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(Note: This home study course deals with clients who feel they are unlovable. Taken to an extreme unlovability, as you know, can result in suicide. As you read this article use it as a checklist to review before your next session with your client who may have a suicide potential. After each commonality is described by Shneidman, ask yourself, how does this apply to a client I am currently treating? Your thoughts might be noted in the Personal Reflection Journaling Exercise at the end of this section.)
By commonality I mean a feature that is present in at least 95 of our 100 committed suicidesan aspect of thought, feeling, or behavior that occurs in almost every case of suicide. I am not talking about suicide among males, or suicide among African Americans, or suicide among teenagers, or suicide among manic-depressives. I am talking about suicideall suicide. I wish to focus not so much on specific cases of suicide so that we can understand the personality of the suicidal personand, of course, why they are driven to such an extreme act.
Here are the 10 psychological commonalities of suicide that I have found in my studies.
1. The common purpose of suicide is to seek a solution. Suicide is not a random act. It is never done without purpose. It is a way out of a problem, a dilemma, a bind, a difficulty, a crisis, an unbearable situation. For everyone, the idea of suicide acquired an inexorable logic, taking on an impetus of its own. Suicide becomes the answerseemingly the only available answer to a real puzzler: How can I get out of this? What am I to do? The purpose of suicide is to solve a problem, to seek a solution to a problem generating intense suffering. To understand what a suicide is about, we must know the psychological problem the suicidal person intends to address. As a patient told me, she needed to do something so that she would hurt no more. She reiterated this purpose: I would obtain the peace that I had sought for so long.
2. The common goal of the suicide is cessation of consciousness. Suicide is best understood as moving toward the complete stopping of ones consciousness and unendurable pain, especially when cessation is seen by the suffering person as the solutionindeed the perfect solutionof lifes painful and pressing problems. The moment that the possibility of stopping consciousness occurs to the anguished mind as the answer or the way out, then the igniting spark has been added and the active suicidal scenario has begun. I committed myself to the arms of deaththis was a patients way of telling me that he wanted all things to stop, now, permanently.
3. The common stimulus in suicide is psychological pain. If cessation is what the suicidal person is moving toward, psychological pain (or psychache) is what the person is seeking to escape. In any close analysis, suicide is best understood as a combined movement away from intolerable emotion, unbearable pain, and unacceptable anguish. No one commits suicide out of joy. The enemy to life is pain. I died inside. I was hurting very badly inside. Overflowing waves of pain washed through my body. Pain is the core of suicide. Suicide is an exclusively human response to extreme psychological pain, the pain of human suffering. I believe that if any one of us is able to capture the attention of a suicidal person, the key is to address the pain. If we are able to reduce the level of another persons suffering, even just a little bit, that individual may then see options other than suicide and can choose to live.
4. The common stressor in suicide is frustrated psychological needs. As we have seen in cases, suicide stems from thwarted, blocked, or unfulfilled psychological needs. That is what causes the pain and pushes the suicidal act. To understand suicide in this context, we need to ask a much broader question: What is the psychological underpinning of most human acts? The best non-detailed answer is that, in general, human acts are intended to satisfy a variety of human needs. Of course, most suicides represent combinations of various needs. At a fundamental level, the suicidal person believes the act of suicide has a purpose. There are many pointless deaths, but every suicidal act reflects some specific unfulfilled psychological need.
5. The common emotion in suicide is hopelessness/helplessness. At the beginning of life, the infant experiences a number of emotions (rage, bliss) that quickly become differentiated. In the adolescent or adult suicidal state, the pervasive feeling is that of helplessness/-hopelessness. There is nothing I can do [except commit suicide], there is no one who can help me [with the pain I am suffering]. The early psychoanalytic formulations about suicide emphasized unconscious hostility, but today we suicidologists know that there are other deep basic emotions. The underlying one of these is that emotion of active, impotent ennui, the despondent feelings that everything is hopeless and I am helpless.
6. The common cognitive state in suicide is ambivalence. Freud brought to our unforgettable attention the psychological truth that transcends the surface appearance of neatness of logic by asserting that something can be both A and not A at the same time. We can both love and hate the same person. I cant really say if I hate you or love you. A patient told me, It all came out that I really did love my father. I thought I hated him. We are of two minds about many important things in our lives. I believe that people who are actually committing suicide are ambivalent about life and death at the very moment they are committing it. They wish to die, and they simultaneously wish to be rescued. As the young woman said about her walking across the steel beam at the hospital, [I was] hoping that someone would see me out of all those windows; the whole building is made of glass. The prototypical suicidal state is one in which an individual cuts his throat and cries for help at the same time, and is genuine on both sides of the act. Ambivalence is the common state in suicide: To feel that one has to do it and, simultaneously, to yearn for intervention. I have never known anyone who was 100 percent for wanting to commit suicide without any fantasies of possible rescue. Individuals would be happy not to do it, if they didnt have to. It is this omnipresent ambivalence that gives us the moral imperative for clinical intervention. In a life-and-death struggle, why would any civilized person not throw in on the side of life?
7. The common perceptual state in suicide is constriction. I am one who believes that suicide is not best understood as a psychosis, a neurosis, or a character disorder. I believe that suicide is more accurately seen as a more-or-less transient psychological constriction, involving our emotions and intellect. There was nothing else to do. The only way out was death. The only thing I could do [was kill myself], and the only way to do it was to jump from something good and high. Those are examples of the constricted mind at work.
Synonyms for constriction are tunneling or focusing or narrowing of the range of options usually available to that individuals consciousness when the mind is not panicked into dichotomous (either-or) thinking. Either I achieve this specific (almost magical) happy solution, or I cease to be. All or nothing.
The sad and dangerous fact is that in a state of constriction, the usual life-sustaining responsibilities toward loved ones are not merely disregarded, much worse, they are sometimes not even within the range of what is in the mind. A person who commits suicide turns off all ties to the past, declares a kind of mental bankruptcy, and his or her memories can no longer save him. From the first, with the suicidal persons psychological constriction, the challenge and the task are clear: open up the possibilities; widen the perceptual blinders.
8. The common action in suicide is escape or egression. Egression is a persons intended departure from a region, often a region of distress. From the suicide notes: So Ill get out by taking my life. Now, at last, freedom from the mental torment. Suicide is the ultimate egression, besides which running away from home, quitting a job, deserting an army, or leaving a spouseall egressions or escapespale in comparison. We speak of unplugging the world when most of us distinguish between the wish to get away for a while and the desire to shut out life forever.
9. The common interpersonal act in suicide is communication of intention. One of the most interesting things we have found from the psychological autopsies of unequivocal suicidal deaths done at the Los Angeles Center was that there were clues to the impending lethal event in the vast majority of cases. I am dying, a patient said to a perfect stranger; another patient said, I began to say good bye to friends. Many individuals intent on committing suicide, albeit ambivalent about it, consciously or unconsciously, emit clues of intention, signals of distress, whimpers of helplessness, or pleas for intervention. It is a sad and paradoxical thing to note that the common interpersonal act of suicide is not hostility, not rage or destruction, not even withdrawal, not depression, but communication of intention. Of course, these verbal and behavioral communications are often indirect but audible, if one has the ears and wits to hear them.
10. The common pattern in suicide is consistent with lifelong styles of coping. People who are dying of a disease (say, cancer) over weeks or months are very much themselves, even exaggerations of their normal selves. In almost every such case, we can see, if we look, certain patterns: displays of emotion and uses of defense mechanisms consistent with that persons immediate and long-range reactions to pain, threat, failure, powerlessness, and duress that match earlier negative episodes in that life. People are enormously loyal to themselves, and they show this by the consistency of their reactions to certain aspects of life throughout its span. In suicide, however, we are initially thrown off the scent because suicide is an act which, by its definition, that individual has never done before, so there is no exact precedent. Yet, there are some consistencies with how that individual has coped with previous setbacks. We must look to previous episodes of disturbance, dark times in that life, to assess the individuals capacity to endure psychological pain. We need to see whether or not there is a penchant for constriction and dichotomous thinking, a tendency to throw in the towel, for earlier paradigms of escape and egression. Information would lie in the details and nuances of how jobs were quit, how spouses were divorced, and how psychological pain was managed. This repetition of a tendency to capitulate, to flee, to blot it out, to escape is perhaps the most telling single clue to an ultimate suicide.
I was once asked to participate in investigating the suicide of an old man (in his eighties), in the terminal stages of cancer, who took the tubes and needles out of himself, somehow got the bedrail down, summoned the strength to lift the heavy window in his hospital room, and threw himself out the window to his death. I puzzled over him (as I do over all suicides). What was his great hurry? If he had done nothing he would have been dead in a few days. He was a veteran of World War II, and there was a full record on him. The relatively few social (occupational, marital, educational, military) facts were especially illuminating. This was a man married several times, sparsely educated, a rather itinerant fellow who was never fired by a boss or divorced by a spouse. Rather, it was he who quite the job before he was fired. His wives did not walk out on him; he left them. Before a possible court martial, he got himself transferred. His life seemed like a series of precipitous departures. Death by cancer was not going to get him; he would die in his own way, when he decided. In 20/20 retrospect, his suicide seemed totally predictable from an extrapolation of his character.
To repeat: People are very consistent with themselves. But I hasten to add that no possible future suicide is set in stone, and the capacity for change is our great hallmark as human beings. It is probably next to impossible to behave out of character, but what is possible, and happens all the time, is for changes in charactergrowth and maturityto occur, and for transiently overwhelming psychache to be resisted and survived.
Some of our most beloved novels weave suicide into their plots. I am thinking of Kate Chopins The Awakening, Flauberts Madame Bovary, Goethes The Sorrows of Young Werther, Lagerqvists The Dwarf, Tolstoys Anna Karenina, to name a handful. What is interesting about them (aside from their gorgeous writing) is the consistency of the chief characters, and our acceptance of the deaths as almost fitting endings to their lives. The suicidal outcome is not DeMaupassant-like surprise, but rather an understandable outcome within the confines of that character, a lamentable but psychological necessity, given the unhappy circumstances and unhappy deficiencies of that person. Can anybody commit suicide? Not likely. But if you are an Anna or an Emma or an Edna, then you must be very careful how you turn lifes pages and into what corners you paint yourself.
There are also certain questions we might pose to help get a person out of a constricted suicidal state: Where do you hurt? What is going on? What is it that you feel you have to solve or get out of? Do you have any formed plans to do anything harmful to yourself, and what might those plans be? What would it take to keep you alive? Have you ever before been in a situation in any way similar to this, and what did you do, and how was it resolved?
should be thinking how to help the suicidal person generate alternatives to
suicide, first by rethinking (and restating) the problem, and then by looking
at possible other courses of action. New conceptualizations may not totally solve
the problem the way it was formulated, but they can offer a solution the person
can live with. And that is the primary goal of working with a suicidal person.
(Excerpt from Shneidman, Edwin S. The Suicidal Mind: Chapter 7: The Commonalities
of Suicide. Oxford University Press, Oxford. 1996).
The Role of Self-Esteem in the Development of Psychiatric Problems:
- Henriksen, I. O., Ranøyen, I., Indredavik, M. S., & Stenseng, F. (2017). The role of self-esteem in the development of psychiatric problems: a three-year prospective study in a clinical sample of adolescents. Child and adolescent psychiatry and mental health, 11, 68. doi:10.1186/s13034-017-0207-y.
Reflection Exercise #2