Missing Christopher

by Jayne Newling

The teenage years are marked by emotional swings and where depressed ‘moods’ are normal. In an earlier book, my co-author Kerrie Eyers and I sought to nominate features differentiating ‘clinical’ depression from ‘normal’ depression, although acknowledging that no one feature is absolute.6 While depression is itself defined by a drop in self-esteem and a rise in self-criticism, clinical depression is reflected in more dimensionally extreme plummets into feelings of worthlessness and numbness and the belief that life is not worth living. Other candidate features (and principally ones indicating ‘melancholia’—the biological expression of clinical depression) are becoming ‘asocial’ (not mixing with friends or, of more concern, not responding to their mobile phone calls and texts), remaining in their room, lacking energy to get out of bed or even bathe, losing the light in their eyes, not reacting to pleasurable events and seemingly not able to be cheered up (other than superficially or temporarily), experiencing distinct changes in appetite and sleep, having impaired concentration, and being physically slowed down or agitated. A significant minority will be extremely irritable, angry and volatile. The gravity of the state is increased if it persists.

  Bipolar mood disorders appear increasingly prevalent in adolescents. Such conditions are marked by oscillations in mood states from depressions to ‘highs’ (or ‘mania/hypomania’), with the individual full of verve and zest in those latter states. At such times, the adolescent is highly energised (often childishly playful), overtalkative to loud, sleeping less if not minimally—but not tired.

  Their day-to-day worries disappear and they feel bulletproof and invulnerable, often highly creative, and become verbally and socially indiscrete—with their high libido and disinhibition, and perhaps driving faster, drinking more (and often less likely to appear intoxicated), and buying unneeded or unaffordable clothes. Such states may last hours to months, are usually followed by a sense of shame about activities engaged in and, as the mood can drop precipitously from a high into a melancholic depression (remembered by the adolescent as a ‘black hole’ of despair), the suicide risk is high—the suicide rate for bipolar II disorder (the bipolar type where the individual is not psychotic during the ‘highs’) exceeds all other psychiatric conditions.

  CANDIDATE SUICIDE RISK SCENARIOS

  As noted, those with a bipolar II condition and experiencing a rapid drop from a hypomanic ‘high’ manic to a melancholic state are at high risk of suicide. For those with a melancholic depression the risk is present during the episode but a time of increased risk is as the individual is emerging from their depression and, being more energised, is more likely and able to act on their suicidal preoccupations. In one study conducted by Jamison, one-third of hospitalised patients looked normal to ‘their doctors, family members or friends in the minutes or hours just before suicide’.7 For those with non-biological mood disorders, certain life-event stressors alone, or in conjunction with the adolescent’s personality, may fuel suicidal thinking and acts. For example, demeaning stressors such as being bullied, being rejected by a partner or even by the adolescent’s peer group or being dismissed unfairly at work can induce suicidal thinking by their ‘meaning’ to the adolescent as well as by their acuteness. We can all generally adjust to chronic stressors but we are much more likely to be perturbed by stressors with an acute onset and a demeaning impact, and particularly if they induce a sense of hopelessness.

  Over-represented personality styles include traits of perfectionism—as the adolescent sets such high standards and over-reacts to any perceived failure to achieve a goal, while they also lack the flexibility to concede that there is always a third option rather than ‘bust through or bust’. Those with a personality style hypersensitive to judgement by others—and particularly to abandonment and rejection—and those with a ‘short fuse’ are also more likely to put themselves at suicidal risk. Any at-risk period is clearly advanced by easy access to the means to commit the act, any glorifying of suicide (with the suicide of an adolescent’s idol provoking a ‘copy cat’ phenomenon), the adolescent having friends or peers who have killed themself (leading to so-called ‘cluster suicides’), and disinhibiting drugs and alcohol. ‘Substance abuse loads the cylinder with more bullets,’ Jamison explains. ‘By acting to disinhibit behaviour, drugs and alcohol increase risk-taking, violence and impulsivity. For those who are suicidal . . . this may be lethal.’8

  CHALLENGES TO SOME MYTHS SURROUNDING ADOLESCENT SUICIDE

  • Suicidal thinking is not that rare in adolescents. Jamison reported several US studies of school and college students, with some 50 per cent having suicidal thoughts, some 20 per cent seriously considering killing themselves in the preceding twelve months and 16 per cent of those having drawn up a plan.9

  • If an adolescent attempts but survives suicide, many people judge that it was simply an attempt and the adolescent would not have followed through, or view talking about suicide as ‘just talk’. Not so. Adolescents who commit suicide are distinctly more likely to have made previous attempts (and to have self-harmed) and to have communicated their intention or preoccupation. So-called ‘cries for help’ should be recognised as just that—and not simply as an attention-seeking strategy.

  • Conversely, some people believe that if an individual has attempted suicide, they will inevitably kill themself by a future attempt. One researcher traced 515 people who had been restrained from jumping off the Golden Gate Bridge. Decades later only 6 per cent of these individuals had killed themselves or died in circumstances suggestive of suicide.10

  • Some parents and even mental health professionals believe that seeking promises or drawing up contracts will prevent the adolescent from attempting suicide. While an adolescent might genuinely commit to the plan at the time, it has little holding power in itself if the adolescent returns to a suicidal mood. As such ‘contracts’ have no binding power and can offer a false sense of relief, they should neither be negotiated nor trusted.

  • While all professionals will check at appropriate times about suicide risk, denials may not be valid and often the professional must proceed by their ‘instinct’ or by indirect appraisal. This reality holds for adults as well. As observed by Jamison: ‘Suicide is not beholden to an evening’s promises, nor does it always hearken to plans drawn up in lucid moments and banked in good intentions.’11

  • Professionals are not very accurate in judging the risk of suicide with a number of studies establishing that their capacity to predict is comparable to that of intelligent non-professionals. The lack of such skill largely reflects the low prevalence of actual suicide in those at risk. Of any ten adolescents that I might judge as being at high risk over a year, and requiring close attention, contingency plans and even hospitalisation, only one might remain in that high-risk category after a year. Thus, while we can retrospectively analyse the individual factors that may have caused an adolescent to suicide, our prospective capacity to predict is quite limited.

  • Adolescent suicides are not currently increasing in Australia. Suicide rates vary considerably across the decades, across age bands (being second highest in Australia in those aged 15–19) and across regions and countries (Australia is mid-range), and reflect a range of socio-cultural determinants (e.g. unemployment, rural and remote communities) and protective or therapeutic strategies. An Australian report quantified that suicide had declined in males aged 20–24 from 40 in 100 000 males in 1997–98 (when Australia’s National Suicide Prevention Strategy was initiated), to 20 in 100 000 in 2003.12 While we cannot become complacent—as every suicide is a tragedy and suicide is the leading cause of death in the 15–24 age band—the situation is improving and is likely to reflect a number of factors. A key factor, I believe, is the destigmatisation of mood disorders in Australia. This has succeeded beyond expectations and so encouraged young people to seek support from their friends and, in particular, to be more prepared to seek and obtain professional help. Effective preventative programs have been initiated by a large number of organisations and He
len Christensen is currently developing internet-based suicide prevention programs at the Black Dog Institute that feature psychological strategies, distraction interventions and crisis planning.

  • While antidepressant medication has been shown in large trials to increase the risk of suicidal thoughts and attempts by about 2 per cent, such medication use is associated with a decreased rather than an increased rate of completed youth suicide.

  REDUCING THE RISK OF ADOLESCENT SUICIDE—A CLINICAL PERSPECTIVE

  Jamison writes: ‘Together, doctors, patients, and their family members can minimise the chance of suicide, but it is a difficult, subtle, and frustrating venture. Its value is obvious, but the ways of achieving it are not. Anyone who suggests that coming back from suicidal despair is a straightforward journey has never taken it.’13

  While prevention spans socio-cultural, economic and other domains in addition to the psychological state of the adolescent, a few clinical principles are offered for consideration. As noted, all adolescents experience depressed times but, if there is the possibility of a clinical mood disorder and/or if the individual is exposed to high-risk scenarios, a parent should seek professional help, whether it be from a school counsellor, a general practitioner or a mental health professional, and if their management or advice seems ineffective, transfer management to another professional. In our book Navigating Teenage Depression we detailed what a parent should expect of a professional assessment.

  About the maintenance of confidentiality, while many professionals disallow any contact between themselves and the parents, I do not believe such a position is sustainable. Ideally, the depressed or troubled adolescent will agree for the professional to provide some initial and subsequent feedback to the parents (after the therapist has checked with the adolescent about what should remain confidential) and management should effectively be a ‘team game’. This may involve the professional working with the adolescent but, at the end of the session and with the adolescent in the room, allowing the parent to add their observations and to tweak management nuances.

  The professional should accept urgent or emergency calls from parents rather than regard the therapeutic arena as sacrosanct to the adolescent and themself. In such instances, the professional should act as a ‘receiver’ (to the concerns raised by the parent) but is not required to act as a ‘transmitter’ (i.e. discussing what the adolescent has raised with them). The last is, in my view, overridden if the adolescent is at high risk, where I believe it is not only appropriate for the parent to be contacted and options for proceeding discussed but may be mandatory. An admission to a psychiatric hospital may be extremely stigmatising to an adolescent and distressing at the time but, again, in my view, it is preferable to be overprotective rather than laissez-faire. Perhaps, more importantly, it is rare in my experience for an adolescent to criticise their practitioner for so acting after they have been discharged from hospital.

  Other strategies include media and school education, restricting access to means of self-harm, training ‘gatekeepers’ (e.g. teachers) who will recognise and respond to those at risk, and—of key impact—awareness of crisis support services such as Lifeline, Kids Helpline and the Suicide Call Back Service. Suicide Prevention Australia (www.suicidepreventionaust.org) has prepared informative reports that address this priority area practically, sensitively and with much wise advice.

  THE FALLACY OF ‘MOVING ON’

  Of the many points and lessons we can assemble from Jayne’s heart-wrenching account, one in particular is that when speaking with a parent whose child has killed themselves, we should shun the question (implicit or explicit) as to whether they have ‘moved on’ or, perhaps even more insensitively, indicate that it is time for them to ‘move on’. There is, in my view, no finite period of grief, and I cannot imagine any parent ever completely moving on from the death of their child. Bert Facey, the Australian writer of A Fortunate Life, described a childhood of sadistic abuse and deprivation, and an adult life marked by privation, losses, unrelenting labour and horrors—the last including his time at Gallipoli in World War 1. Yet, in his simply written and compassionate book, he regarded himself as ‘fortunate’, with reviewers emphasising his tranquillity of spirit, equanimity and absence of recrimination about all those who exploited him. There was only one event that Facey judged that he never overcame—the death of his son in the Battle of Singapore in World War 2.14

  When a child has killed themself there is—as experienced by Jayne and Phil—an extra dimension to the grief experienced by parents. The world of ‘if only’: ‘What if we had done X or not done Y?’ Most feel that they had failed in their role as parents—to provide a safe harbour, to raise their child to adulthood and, commonly, because they weren’t ‘there’ for their child in those final hours or minutes.

  These strictures are unique to parental grief and do not come from depression, which intriguingly can have benefits over time. We reported a survey of patients attending the Black Dog Institute Depression Clinic and with most currently still ‘on the journey’ of dealing with their mood disorder. When asked the Stephen Fry question: ‘If there was a button that, if pressed, would remove your mood disorder, would you press it?’ twenty two per cent of those with a depressive condition and 62 per cent with a bipolar disorder stated that they would still choose to have their mood disorder.15 Offered reasons included that in knowing pain they had learned more how to experience joy and they had developed greater empathy. They had learned to appreciate (and not take for granted) the days when the sun was shining, they had cut out negative people and negative influences from their lives, they were kinder to themselves, they re-evaluated their goals and changed their life priorities, and had developed a new self-respect and compassion for themselves. They could pace themselves better during fresh episodes, operating to the mantra ‘This too will pass’.16

  By contrast, grief for a parent has no redeeming features. While it will not pass, it will ease over time. As a crisis, it makes the parent more subject to change—as it is a rare individual who changes when life is proceeding without a crisis. For many, the change can be for the worse or initiate a cascade of negative consequences and events. Parents are far more likely to separate; grief may be drowned in alcohol or expressed across a range of self-destructive acts.

  Suicide of a child increases all such risks. Jamison judges that suicide is ‘a death like no other, and those who are left behind to struggle with it must confront a pain like no other. They are left with the shock and the unending ‘what ifs’. They are left with anger and guilt . . . to a bank of questions, both asked and unasked, about why; they are left to the silence of others, who are horrified, embarrassed, or unable to cobble together a note of condolence, an embrace, or a comment; and they are left with an assumption by others—and themselves—that more could have been done.’ She adds: ‘It rips apart lives and beliefs, and it sets its survivors on a prolonged and devastating journey . . . of having failed the child at the most critical time of his life, of being insensitive to the extent of his pain, or of overlooking final cues.’17

  Can we find—or speculate—that the death of Chris has led to changes in the lives of the Newling family and others who experienced its impact? Let me gratuitously suggest several. Jayne is clearly a superb writer—that latent ability may never have been brought to full fruition otherwise—and she has produced a book that will be accorded ‘classic’ status. She has elected to work in palliative care and it would be hard not to imagine that her grief has not brought an additional understanding to her intrinsic empathy. Both she and husband Phil now have a deeper understanding of each other and of their bond. All Chris’s friends will have a greater appreciation of the tenuous nature of life and its immanent risks. For some, it will have decreased the chance of them being victims of alcohol and drugs, some will have grown up more quickly and matured more rapidly, and some might therefore have reset feckless life priorities to substantive ones. These are all speculative musings, but there i
s one consequence where Chris’s death led to a calling for his brother Nic that is enduring and almost beyond comprehension.

  NIC NEWLING

  Nic was referred to me in 2001 when he was fifteen. As recorded by Jayne he had been awarded an academic scholarship to Shore and additionally was an accomplished actor in school productions. At thirteen, however, he developed a gravid mood disorder, marked by delusions and hallucinations as well as mood swings and severe anxiety attacks. At fourteen, he was beset by intrusive suicidal preoccupations. An expert in anxiety disorders diagnosed anxiety and initiated hypnotherapy, an expert in obsessive compulsive disorder diagnosed OCD, while an expert in schizophrenia diagnosed schizophrenia. In consequence, Nic was hospitalised for ten months in an inpatient psychiatric unit and prescribed multiple antidepressant and antipsychotic medications.

  My initial assessment of Nic identified relatively distinct ‘highs’ as well as depressive episodes and I favoured a bipolar disorder diagnosis. Nic had great difficulty getting to school and when he did (usually once a week), his mood and markedly impaired concentration led to him generally spending the day in the sick room. Numerous investigations were undertaken and I sought the views of a number of other experts in Sydney and also one in the United States, both to clarify diagnostic nuances and to consider possible treatment options after he had been unable to benefit from so many differing classes of psychotropic medications.

  Despite the gravity of his condition, there was something about Nic. He had the maturity of a wise adult, his questioning of options and management nuances was extraordinarily sophisticated and, when the light came to his eyes, the pre-morbid intelligent, creative and bantering Nic was a joy. We knew—and he had a superb counsellor and later an equally superb psychologist—that if we could keep him alive, he would one day flower.

  His last few years at school were all the more difficult because he had fallen behind academically and lost his peer group as they proceeded to their HSC year—despite Shore providing exceptional support. His father reported a weight being lifted from his shoulders when Nic left school, went to work in Phil’s office and began to rebuild the company’s website. He had also been accepted into a drama course. By 2003, he and his parents felt that he had ‘turned the corner’.