If you’re in Bangalore, you can make an appointment with my doctor here: https://www.lybrate.com/bangalore/doctor/dr-ravi-prakash-psychiatrist

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