Dedicated to those who are thinking about suicide, and those who have passed by their own hand. May all beings find happiness and health, may we all be safe and free.

By the time you finish reading this article, one person in the US will have killed herself or himself.

I recently had the sad and shaking experience of walking through the moments before what turned out to be a suicidal gesture. I could see the traces and the footprints of the desperation that led to such an act: the smoked cigarettes on the ashtray, the, half read books lying on the floor; scotch tape, and the note written with blue marker “call 911; do not enter”. There was a candy wrapper on the floor, and the newly opened box of a firearm with an inviting card to join the NRA and get a free duffle bag. These were the last minute preparations for a haphazard and hurried departure, last minute travel arrangements. What’s important to say? What’s important to leave behind in those final moments?

Often people who are contemplating suicide fantasize that suicide will stop their pain and burden of others, but in reality, that sort of pain and burden, like energy, cannot be destroyed; it is simply transferred along with a new heavy dose of anger to those surviving the dead.

I am not foreign to suicide in my clinical work. I have been close to those who are no longer with us and to those who have survived a suicide attempt, yet, one can only experience the tremendous blast of violence such an act unleashes if you happen to be on the other side of the clinical fence among loved ones, friends and relatives, and share the uncertainty and pain of illness to different degrees. “Illness is the night-side of life” writes Susan Sontag in Illness as a Metaphor, “a more onerous citizenship. Everyone who is born holds dual citizenship in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”

Suicide is never a silent act but a violent statement, not only self inflicted by the person who kills herself or himself, but towards the people that survive them, and to one person in particular, “No person harbors thoughts of suicide which are not murderous impulses against others redirected upon himself” said Sigmund Freud in Totem and Taboo. [Italics are mine] There is almost always someone who is going to find the body, always someone who will find the suicide note, someone to receive that last farewell call.

Some spiritual traditions both East and West, have a version of heaven and hell that reside in this world, in this life, and that deeply depend on how we are living. I have experienced on many occasions both the bliss of heaven and the flames of hell.

I have had tremendous compassion for the incomparable pain that leads to such an act and yet, I am also aware that in the turbulent path that leads to this end, there are many turns and many forks, with opportunities to make either skillful or unskillful decisions.

I do believe that the majority of suicides are a symptom of a greater malady, both from the biological and familial predisposition, to the spiritual and cultural, but I also believe that there is responsibility as to what decisions are made at each fork of the road. There are innumerable chances to seek help, chances to make provisions to ensure that this does not happen again during the islands of clarity and sanity.

People find themselves in hell, and it is hard to see a light at the end of the tunnel, but I am reminded of the words of Winston Churchill: “If you find yourself in hell, the only way out is to keep on walking,” and the words of another guru, Afrim, our beloved colleague from the Gaza Strip who taught my dear friend James Gordon that, “when you lose hope, you find hope in the eyes of somebody else.”

I hope that if you find yourself in such a dire situation, that you take a turn towards the possibility of more fulfilling living, rather than narrowing your life. I hope that you make skillful choices to open doors and not choices that will narrow your opportunities. I hope that you call 911 or a suicide hotline; I hope that you reach out; I hope that you seek professional or spiritual help and the help of friends. I hope that you forgive, for it will ease the burden of depression; I hope that you keep walking if you find yourself in hell, and I certainly hope that, if you find yourself hopeless and lost, you turn to look for hope in the eyes of another.

Deconstructing suicide

suicide fact boxThe imminent decision to take one’s life is often an impulsive act and almost always regretted by those who have tried and failed. This can be seen in the survivor accounts of people who have jumped off of bridges and fell halfway before realizing that it was a mistake. It can also be heard in the testimony of those who woke up after overdoses, and those who shot themselves but survived.(see New Yorker Magazine October 2003 article on jumpers)

The French sociologist Emile Durkheim, in his typology of suicide, identifies four types of suicide based on an individual’s relationship to society. For Durkheim, suicide can be egoistic, when an individual feels alienated, estranged, and isolated from society. Suicide can also be anomic, when an individual feels that he or she has too little regulation of her or his emotions and too little ability to influence the external world, particularly during very stressful times. Fatalistic suicide occurs when an individual is living in a strictly controlled environment, for example as a prisoner without end in sight. The last type, altruistic suicide, is often culturally accepted or even idealized, for example, when in the spirit of “self sacrifice” an individual surrenders her or his life for the benefit of some greater cause. (Durkheim, Emile, Suicide: A Study in Sociology, New York, The Free Press, 1951). Industrialized countries where an increase in life expectancy is burdened by chronic illnesses lead the debate on right-to-die and assisted dying. Euthanasia is generally defined as the act, undertaken only by a physician, that intentionally ends the life of a person at his or her request. The physician therefore administers the lethal substance. In physician-assisted suicide on the other hand, a person self-administers a lethal substance prescribed by a physician. Physician assisted suicide is often called benevolent suicide.

Four European countries and three US states allow assisted suicide, euthanasia, or both: Switzerland, The Netherlands, Belgium and Luxemburg in Europe, and Oregon, Washington and Montana in the US. Vermont’s ruling came half way by making legal medical treatment for committing suicide using prescribed medications. (http://healthresearchfunding.org/physician-assisted-suicide-statistics/)

Physician assisted suicide and euthanasia are usually debated in the context of patients suffering from serious irreversible and terminal illnesses that cause significant unbearable physical suffering, such as cancer and nurological conditions (i.e Huntington’s chorea, Parkinson’s disease or dementia). In the West, with the exception of altruistic and benevolent (physician assisted suicide) other forms of self initiated death are considered a clinical condition, a symptom to treat, for it is a radical, violent, desperate and permanent act to alleviate intense impermanent suffering.

What is suffering?

Suffering has no clear medical language, and resides in the no-man’s land between the clinical and the philosophical-spiritual. Suffering has been defined as a specific state of distress that occurs when the intactness or integrity of a person is threatened. It involves intense agitation, anguish and fear from our perceived inability to cope with such a threat and the cognitive distortion that we are unalterably stuck in such an unbearable place. Suffering is to “…feel the future dissolve in a moment like salt in a weakened broth…” says the Palestinian-American poet Naomi Shihab Nye.

For more on suffering see Eric Casell’s article: Diagnosing suffering, a perspective.

What are the factors that lead someone who is suffering to actually attempt suicide?

Suicide, like suffering, can occur within or outside the context of depression. Suffering and suicidal ideas can come on suddenly, as with an abrupt loss, or can creep-in like mold on an abandoned house, as in chronic melancholia seeded with hopelessness.

One of the most interesting research on suicide prediction comes from Thomas Joiner, Ph.D. at Florida State University. Dr. Joiner’s research stands on biological and psychological data that supports humans as social and interdependent beings. For Joiner the imminence of suicide happens when we perceive been thwarted from human contact and that our life is burdensome to others. Feeling or being expelled from the social group, becoming a social pariah, can lead to intense suicidal thoughts. In this context, shame, guilt and rage are powerful drivers for suicide if one feels left outside the proverbial city walls into the desert of despair. His research is been proven by clinical evidence and supports maintaining contact with at risk individuals to reduce suicide risk. (see Joiner)

Suicide thus comes at the convergence of suffering, disinhibition/impulsivity on a neurological level, and misapprehended cognitive appraisal of a situation.

A number of factors have the ability to increase impulsivity and further obscure perspective such as inebriation, psychotic states, certain head injuries, mental retardation, and manic states.  Some of these altered states can be addressed in a direct way, such as looking after somebody who is drunk or intoxicated, or ensuring treatment for psychosis or mania.  Other factors require time and practice, as people learn skills to regulate more carefully impulsive and aggressive acts.  For example, undergoing mental health treatment that includes Dialectical Behavioral Therapy (DBT) has shown to reduce impulsivity and self-harm.  (see Linehan 2015 review in http://archpsyc.jamanetwork.com/article.aspx?articleID=2205835) In New Orleans, several therapists are DBT trained and offer this modality (see www.dbtnola.com and others).

In terms of cognitive distortions, people may (a) fail to see the whole picture and lose their perspective, for example, not thinking through the details of what will happen after their death, and (b) fantasize that “life” after suicide will be better, or (c) perceiving social alienation beyond repair. These tragic misrepresentations often manifest within a broader set of experiences that normalize suicide making it appear to be an acceptable possibility. These larger circumstances may include, for example, past suicide attempts, suicide attempts in family members, or even the suicide of somebody we identify with, be it a fellow student, worker, or a celebrity we admire.

Suicide almost never occurs in isolation, its effects ripple or more so, “tsunami” out to impact others. Families with a history of suicide may pass on destructive coping methods and self-defeating thought processes. A patient of mine once said, “It is ok to check out and abandon, and join my dead mother” who also committed suicide. Studies on suicide patterns within families show that there may be a shared genetic predisposition for ineffective serotonin production, impulsivity, drug use, alcohol use, and depression- all factors which could, in conjunction, lead to suicide.

Screen Shot 2015-06-24 at 8.40.54 PMWhile the above lethal mix of disinhibition/impulsivity, plus strong suffering, plus cognitive distortions is tremendously dangerous and explosive, the ultimate fuse or trigger (no pun intended) that can bring the nightmare to fruition is having readily accessible means to commit suicide. The means may include the presence of a weapon, the unguarded rail of a bridge, or having bottles of several medications in the cabinet.

How can suicide be prevented?

In the midst of tremendous suffering, there are islands of sanity where skillful decisions can be made; where we can reach out, call for help, or avoid behaviors that will make a bad situation worse, such as ingesting alcohol or purchasing a firearm when deeply emotional.

The more distance we place between ourselves and the means of suicide, the less risk. A guardrail above waist height, locking away and monitoring medications, or an unloaded firearm with ammunition kept locked away in a separate place can significantly reduce suicide completion. (See Grossman on gun storage practices and suicide prevention) Removing the gun altogether and/or having no access to firearms is a much safer alternative however.

“If one path leads toward suicide, I want to do anything I can to lead people in the opposite direction,” says Ittetsu Nemoto, the Japanese priest who has made suicide prevention his calling.

The opposite direction is often called “recovery,” and it is a journey of transformation, a process. “The goal of recovery,” says Patricia Deegan, Ph.D. consultant to the National Empowerment Center, “is not to become normal.  The goal is to embrace our human vocation of becoming more deeply, more fully human… not normalization. The goal is to become the unique, awesome, never to be repeated human being that we are called to be.”

“I’ve had many lives,” said the American meditation teacher Ram Dass. We all have had many lives: we were all a child, a sister or brother, a son or daughter once, a friend and student, a partner, a teacher; some were a doctor or a lawyer, or a carpenter and a drunk, a player or a killer. All of these lives have run their courses, coming to where we are now: at the brink of another transformation that may be fueled by pain, sorrow, or joy.

If we understand suicidal suffering not only as a dead-end of possibility, but as a vehicle of transformation, “a wake up call,” says Namoto, we become “like caterpillars about to become butterflies, about to take flight…”

Of course, that transformation can only happen here and now, within our own life and not with our death. “While there is life, there is hope,” says the old adage. Save yourself from the fantasy of suicide. It is the most heroic act, in the midst of such suffering, to choose life, for if you save one life, (yours), says the Jewish Talmud, “you will be saving the whole world”.

On Suicide

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