宇聯心理健康志業群

by Irene Chiang

[Abstract]
This research paper discusses the phenomena of the ever-increasing incidents of adolescent suicide in Taiwan and its causes, based on official statistics and research data, as well as mental health journals from Taiwan and abroad. The aspects of discussion are (1) adolescent suicide behavior; (2) risk factors of suicide behavior; (3) warning signs of suicide behavior; (4) intervention and prevention strategy for suicide behavior. What kinds of strategy could we, as parents, educators and members of society, adapt to prevent such tragedies from happening? Moreover, how could we teach adolescents the healthy attitudes toward life itself? Actually, parents, teachers, and adolescents themselves all have responsibilities on reducing youth suicide rate, and working together toward the goal of a healthier society.

DISCUSSION ON YOUNG PEOPLE’S SUICIDE BEHAVIOR IN TAIWAN AND PREVENTION STRATEGY

“Adolescence is a period of transition to adulthood that includes separation from parental influence and adaptation to changing expectations from peers and adults”(Adolescent suicide prevention plan, task force report to the Florida Department of Health, Bureau of EMS, 2000). As Taiwan entered the process of capitalized social development, adolescents have obtained far greater luxury than before. They have more money to spend and more leisure options to choose from, but this does not necessary help enhancing their emotional quotient and spiritual aspect of life. As a result, the number of adolescents who commit suicide increases each year. There were two youth suicide tragedies, among several others, attracting public attention in 2004: Tzu-Ting Hsu, the daughter of an entertainer couple, took her own life in August because of relationship issues, and Hsin-Yi Huang, with a history of Melancholia, and the daughter of a Legislative Yuan member, committed suicide in October because she felt that she did not live a happy life. Both of them were from prominent families with everything they could ask for, and yet, they chose to end their lives because of solvable issues.

As a result of rapid transformation of social environment and economic condition in Taiwan in recent years, individuals do encounter far greater pressure and frustration than before, and probably even more so for adolescents. When the pressure surpasses the scope which individuals could withstand, or because of their inability to adapt the complexity, more and more people choose suicide as the final solution. According to official statistics, suicide is the ninth leading causes of death. In average, nine people committed suicide daily, 2.46% among total death toll, and the incident of suicide happened in every 2.75 hours (Statistics on the ten leading causes of death, 2004).

In recent years, the annual increase of suicide rate for adolescents has topped every other group in Taiwan. During the mid-adolescent years, the incident of suicide attempts reaches a peak, and mortality from suicide increases steadily through the teens (Anonymous, n.d.). According to the announcement from Department of Health in 2002, the suicide rate for adolescents from age 15 to age 24 has been rising since 1997, and shows no signs of decrease. In the same year, there were 222 adolescents under age 24 who committed suicide, a 20% increase comparing to the previous year (Statistics on the ten leading causes of death, 2003).

Mortality rate for youth suicide has also increased in recent years. There were 3,053 people committed suicide and succeed in 2003, and according to statistics from Department of Health, suicide mortality rate of people from age 15 to age 24 was 11.74% in the same year. Furthermore, there was a 20% increase on youth suicide mortality rate for people under 24 years old, the highest among all age groups (Statistics on the ten leading causes of death, 2004). In Taiwan, suicide is the third leading causes of death in young people, after accident and malignant tumor. However, it is worth attention that youth suicide is often treated and processed as mere accident (Guetzloe, 1991).

The majority of media exposure indicates that adolescents take their own lives mainly because of relationship issues and problems in school and family. However, two questions arise from the above assumption: first, the reasons for young people to commit suicide are truly as straightforward as media has reported? Second, is there no any other way out besides death? Are our youth lacks the abilities of tolerance, flexibility and adjustment? Or, does our society not provide a proper setting for them to grow properly, so when they need help, the assistance frequently does not arrive at the right moment? The aim for this discussion is not to investigate who should be responsible, but to thoroughly understand young people's needs and worries in order to prevent more tragedies from happening. Therefore, this article will thoroughly discuss adolescent suicide behavior, the high-risk elements, and strategy of intervention and prevention.

ADOLESCENT SUICIDE BEHAVIOR

For the purpose of understanding adolescent suicide behavior, the following discussion is based on three different aspects: people who commit suicide, suicide-related factors, and the myth of suicide.

Thought and Attitude of People Who Commit Suicide

Suicide is the self-destructive behavior that young people use because they are not able to cope with mental and environmental conditions. In generally, the mental characteristics of people who commit suicide are: they can not discover their purpose of life, a sense of helplessness and hopelessness, revenge toward someone else, acquiring attention from others, and lack of strength to keep life going on (Wu, 1996). Holden (1986) considered suicide as the result of unsolved, serious emotional anxiety (Allberg and Chu, 1990). However, many researchers have indicated that adolescents commit suicide after experiencing enormous pain, and the only thing they desire is to separate from such pain (Popenhagen and Qualley, 1998). In additions, suicide is also considered to be a method for adolescents to communicate for the purpose of gaining the power of control (Matter and Matter, 1984).

Suicide-Related Factor

The reasons why young people commit suicide might be quite complex. Ying-Chang Wu and Wen-Yao Hsu (1995) integrated the related factors that cause suicide, and proposed a process pattern for suicide behavior and divided this into two types: chronic process and the acute process. Chronic process is the long-term accumulation of negative thoughts and feelings from inside of the mind and context, and acute process is the pressure or emotional fluctuation individuals feel due to changes in daily lives, which later triggers the suicide behavior (Hsu, 1998). Other suicide behaviors include melancholia, interpersonal conflict, isolation, emotional tumor, egocentrism, and family factors such as family destruction, poor communication and family relationship, neglect and abandonment (Allberg and Chu, 1990). In additions, parental negligent and family conflicts also increase the possibility of adolescent suicide (Phillips, 1981).

The Myth of Suicide

There have been misunderstandings regarding adolescent suicide behavior (Chen, 1993; Popenhagen and Qualley, 1998), including:
1. People who frequently claim they must commit suicide will never really do so.
2. Discussing suicide with suicidal people will increase the danger of actual attempt.
3. The crisis will pass once the suicidal people appear to make positive progress.
4. All suicidal people truly want to end their own lives.
5. Suicide only occurs in certain type(s) of people.
6. People who fail in suicide attempt will never try again.
7. Suicide happens suddenly and frequently, there is no portent.
8. Suicide is inheritable.

The aforementioned statements are all misconceptions. However, according to a nation-wide survey for 1,293 adolescents from age 13 to 18, around 50% adolescent considered the first, fourth and the seventh statements to be correct, almost 60% did not agree to discuss suicide issues with suicidal people, and 18% agreed that suicide survivors will not do it again (Huang and Yang, 1998). The result of this survey indicates that half of adolescents in Taiwan do not perceive suicide correctly, and educators need to pay special attention to such result.

RISK FACTORS OF SUICIDE BEHAVIOR

According to Wodarski and Harris, extreme depression is the most obvious characteristic for adolescent suicide (Chen, 1988). Wise and Spengler considered that suicide thought and attempt are the two high-risk factors for those who are under age 14 to commit suicide. Moreover, adolescents tend to be egocentric and think themselves the only ones who understand the world. Therefore, their pain and the possibility for suicide increase (Liu, 1996). In additions, mental illness, behavioral problem, background variables such as age, sex, race and suicide attempt, social-psychological conditions such as the loss of parents, destruction of family, and unexpected pregnancy all contribute to risk factors of suicide.

The followings are risk factors integrated based on several related research (Popenhagen and Qualley, 1998):
1. General factor: including severe loss, suicide attempt, substance abuse, lack of familial cohesion, family history of mental illness, child abuse, and gang participation.
2. Sex: generally, more women think about suicide, but more men actually die from it. Adolescent female tend to choose less fatal method, while adolescent male usually take more radical actions.
3. Sexual orientation: homosexual people have a higher suicide ratio then heterosexual ones, from two to sixfold, because of less social support, greater social rejection, pressure during the process of coming out, and the sense of isolation.
4. Race: in the United States, suicide rates differ from one race to another.
5. Talent: gifted and talented adolescents from age 14 to age 17 are one of the high-risk groups for suicide. The reasons are perfectionism, unrealistic expectations from parents and society, lack of humor, and the unreasonable faith that academic achievement equals personal value.

WARNING SIGNS OF SUICIDE BEHAVIOR

Actually, adolescents usually show signs before they commit suicide as the way to ask for help. Common warning signs are as follows: suicide attempt, concise suicide plan, family member who used to commit suicide, lack of interest for life, sense of helplessness and desperation, sudden alcohol and drug abuse, change of habits, recent and severe loss, giving-away of memorable objects, unstable emotions, frequent appearance of suicidal topics, and oral expression of the wish to die (Lin, 1993; Lin, 1992). Some behavioral or language clues could also be treated as warning signs of adolescent suicide, including serious depression possibly followed by weight loss, change of sleeping habit, sense of hopelessness and low self-esteem, sudden behavioral changes such as becoming more aggressive, anxious, suspicious and selfish, daydreaming and even hallucination (Peters, 1985).

Suicide thought, suicide threat, the attempt to commit suicide, extreme changes in behavior, suicide attempt, verbal expression of suicidal action, and symptoms of depression are also warning signs of actual suicide (Guetzloe, 1991). Furthermore, uncommitted suicide is considered the most obvious and direct warning sign. Each suicide attempt is the signal of calling for help, and should not be regarded as a way to simply get attention from others; otherwise, what follows might be a suicide attempt with greater fatality (Popenhagen and Qualley, 1998).

INTERVENTION AND PREVENTION STRATEGY FOR SUICIDE BEHAVIOR

The educational system in Taiwan has been emphasizing the teaching of knowledge and development of intelligence, but frequently ignores how students could deal with frustration, pressure, communication problems, and relationship issues. As a result, there are many regular tests and examinations at school, and the majority of students are sent to cram schools by their parents after regular school hours and / or on weekends, for the purpose to have greater academic achievement. Therefore, the school, parents and students all strive for grade improvement; all other issues are left to become secondary, and even more tragic, some adolescents committed suicide merely because they could not achieve higher grades.

Besides knowledge and academic achievement, it is suggested that parents, school administrators and faculties to pay more attention to the emotional and mental states of their students and children. They should discuss such issues in addition to test scores during regular meetings, be more aware of the warning signs, and well equipped with related information and methods of intervention.

Intervention Strategy for Suicide Behavior

When parents or teachers discover that adolescents talk about or attempt to commit suicide, they should take proper actions in time to prevent the worsening of such situation. When encountering those who try to end their own lives, honesty is the best policy. They need to be taken care of and understood, instead of receiving unrealistic promises (Popenhagen and Qualley, 1998). Therefore, responses such as “I think I understand how you feel,” “I will always be here if you need me,” “Tell me more about your feelings so I can help you” will be more suitable for this kind of situation. In additions, it is crucial that people do not promise adolescents for keeping their suicide attempt as secrets.

The followings are some basic principles for reference when counseling adolescents who attempt suicide (Peters, 1985):
1. Do not be judgmental.
2. Treat youth problems and threats as serious issues.
3. Do not discuss such issues with irrelevant person(s).
4. Make direct inquiries, for example, “Have you ever thought about committing suicide?”
5. Express your care and support.
6. Be a caring listener before providing further professional assistance.
7. Try to evaluate the seriousness of the suicidal crisis to properly process to referral.
8. Do not swear to keep secrets.
9. In times of critical situation, do not leave the client alone.

Prevention Strategy for Suicide Behavior

There are several ways to prevent adolescent suicide behavior. Wodarski and Harris suggested the following methods for suicide prevention: discussing with adolescents the ways to prevent suicide and deal with daily pressure, teaching adolescents how they could improve their communication, interpersonal and problem-solving skills, and educating parents the concept of suicide prevention and methods to enhance family interaction (Chen, 1988). Next, the reinforcement of school education is also an important part of adolescent suicide prevention. “School based programs that educate students about the warning signs of depression, suicide and aggression and that decrease the barriers of communication between faculty and students on these sensitive issue, can have a positive effect” (Chin, 2003). Therefore, school counselors and counseling centers should educate students to understand the meaning and dignity of life itself, and work closely with parents.

Moreover, parental involvement does contribute to the success of suicide prevention, and the recognition from both parents and caretakers to take appropriate actions can also have a positive effect (Chin, 2003). Suicide is a subject of high sensitivity that many parents are reluctant to face this issue and afraid of discussing with their children. Having full parental participation in the strategy planning process with the school ensures the program would reflect parental concerns from parents, encourages better understanding of specific prevention activities, and gains greater support. Presentations for parents should be held regularly at school, public library and community centers. Parent-teacher associations and other community groups that are willing to sponsor adolescent suicide prevention programs are encouraged to hold their programs during the time of school activities, so teachers and students who are interested in knowing more details on such topics would be equally well-informed (Anonymous, 1985).

In view of suicide prevention for adolescents, Miller and DuPaul (1996) proposed a school-based prevention strategy, and stated that an effective intervention should include early and secondary preventions. Plans for early prevention should include curriculum-based program and on-job training for faculty and school administrators. The purposes for curriculum-based program are to help students recognize suicide behaviors, train them to distinguish warning signs, and provide them with school and community resources. For faculty training, the purpose is to equip school personnel with skills to distinguish students with suicide tendency, conduct case study, and provide referral service for such students. Moreover, the main purpose of secondary prevention is to utilize evaluation tools to sift high-risk students, and offer proper counseling service and psychotherapy.

Furthermore, school personnel and parents should take the following suggestions into consideration (Miller and DuPaul, 1996):
1. All members of the school faculty should receive on-job training to understand the warning signs of adolescent suicide, and related academic and community resources.
2. Each school district should have a concise referral procedure for high-risk students. Next, Schools should take the following responsibilities: (1) Discover students with suicide tendency; (2) Evaluate the degree of seriousness of suicide behavior; (3) Inform parents or guardians; (4) Ensure students with suicide tendency receive treatment and mental health service; (5) Participate in the follow-up process.
3. Reduce the possibility for students to get in contact with firearms or other weapons.
4. An effective suicide prevention plan should include direct evaluation for high-risk adolescents.
5. Integrate early and secondary prevention strategies to enhance the effect of suicide prevention plan.
6. For greater effectiveness, suicide prevention plan could be considered for solving broader and more serious mental problems.
7. Faculty, school administrator, and parents should fully support suicide prevention plan.

Last but not the least, adolescent peers do play an important role on suicide prevention, and most adolescents would ask for help in times of emergency or crisis. Therefore, suicide prevention plan should include information for adolescents to distinguish suicide behaviors, and where to seek assistance.

CONCLUSION

In summary, there are complex and intriguing factors underneath adolescent suicide behaviors. However, it is highly possible that suicide is a way for adolescents to express their frustration and communicate with the outside world, for the purpose of letting people know that they need help. Therefore, adolescent suicide is an issue not to be neglected. Also, it is only through the cooperation of parents, schools and communities that suicide prevention plan is possible. If they could spend more time to pay attention to emotional needs of adolescents, listen to them, and plan life education curriculum to teach them how to respect life, and provide related courses on emotion management to enhance their tolerance for anger and frustration, adolescent would have the necessary assistance to go through this life stage of transition.

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