Lessons learnt: A 14-year-old girl committed suicide yesterday

I was saddened by the news in today’s newspaper that a 14-year-old local Hong Kong Chinese girl hung herself in her bedroom at home in Tsim Sha Tsui after a dispute with her parents.  It was reported that the parents objected to their daughter to having a close relationship with her boyfriend because of her young age.  However, to this girl, having a relationship was the most important thing.  After hearing the parent’s objection, the girl returned to her bedroom and hung herself.  The parents discovered later in the evening at 6pm when they knocked on the door and there was no reply.

 Two immediate contradictory thoughts came to mind: (1) is there anything wrong with the 14-year old?  Surely the parents’ stance is justified.  (2) What the parents could have done to prevent this?  I think many people would almost have a reflex action and jump to conclusion of putting blames on the new generation, whose generational values are known to be the “i-generation”, characterized by high self-centeredness.  However, being a clinical psychology student now, I realize I am more attuned to the second question of seeking prevention.  I have a vast interest in positive psychology since I first exposed to the concept in my advanced psychopathology class with Dr Wedding. 

I had a quick search on the Internet and happily found that there are quite a lot of material on positive psychology and suicide.  Love and humility works well for depression. Often times, persons who are depressed and eventually commit suicide speak of feeling of being alone in the world. They feel that if one person would have cared for them they would not have done this. Many times a person’s family is not able to lend out emotional support for their depressed relative.  This may well be the case for this 14-year-old girl.  What the parents could have done is to provide I nurturance, reciprocal attachment and kindness.

What I would like to share here is some tips with parents or we as adults that I learnt from the Internet to apply positive psychology to talk to unhappy youths or young adults.  I have used the “three good things” for a while myself, and have told my undergraduate students to do the same when they are down.  I find it pretty effective.

 

•Gratitude Exercise: The youth is told to think of someone who has been good to them or influential in a positive way. This may be a parent, friend, teacher, or coach, anyone who comes to mind as being a positive influence. The youth is then told to write this person a letter, expressing thanks and gratitude, being sure to include what this meant and how the youth feels. This exercise is most meaningful if the letter can be read to the intended recipient in person.

 •Appreciation: This is another form of the gratitude exercise. At the end of the day, we can ask a child to identify something occurring that day for which he or she is appreciative. Anything, no matter how large or small, can be appreciated.

 •Three Good Things: In this exercise, the youth is asked, to name three good things that occurred that day. We should not accept a response of "nothing good happened," instead encouraging the child to focus on even little events that are good, such as a sunny day, a good dinner, or play with a friend.

I should continue to learn more about positive psychology and depression / suicide.  Hopefully I can develop a set of instruments of positive psychotherapy to help parents and teachers to apply at school or at home.  Or even develop a tool kit for youths and young adults for them to extend peer / social support. 

Attitudes of Hong Kong Youth and Young Adults Towards Suicide

We have gone through some basic understanding of broad suicide situations and risk factors, and compared between the West and Asia suicides, we can now focus on issues specific to Hong Kong, and our target groups youths and young adults.  Hong Kong has experienced a roller coaster cycle of suicides rates with a 50% increase from 12.5 per 100,000 in 1997 to a historical high of 18.6 in 2003, followed by a 23% decrease to 13.8 in 2009.  The peak rate from 1997 to 2003 can be attributed to the 1997 Asian financial crisis coupled with the SARS disease outbreak in 2003. 

What worth our attention is that youth suicide is the leading cause of death among the 15-24-year-old age group.  Figures showed that more teenagers attempted suicide (completed and uncompleted) than other age groups.  The suicide rate of male teenagers (15-24) has experienced a 30% rise from 8.9 to 11.7 per 100,000 between 2008 and 2009.  In addition, among school drop-outs, the underemployed and unemployed, these young people are experiencing a 10 to 20-fold increase in suicide rate compared to those who are at school for the same age group.  Some of the common reported probable risk factors include lack of problem-management skills, low self-esteem, low need for achievement, depression, general anxiety, poor help-seeking tendencies and withdrawal from life.  I will discuss these in the later posts.  For now, I would like to explore a basic question, namely what are the attitudes of Hong Kong youths and young adults towards suicide.

First and foremost, it is interesting to note that there is no mastery theory that adequately explains how Chinese people perceive suicide.  Rather, suicide might be endorsed and/or condemned by particular individuals under a variety of life situations.  Of special interest here is the type of stressful life events perceived by Hong Kong Chinese that may trigger them to consider suicide.  I have suggested in my earlier post that an underlying cause that explains the differences of the nature in stressful life events between Asian and the West is the Confucian notion of hierarchy and familial relationships.  Lee, Tsang, Li, Phillips and Kleinman (2007) reported that the top six difficult life scenarios that respondents might consider suicide were: (i) “being terminally ill”, (ii) “having a chronic psychiatric illness,” (iii) “being severely depressed”, (iv) “being a burden to others and feeling hopeless about the future”, (v) “being heavily indebted because of gambling” and (vi) “not having anyone to provide financial or emotional support in old age.”  In my personal view, these six scenarios reflect a strong tendency of Hong Kong Chinese not want to bring trouble or burden to their family members.  This is consistent with the collectivist Chinese culture in which people are more willing to consider others’ feelings and avoid arousing negative emotions. 

Nonetheless, there are four findings from my readings about youths and young adults’ attitudes that caught my attention.  First, “negative appraisal and fatalistic view of suicide decreased with age.” (Lee et al., 2007, p.568).  Second, findings from a cross-cultural study between Chinese and Norwegian respondents reported that Chinese demonstrated more agreement to “suicide happens without previous warnings” and less agreement with “suicide can be prevented”.  Third, there are other studies that found “superstition was positively correlated with anxiety level among adolescents” (Okebukola in Wong, 2012, p.58).  Fourth, young people tend to have more fears of deaths than older adults.  How do I make sense from these findings?

To me, I would interpret that since youths have strong death anxiety and fear of death, coupled with the fact they do not want to bring trouble or cause their family to lose face, they regard suicide as a form of their fate / destiny.  This echoes with the frequent reports that the youths commit suicide because they feel hopelessness.  They do not see there is an alternative since Chinese tend to disagree that “suicide can be prevented”, this goes back to the fatalistic view.  Moreover, despite the high level of fear / anxiety of death, even in Hong Kong, death is a taboo topic.  Chinese may be considered among one of the most superstitious nations in the world.  In Hong Kong, we have “Feng Shui” and “Tong Sing” which lists a person’s luck in that year.  It is a commonly held superstitious belief that discussing death and dying will bring bad luck or consequences.  This in turn supports the above-mentioned view held by Chinese that “suicide happens without previous warnings” because Chinese including youths, just do not talk about it.  Choosing suicide as their ultimate solution also coincides with the strong support of the Chinese to follow the terror management theory (TMT).   This theory suggests that culture is the crucial factor in explaining and giving meaning to death.  In the presence of terror, a Hong Kong Chinese youth or young adult may well interpret the “misfortunes” of his/her present life is due to the wrong deeds of their previous lives which they do not have control.  By ending their lives may well benefit to their parents as a repent for their wrong deeds.  As a result, following such cultural beliefs help the youth / young adults legitimize their suicidal acts.

From the above analysis of the attitudes of youths and young adults towards suicide, I am of the opinion that an effective means of suicide prevention is to let them know there is hope.  Encouragement and positive psychology I believe can be one avenue to explore.  I would like to end this post by borrowing the words from a very touching video from Nick Vujucic “Failure is not the end.  It matters how you finish.  Are you going to finish strong?”  I am still very touched and inspired every time I watch this video.  I show this video in my class with undergraduate students when we talk about courage.  A few of them told me this video changed their perspectives of how they see failure.  I hope you will spare two minutes to watch it.

http://www.youtube.com/watch?v=KIy8OytmFkA&feature=related

References

Lee, S., Tsang, A., Li, X.Y., Phillips, M.R. & Kleinman, A. (2007). Attitudes toward suicide among Chinese people in Hong Kong.  Suicide and life-threatening behavior, 37(5), 565-575.

 

Wong, S.H. (2012) Does superstition help?  A study of the role of superstitions and death beliefs on death anxiety amongst Chinese undergraduates in Hong Kong.  Journal of death & dying, 65(1), 55-70.

Yip, P. & Chak, S. (2011) Suicide in Hong Kong: epidemiology, changing patterns, associated phenomena and prevention.  Irish Psychiatrist, 12(1), 23-24.

Suicide in Asia

The purpose of this post is to highlight the differences in epidemiologic characteristics and the risk factors between Asia and Western suicides.  A study by Chen, Wu, Yousuf & Yip (2011) reported that the overall suicide rate in Asia is approximately 19.3 per 100,000, about 30% higher than the global rate of 16.0 per 100,000. (p.129).  During a 12-year period (from 1995-2009), the top three suicide rates countries are Japan (24 per 100,000), South Korea (31.0) and Sri Lanka (23.0).  Hong Kong and China stood at 13.8 and 6.6, respectively. 

Unlike the Western countries, where suicide rates for males are about 3-4 times higher than those for females, in several Asian countries like Hong Kong, the gap between male and female suicide rates is smaller.  Whilst Hong Kong and Australia have similar suicide rates, the gender ratio (male-to-female) are about 4 and 2, respectively.  The gender ratio for the US was 3.8 in 2009.  This implies that the suicide rates for Hong Kong females is higher than that of the Australian and US females, while a lower suicide rate for males in Hong Kong is observed compared to the Western counterparts.

Although the risk factors for suicide such as mental disorders, alcohol-related disorders, previous history of suicide attempt, and stressful life event appear to be universal (as reported in the earlier blog post), there are differences with respect to mental disorders and stressful life events.  As mentioned in an earlier blog post, Tondo and Baldessarini (2011) that 90% of suicides in the US occur in persons with a clinically diagnosable psychiatric disorder, particularly patients with bipolar depression disorder.  However, it was reported that in China 40% of suicides suffered from depression and that the overall rate of mental disorders in suicide completers is 63%.  In Hong Kong, depression was found in 51% and 53% of middle-aged and old adult suicides, respectively. 

An underlying cause that explains the differences of the nature in stressful life events between Asian and the West is the Confucian notion of hierarchy and familial relationships.  This in turn can also help explain the narrower gender ratio gaps in Asia.  Family dispute is a critical factor for suicide among women in many Asian countries.  The low social status of women has been suggested as a potential link to the high suicide rates for Asian women involved in abusive family relationships.  Abusive marriage relationship is a common cause for women suicides reported in Hong Kong.  Moreover, under a family-centered culture where the male is the head of a family, unemployment or job-related stress is a more common reason of suicide among Asian men than their Western counterparts.

 

An important implication of these differences in risk factors between Asian and the West is a need to develop cultural-specific intervention strategies.  Social support is likely to be a critical protective factor for preventing suicidal behavior in Asia.  In addition, community-based suicide intervention programs are an effective tool in light of the strong family and community ties in Asia.

In the coming posts, I will focus on the topic of this blog - suicide of youths and young adults in Hong Kong.  Besides sharing on research article reviews, I will also provide some personal views of how to prevent youth suicide.  Stay-tune!

References

Chen, Y. Y., Wu, K.C.C., Yousuf, S. & Yip, P.S.F. (2011). Suicide in Asia: opportunities and challenges.  Epidemiologic Reviews, 34, 13, 129-144. Doi: 10.1093/epirev/mxr025

Suicide and Culture

Suicide is defined as “the act of intentionally ending one’s own life.” (Nock et.al, 2008, p.134).  Global estimates suggest that suicide continues to be a leading cause of death.  The World Health Organization (WHO) in 2012 estimates that each year approximately one million people die from suicide, which represents a global mortality rate of 16 people per 100,000 or one death every 40 seconds. It is predicted that by 2020 the rate of death will increase to one every 20 seconds.

 

The general trend of suicide is provided by a WHO report in 2012 and Nock et al. (2008):

l   In the last 45 years suicide rates have increased by 60% worldwide. Suicide is now among the three leading causes of death among those aged 15-44 (male and female). Suicide attempts are up to 20 times more frequent than completed suicides.

l   There is a cross-national consistency in the early age of onset of suicide ideation and the rapid transition from suicidal thoughts to suicidal behavior.  Suicides globally by age are as follows: 55% are aged between 15 to 44 years and 45% are aged 45 years and over.  Youth suicide is increasing at the greatest rate.  This trend is confirmed in Hong Kong.  In Time Out Hong Kong 7 Dec 2011, it was reported that the suicide rate among teenagers aged 19 and under increased by 58%, while suicide rate among adults steadily decreased.

l   Mental health disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide.  This view is shared by Tondo and Baldessarini (2011) that 90% of suicides in the US occur in persons with a clinically diagnosable psychiatric disorder, particularly patients with bipolar depression disorder.

Moreover, there is significant cross-national variability reported in suicide and suicidal behavior.  The implication is that it is important to address specific underlying issues unique for each country.  The WHO and other researches find that:

l   In Europe, particularly Eastern Europe, the highest suicide rates are reported for both men and women.

l   The Eastern Mediterranean Region and Central Asia republics have the lowest suicide rates.

l   India, China and Japan account for more than 40% of all world suicides.  In 2006, Beautrias estimated that within Asia national suicides rates vary widely, from as low as 2 per 100,000 per year (in countries like the Philippines and Pakistan) to rates of more than 20 per 100,000 in Japan, rural China and Sri Lanka.

What are some factors that explain national differences in suicide?

Socio-demographic and economic variables – Lower suicide rates were found for nations with less economic development and where Islam was the dominant religion.

Physiological differences – The higher the proportion of people in the nation with Type O blood, the lower the suicide rates.

Societal differences – Suicide in modern societies seems to increase as social integration and regulation decrease.  There is one suicidal theory proposed by Naroll that suicide occurred in those who were socially disoriented.  “Thwarting disorientation contexts are those in which the individual’s social ties are broken or weaken and those in which another person thwarts the individual and prevents him or her from achieving desired and expected satisfactions or in which they experience frustration.” (Lester, 2008, p.62).  Naroll’s view seems to provide a good explanation to the high suicide rates in Hong Kong.  The lack of parents and teachers’ recognition in academic performance is one commonly reported reasons for teenage and college students’ suicides.  Vengeful suicide is another common reason whereby the teenagers want to get back at those who they believe have caused them misery, such as feelings of isolated and alone from parents’ divorce.

Besides the above factors that explain the national differences, some risk factors that cause suicide are:

Psychiatric factors – Mood, impulse-control, alcohol/substance use, psychotic and personality disorders convey the highest risk for suicide and suicidal behavior.

Psychological factors – Factors such as hopelessness, anhedonia, impulsiveness and high emotional reactivity will increase a person’s psychological stress level, thus increasing suicidal risks.

Biological factors – family, twin and adoption studies provide evidence for a heritable risk of suicide and suicidal behavior.  Much of the family history of suicidal behavior may be explained by the risk associated with mental disorders.

Stressful life events – Such events interact with the above factors to increase suicidal risks.  Examples of stressful life events are family and romantic conflicts and the presence of legal and disciplinary problems.  In the case of Hong Kong, a common risk factor for youths and young adults suicide are due to family conflicts with respect to their academic achievements which may lead to disciplinary consequences.

In the next blog post, I will look into the specific issues prevailing to suicides in Asia.

Reference list:

Beautrais, A.L. (2006). Suicide in Asia.  Crisis, 27(2), 55-57. Doi: 10.1027/0227-5910.27.2.55

Befrienders Worldwide. (2012). Suicide statistics.  Retrieved from http://www.befrienders.org/info/index.asp?PageURL=statistics.php

Lester, D. (2008). Suicide and culture. World Cultural Psychiatry Research Review, 3(2), 51-68.

Nock, M.K., Borges, G., Bromet, E.J., Cha, C.B., Kessler, R.C. & Lee, S. (2008). Suicide and suicidal behavior.  Epidemiologic Reviews, 30, 133-154. Doi: 10.1093/epirev/mxn002

Tondo, L. & Baldessarini, R.J. (2011, February 10). Can suicide be prevented? The Psychiatric Times.  Retrieved from http://www.psychiatrictimes.com

Zhao, S. (2011, December 7).  The shocking rise of child suicide. The Time Out Hong Kong.  Retrieved from http://www.timeout.com.hk

Welcome!

The purpose of this blog is to explore suicide of youths and young adults in Hong Kong.  Why did I choose this topic?  My first encounter with suicide is in May 2000 when my close friend Ronald in his late twenties committed suicide by charcoal burning.  It was rumored that he had very heavy financial debts attributed to the 1997 Asian financial crisis.  I had known him since Form 1 (Grade 8).  The last time I saw him was Christmas 1999 when we had drinks after our high school gathering.  I did not notice anything unusual about him (or I was not paying close attention).  I was shocked when I heard the news.  Since four years ago, I have had close acquaintance with a local university which is dubbed as “the university of stress and tension” whereby suicidal rate is reported to be highest in Hong Kong.  Two suicides and one suicidal attempt were reported in the last twelve months.   Then in December last year, I was shocked to read that five children aged between 10 and 16 years old committed suicide in Hong Kong during November.  These personal experiences and observations made me ponder “why”.  Why is it that these youths and young adults took their own lives?  Isn’t it that “tomorrow is another day” (from the movie “Gone with the Wind”)? 

I would like to explore this topic through various perspectives starting from the broadest view, such as discussions of suicide and suicidal behavior, cultural impact on suicide, followed by suicide in Asia, and finally narrowed to suicidal issues in Hong Kong faced by youths and young adults, such as their attitudes towards suicides and their belief systems.  I believe through an understanding of big picture of suicide will allow us to differentiate unique issues faced by Hong Kong youths and young adults.  In doing so, we will carry this journey in various stages (blog posts), and during this journey, I will share my research findings as well as my personal observations and thoughts.