In September 1996 Bob Dent chose to die. Few of us do not know his story. Terminally ill with cancer, he sought euthanasia under new Northern Territory legislation. Bob Dent died peacefully when his doctor administered a lethal dose of drugs.
If it was an average day, 246 other Australians also sought to die that Sunday. Six of them succeeded. The rest did not die - they became failed suicides.
"I remember very little about it," Karen says. "I was in my own bed, then I was on a stretcher. Someone said to me, 'And how often have you done this?' Her tone was unfriendly, sarcastic," - Karen sighs deeply - "I felt terribly thirsty, and I started to cry."
She continues, "It was a Friday. I found out later that Fridays and Saturdays are the most popular for 'overdoses' - hospitals don't like them, and don't treat them especially kindly."
Karen had swallowed a large dose of her anti-depressant medication. "Not enough," she says. "I lost my nerve. There was a moment of choice - in that instant, I could have chosen death, eternal oblivion. I have never felt so terrified."
It is not a topic for casual conversation - suicide. How many of us know the views on suicide of even our closest friends?
Yet suicide, like chronic and terminal illness, sudden death, and grief, must be acknowledged.
"I tried to get help," Karen says. "I tried to tell people. I wanted to die. I kept saying, 'I want to die'. It was like no-one could hear me, no-one knew what to say." Tears roll down her cheeks, as she begins to cry quietly.
An Adelaide psychologist confirms that the intending suicide often gives many warnings. "It's one of those myths that we fall back on because we feel uncomfortable," she says. "A dangerous myth. 'Those who talk about it don't do it'. It's simply not true." Othersigns? We should worry when a severely depressed person contacts friends from the past, makes unusual visits to family members, or gives away valued possessions. The onset of a more relaxed mood, an air of resignation, can also be significant.
In his book, Waking Up Alive, Californian psychotherapist Richard Heckler traces the course of a group of survivors of suicide. Common to their histories were traumatic loss, alienation, or family dysfunction.
Without help to manage overwhelming pain and grief, the person begins a downward descent towards suicide. The first step is withdrawal.
Karen describes her experience: "I just stopped talking to people. Even in shops - if I couldn't select what I wanted from the shelf, I'd walk out. I felt irritated by people. Distracted. It was as if I was trying to solve a problem, and everyone was trying to distract me."
"During the week just before, I don't think I heard a single word my flat-mate said," she continues. Karen had entered what Heckler calls 'the suicidal trance'. Suicide now appeared to be the only solution to pain. In the mind of the suicide, it is a perfectly logical solution. The future appears black and grim, images of the suicidal action recur. Death beckons.
There may be a final triggering event, a row with a parent, partner or friend, a disappointment, a failure. But just as often, the decision can seem, to the outsider, to be taken quite casually.
Karen went to work that day. "Halfway through the morning, I decided that this was the day. I felt calm, relieved. I left everything just as it was on my desk. I simply walked out." The trance becomes an altered state of consciousness. Time can seem to stop, things happen in slow-motion. "It was like I was in limitless space. I became an animated zombie, all my movements stiff, mechanical," says Karen.
Writer William Styron, author of Sophie's Choice, described his experience in Darkness Visible: "I watched myself in mingled terror and fascination as I began to make the necessary preparation..."
Before he took his final step, Styron heard the Brahms Alto Rhapsody. The music evoked poignant memories, and shook him from his trance. The following day, he entered hospital for treatment for severe depression.
Many others wake up in hospital, involuntary patients. For many of these survivors, self-inflicted physical damage is now superimposed on their emotional pain. If they are lucky, like Karen, they escape with just the nasty after-effects of large doses of charcoal and sorbitol. If their action was more violent than Karen's overdose, they could need micro-surgery to re-join severed nerves and tendons. One of Robert Heckler's survivors would never walk again.
Returning to life is difficult. Many will try again, some will succeed. It is early days for Karen - just eight weeks. She is uncertain of the future. "I transferred to a private hospital where I stayed for a week, but I have still not gone back to work," she says. "I need time to understand. I feel that this is it, this is my life - next time, I'd have to succeed, I couldn't lose my nerve again."
Professor Riaz Hassan of Flinders University in South Australia has studied patterns of suicide in this country over the past 15 years. He would like to see a national suicide prevention program. Poverty, unemployment and feelings of isolation, especially among young people, are major contributing factors. Intervention at the societal level must therefore have a high priority.
"We must give the young something to work for, something to look forward to," says our Adelaide psychologist. "Young people see that they do not have the same opportunities that their parents had. We send them to school, educate them, but we are preparing them for a future that doesn't eventuate."
There could be no reprieve for Bob Dent, no second chance. Every day in Australia, 240 people do get a second chance. "I recently read a book by the psychologist Dorothy Rowe," says Karen. "She argues that suicide is always foolish, because if our total being, body and person, is ready to die, we will just die. If we need to commit violence to our body, we are not ready - I guess I wasn't ready." Karen's face contorts, and she looks away.
Can we intervene at the level of person-to-person? What should we do in the crisis? "Most people become tongue-tied if someone simply makes a joke about committingsuicide," says the psychologist. "Even professionals can be caught off-guard when a client announces casually that they intend to kill themselves. We have some ideas about what not to do, but we can't always know with certainty what to do in a given case."
She recommends direct action to remove the means of suicide from the person. They should not be left alone. If necessary, they should be hospitalised until the immediate danger has passed.
"Let the person talk. Don't be afraid of their strong emotions. Don't try to give advice, or deny their feelings. Just listen to them. Most of us are very bad at listening. I teach reflective listening skills to volunteer helpers, and they find these to be their most valuable tool. Essentially, we listen for the meaning and the emotion behind the words, and we reflect that back to the distressed person," she explains.
While no-one could envy Bob Dent's fate, he was able to make his decision openly, and to die with loved ones close by. No such support is available to those so deeply despairing that they choose to end their own life. Depression, like cancer, can be a terminal illness. But the suicide dies alone.
How can we help people like Karen to take their second chance? "It's important that the person be put in touch with as many different sources of support as possible," says the psychologist. She recommends suicide prevention workshops, and public education to overcome the taboo against open discussion of suicide. "We teach first aid for physical injury, but we ignore the needs of people with emotional injury. A person like Karen needs to know that her life makes a difference, that people value her and would miss her. What we do now is critical - she needs emotional intensive care."
Karen feels that her friends and family are treating her with kid gloves. "They're always ringing me, dropping in - even now. It's like they're 'checking up' on me. But they don't know what to say, they seem nervous of me. Sometimes, I'd just like to tell them how it was, how I felt, how I feel now. It's almost like I have a criminal record - Name, Karen M.; age, 33; crime, attempted suicide." She smiles weakly. "I know that sounds ridiculous..."
Karen has not yet reached the crucial point in recovery identified by Richard Heckler - the return of a sense of proportion. Trivial problems or setbacks still plunge her into despair, and she is unable to cope with daily routines if they involve too many steps.
"Thoughts of suicide are never far away," she confides. "If things go wrong, I tend to see it as the only solution."
Many of Heckler's survivors emphasise that suicide is never the answer to pain. Yet, paradoxically, their attempt served to waken them to different possibilities. It gave them the impetus to reshape their lives. In William Styron's words, they emerged from 'hell's black depths' into 'the shining world'.
I met Karen through a mutual acquaintance who knew I was planning an article about suicide. Now I turn off my tape-recorder, and thank her for her openness. She tells me it has been therapeutic to talk to me, and promises to keep in touch. I hope that it has been, and that she will.
Australian Women And Suicide - Facts & Figures
* Almost every day, at least one woman somewhere in Australia commits suicide.
* That is, every year, 4.7 women per 100,000 population die by their own hand.
* These suicide figures are underestimates because some apparent "accidents" (e.g., drowning, overdose, car crashes) are actually suicides, and relatives may conceal suicides because of shame and social stigma.
* Queensland and ACT have the highest rate per 100,000 population - NT has the lowest rate.
* Compared with European countries, Australia is in the middle of the frequency range, but the rate for female suicide is twice that for USA, a more similar culture.
* In the 60s, the suicide rate rose due to the increased availability of drugs. A change in the National Health Act resulted in rates returning to previous levels.
* Over time, the trend for women younger than 30 to commit suicide is increasing, and rates for those past 30 are declining.
* Since the mid-60s, there has been a gradual overall decline in suicide among Australian women. This may be attributed, in part, to improved methods of intervention.
* More than two-thirds of people treated for overdose in Accident & Emergency Departments of major hospitals are women.
* Successful suicides are most likely to occur on Mondays.
* Spring is the most popular season.
* Women use different means than do men - fewer shotgun deaths, hangings, or poisoning by carbon monoxide. Drug overdose is the method of choice for women.
* Contributing factors - physical and mental illness (especially depression ), drug and alcohol abuse, unhappy love relationships and family problems, loneliness, feelings of low self-worth and inability to meet social expectations, a downward career move.
* Very strong predictors of suicide are feelings of hopelessness, and a history of previous attempts.
* Media stories about a suicide do not affect women, but the suicide rate for men increases shortly afterwards.
If a friend or family member is depressed, how can I help them?
People close to a depressed person are also affected by their illness. In his book "Speaking of Sadness", David A Karp who interviewed 50 depressed people and some relatives writes of the impotence of friends and relatives to fix the person's depression.
Try not to take it personally that you may seem to be of no help. Probably the best you can do is to be there and listen closely, if asked, undertake any chores for them that you can (e.g., care for pets, shopping). Learn about depression and understand that the depressed person is not lazy, and does not mean to be difficult or irritable.
However, you should not tolerate very bad behaviour - and it's a good idea to get away yourself sometimes to avoid the contagion factor. Thus, deal with your own feelings independently of your relationship with the depressed person.