Dying to Live

Reflections on a South African parasuicide

By Ethelwyn Rebelo


At Chris Hani Baragwanath Hospital, on the outskirts of Soweto, South Africa's sprawling former blacks-only township outside Johannesburg, my colleagues and I see parasuicide patients on a daily basis. In some of these cases, the attempts at suicide are strong reflections of a desire to die, the acts carried out in isolation and secrecy. In most instances, however, someone close is warned about the intentions of the person in question and the probability of rescue is high, if not certain. The motives are rarely that life in itself is empty or meaningless. Rather these acts tend to be most often inspired by some sort of interpersonal difficulty and are to be understood as a communication to the family system or to significant others.

This has been found to be the case in previous studies too. For example, in a retrospective study of 130 patients seen at Chris Hani Baragwanath hospital from January 1989 to June of the same year, carried out by Jeenah, it was found that the precipitating factor in 70 percent of the cases was interpersonal conflict and that there was a good probability of discovery in 49 percent.

Looking back at some fifty or so cases that I dealt with over a two-month period from the end of 2003 to the beginning of 2004 I noticed that 60 percent were women and 86 percent were well able to talk about their feelings. Their actions thus could not be attributed to an inherent problem with self-expression. At the same time in 54 percent of the cases, the patients openly admitted to me that they had made a show of trying to kill themselves in order to convey a message to either a close family member or a sex partner. These messages tended to involve feelings of helplessness, despair related to financial difficulties, or of protest against abuse and feelings of rejection.

Suicide attempts are thus frequently manoeuvres to involve family members in assisting the sufferer with a particular hardship. The problem may already have been spoken about, but its' seriousness may not have been grasped or it may have been denied. It is a message to the family that the person involved experiences certain difficulties as overwhelming, a way of saying "I cannot live with this."

Seventy-four percent of the cases I reviewed fell between the ages of 18 to 30 years, a period of young adulthood associated with social and psychological vulnerability. It is a time when the young person in question has the task of establishing him or herself in life in terms of identity, partnership, parenting and employment. Seventy percent had levels of education below matriculation. Sixty-eight percent were unemployed, although fifty-four percent had hopes of obtaining some sort of temporary work or of embarking on a course of study. Nevertheless, the majority of the people seen could have been described as disempowered and economically dependent on others.

This was not the case with Busisiwe*, a young woman I met in the course of my duties. However there is much else about her life that represents many of the factors and themes commonly found in such patients attending our hospital. This is her story.

Busisiwe's grandmother and two aunts brought her up in the dusty and impoverished environs of Soweto surrounding our hospital. Her mother she described as an incompetent and irresponsible alcoholic with no sense of duty towards her children. Her father was well meaning but largely absent. A younger brother and sister, who were taken care of by their mother, endured a good deal of neglect.

From the time of her birth, she had been recognized by her family as the reincarnation of an aunt who had been a shaman or "sangoma". Her correct premonitions and money that regularly went missing were further confirmation for her that the ancestors were calling her to become initiated into this role, or to "twasa". Each year that she did not fulfil her destiny, she had to appease them with a ritual that involved the slaughtering of a goat and the sprinkling of snuff.

She had always been "the one who knows", she tells me. As a child, her father listened only to her requests so that her siblings had learned to channel their demands through her. She had responded to this powerful position in her family by accepting a considerable amount of responsibility. In adulthood, she had assumed responsibility for the care of her grandmother, as well as that of a younger sister and brother. The latter, a severe drug addict, was often involved in fights. In addition to these family members, she had to take care of herself and her own small daughter and in all of this she felt alone most of the time.

The father of her daughter wanted to be involved with her again, but she was not keen because she perceived him to be an inveterate womanizer and she knew he had fathered a number of children who were living in different places and none of whom he helped to support.

In many ways Busisiwe considered herself to be lucky. She had a job as a sales lady at a fast food outlet. She would, however, have liked to be able to increase her prospects still further by studying, perhaps a course in marketing.

She came to hospital after she had ingested some of her mother's diabetic pills. As with so many of the other cases I have attended to, she was open about the fact that she did not really want to die. In fact, she had taken care not to take too many pills.

She had been trying for months to convey to her family that she felt unable to cope with their emotional and financial demands. Perhaps on account of her shamanistic talents, they overestimated her coping abilities? In any event, despite the perceived positives of her situation, she felt suffocated and discouraged by her family.

In confronting her situation creatively and taking a "fresh look" at her problem from a different point of view, Busisiwe was assisted in her formulation and understanding of the nature of the relationships involved. Richman (1986) found that families that create a susceptibility to suicide in their members have difficulty accepting necessary change. Relationships are close but characterized by too little empathy. Busisiwe recognized this as being very much the case with her family.

For example, her younger brother wanted his girlfriend to live in their house, with little conception of what the implications of this would be for his sister. She was the only breadwinner and this would have entailed having another mouth to feed. His regular fights with friends, neighbours and Busisiwe herself were a further stress. She received no assistance from her parents in providing for her sister's upbringing. It seemed that whenever anyone was in need, they came to her, yet, with the exception of her aunt, no one ever helped or attended to Busisiwe.

It had become important that her family was able to understand that she required them to observe certain boundaries in their dealings with her. She could not take care of everybody; furthermore she needed also to maintain certain financial and emotional resources for herself and her child.

In all of this Busisiwe was framed in therapy as an extremely competent person who had thus far been well able to bear the burdens of her own life and that of her child. It was unfair to expect that she should also single-handedly carry her entire family.

Her incomplete suicide had however successfully passed on the message to the family that they were "killing" her with their demands. In the follow-up sessions it emerged that since taking the pills, her brother and mother had made serious attempts to control their inappropriate behaviour and to limit the pressure they exerted upon her. For the first time since she could remember, her mother came to visit her one Sunday to help her with the housework and, surprisingly also, did not drink. Busisiwe was filled with triumphant pleasure; her life no longer seemed so bad.

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