Let's be honest: Nostradamus we are not. As human beings, our
species has not got a particularly good record at ‘fortune telling’ or ‘prediction’. For a whole raft of reasons, predicting most things is very much a matter of guesswork. Informed it may
be, but at the end of the day it is still guesswork.
For example, there were those who predicted with assured certainty the
actual arrival time of the ill-fated RMS TITANIC. Others predicted a memorable victory for General George Armstrong Custer.
Predicting tsunamis earthquakes
or other natural disaters is not one our most noteworthy successes either. Let's face it, we are not very good at prediction.
This being so, the prediction of suicide would seem to be
a particularly hazardous undertaking for anyone of us to even consider undertaking. Even when dealing in groups of ‘patients’
who are classed as being at high risk.
Researchers would probably begin by looking for tell tale signs such
as failed suicide attempts or acts of deliberate self-harm (parasuicidal activity). Apparently a failed act of suicide
is regarded as a strong ‘predictor’ of future suicide.
It has even been calculated that a person with a history of parasuicide
(or attempted suicide) is said to increase the risk of suicide by as much as 40 times more than that of those
without a history of parasuicide or attempted suicide.
An act of attempted suicide
that was recognised in health care implied a higher risk than having a mental disorder such
as major depression, personality disorder, or dependence on alcohol.
The risk of suicide is generally most prominent during the first
months after psychiatric care.
The risk of repetition and consequently of suicide is believed
to be highest during the first one or two years after an episode of parasuicide. 4 Follow up studies
of hospitalised patients who have attempted suicide show that the initial high risk declines each year.6 But recent studies of people who have harmed themselves
deliberately and attempted suicide show that the risk persists for a long time. 5 7 In a retrospective study of suicide we found that the interval between
first suicidal behaviour and the suicide was related to the patient's sex and mental disorder. For example, in
patients with borderline personality disorder or schizophrenia the suicidal process can take a long
time.8 Follow up studies of parasuicide would improve if diagnostic
subgroups were taken into consideration.
Severity of the attempt indicates higher risk. Extra caution is also
warranted in situations with repeated parasuicide, especially when these occur with increasing frequency. More
extensive planning of the current parasuicide may indicate a high risk. Mental disorder in general and
depressive disorder in particular, if present at the index parasuicide, strengthens the risk for poor outcome.
Likewise, the presence of substance abuse at the time of parasuicide increases the danger.9 Comorbidity such as substance abuse and another mental disorder
is also noteworthy. Concomitant somatic illness should be assessed, especially in elderly people.10
The view that parasuicide and suicide involve totally different populations
has been found to be inaccurate.11 The prevalence of parasuicide is high also in retrospective
systematic interview studies of suicide victims. In a study of young adults, previous parasuicide was
found in 60% of young men and 80% of young women.8 This is a higher rate than among adults in general.
Among men of all ages, previous parasuicide was found in about a third and among women of all ages in
about two thirds. Irrespective of age, women have higher rates of parasuicide even among those who eventually
die by suicide. Expectedly, repeated parasuicide is common in people who commit suicide. Three or more parasuicides
occurred in 17% of men and 56% of women.8
Can we rely on the answers that patients give when we question them
about suicidal ideation in emergencies? Certainly, an empathic interview with the patient yields an honest answer
in most instances. Further, the circumstances of the parasuicide are well worth exploring in the encounter
with the patient. To what extent the verbal presentation of suicidal thoughts is valid in assessing
the risk of suicide is still doubtful. Most people who commit suicide have communicated such ideation in a more
obvious or disguised manner. Fewer than half of them did communicate their intention to family members
during their previous suicidal episode.8 In a study of suicide in elderly people, the doctors
responsible for treating them were less aware of the suicidal thoughts than the family members.12 In relation to this week's paper there is a good reason to
point at previous acts of suicidal behaviour as the most reliable issue to penetrate in the clinical interview.1 To pay attention to previous parasuicide in the assessment
of the patient in the emergency department is crucial, because it may indicate a serious risk even if
the act was committed several years ago.
that low self-esteem is not to blame for anywhere near as many problems as we once believed. Indeed, it appears to be (too)
high self-esteem that is the real villain.
seems that bullies and criminals are much more likely to have unrealistically high self-esteem (and of course - impulse control
problems) than those of us who have low self-esteem.
· People with (too) high self-esteem display an exaggerated sense of entitlement.
Apparently expecting much (possibly too much) from many situations. This is much more likely to lead to frustration, resentfulness
and aggressive, antisocial, or even criminal behaviour.
with low self-esteem are always very sure of themselves.
This manifests in their conviction that they are worthless
or inadequate. As you will know if you have ever tried to argue with someone who puts themselves down continually, it is very
hard to do! When someone with low self esteem becomes less sure of their own opinion of themselves and therefore begins to
assess counter evidence regarding their worthlessness, their self image begins to become more healthy.
4) You Can't
Argue Someone Better!
Telling some one they are great or wonderful when they are constantly negative about themselves
will not work. Arguing with someone who is so sure of themselves does not work, as we all know. You will just break rapport
with that person. We have all met people who feel more comfortable in relationships with people who treat them badly - because
that person seems to see things the way they do.
People with low self esteem can be upset by 'disconfirming feedback.'
In other words if something happens which indicates that they may not be as terrible as they thought, it can feel disturbing
as it contradicts their way of perceiving. Healthy self esteem needs to emerge subtly, not as a sudden result of hearing you
are 'really special' or 'fantastic'.
People need proof that unsettles the certainty that they are so 'defective' or
inadequate and leads to a more realistic and balanced self-assessment. This can only happen when they become calmer and more
relaxed so that they can observe themselves more objectively and less emotionally. Whenever we are highly emotional our perception
is distorted ('emotional hijacking') when people calm down around the idea of themselves then a healthier self-esteem can
5) Child Abuse Increases Likelihood of Low Self Esteem
People who were abused as children (physical
beating or sexual abuse) are more likely to suffer unrealistic low self esteem as adults. This is because of constant repetition
of a 'message' that they are of little value or just an object to be used. In a way they have been 'brain washed' by constant
criticism or abuse that they are a certain way.
When we begin to question our former conditioning or brainwashing then
a healthier and more accurate sense of self can begin to emerge. However we may have to be de-traumatised so the emotional
brain responds differently in future (rather than solely learning to think differently about stuff). However the way we think
and our assumptions need to be observed, understood and if necessary challenged. (explanatory styles)
(Note: Most people
who have low self esteem were not abused as children.)
6) Healthy Pleasures Are Vital
in activities we enjoy and in which we can 'lose ourselves' regularly. The better one's sense of themselves the less they
tend to use words like 'me, myself, I, mine' (personal pronouns) Someone's mental and even, to some extent, physical health
can be directly related to how 'self-referential' they are in their conversation - as people become healthier they use the
'I' word less, in the same way that when your knee stops hurting you don't need to rub it any more.
be encouraged to focus their attention away from themselves as well as to be able to take their own needs into account. A
healthy balance should be encouraged as should the development of real practical skills. Real responsibility should be encouraged
so that self-worth can respond to external evidence on an ongoing basis.
7) Make the Most of Success
self esteem requires a particular attitude towards success. Whenever you succeed at something, you must 'write it off' as
good luck, chance, or someone else's responsibility.To gain a more realistic view of yourself, you need to take appropriate
credit for your successes. In the we call this skill 'Converting'.
This involves learning how to convert real successes
into statements about yourself. The other part of the picture is to view perceived failures as temporary and not statements
about your 'core identity'.
on Solid Foundations
For us to be psychologically, emotionally and physically healthy on an ongoing basis; there
are a set of requirements that must be built into life. The need to give and receive attention
Taking care of the mind-body connection. The
need for meaning, purpose and goals The need for a connection to something greater than ourselves The need for creativity
and stimulation The need for intimacy and connection The need for a sense of control The need for status
course, it is likely that at any one time, one or more of these may be slightly lacking in your life, without dire consequences.
However, in the long-term, they must all be catered for one way or another.
Positive thinking can be useful in that it challenges us to form a different view on things. To
change our self-image and improve low self-esteem, we need to believe in an alternative opinion of ourselves, not just repeat
platitudes about how great we are really!
The costs and causes of low self esteem)
high self esteem
Amongst the characteristics of genuinely low self-esteem are, Social withdrawal. Anxiety
and emotional turmoil. Lack of social skills and self-confidence. Depression
and/or bouts of sadness. Less social conformity. Eating disorders. Inability
to accept compliments. An Inability to see yourself 'squarely' - to be fair to yourself. Accentuating the negative. Exaggerated
concern over what they imagine other people think. Self neglect. Treating yourself badly but NOT other people. Worrying whether you have treated others badly. Reluctance to take on challenges. Reluctance to trust your
own opinion. Expect little out of life for yourself