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Out of This World

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This book is intended for anyone with either an interest in suicide or suicidal behaviour. It is not aimed solely at the professional psychotherapist but at a broad range of professionals who encounter suicidal people in their work. It is also intended for those of us who have been touched by suicide personally.The book approaches suicide from the point of view of the suicidal state of mind and is intended to help us understand more about this condition. In its essence suicide is examined as a largely unconscious aggressive act having its roots in a perceived or real experience of thwarted childhood needs. The wounds of the suicidal person are often long held and deep. The suicidal person is pursued by haunting losses and the suicidal act comes from deep disturbance created by this and from the idea of death as an acting out of some form of suicidal fantasy. The quasi delusional and split quality of the act is examined - namely that suicide is both an act for and against the self. Consequently a strong case is made for the contribution of psychotherapy to the project of suicide prevention since it is in this carefully managed arena the suicidal fantasy can be examined and the settling of these scores can be worked through, rather than acted out by suicide. The hope is that the book will increase understanding, challenge concepts of mental illness and suicidality but most importantly address the understandable fear we all have about suicide and its power to render us impotent. In turn it is hoped this will empower readers, who might otherwise be fearful of suicide, to intervene, support and work with those who are suicidal.

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Chapter One: Why suicide?

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J., a forty-one-year-old nurse, kills herself by taking drugs which she has stolen from her workplace. No one close to J.—her partner, her children, her siblings, her friends, her colleagues—knew she was actively suicidal although she had been low and depressed and anxious at times. Others described her as bubbly and outgoing, always there for others, and expressed shock and astonishment at her death. She had been seen by her GP, but not within the last six months, and had been prescribed antidepressant medication. She recently made an appointment with her GP but did not attend it.

This is not an unusual suicide. Just take a minute to think about your family, friends, colleagues, and neighbours. Do you know any among them, past or present, who has killed themselves or has lost someone close to them to suicide? I expect you do. Pretty much everyone knows someone who is suicidal or has been affected by a suicide, maybe someone very close to you, maybe you yourself. And not all such deaths by suicide are expected, obvious, or readily understandable.

 

Chapter Two: Suicide and Mental Health

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Just as I was about to start writing this chapter (February 2015) I heard a very brief piece on the radio relating to the death by suicide of a young woman in an NHS hospital in Manchester. The report emphasised the need for more government spending and resourcing for mental illness. A government spokesperson was then quoted saying (I paraphrase from memory): “This government is committed to increasing spending on mental illness and reducing death by suicide.” She then referred to the latest national suicide strategy and followed this with a comment about reducing self-harm. This was of course a well-intentioned response. But it sums up the prevailing problematic orthodoxy that positions suicide as part of mental illness and that elides suicide with self-harm. Look at most current DoH and government documents on suicide and you will see two things: suicide conflated with mental illness and suicide conflated with self-harm. In this chapter I want to critique both these conflations in turn, not because I want to undermine good work but because they are only part of a useful understanding of suicide and because they may seriously divert attention and treatment into potential blind alleys, circles, and missed opportunities when it comes to understanding and preventing suicide.

 

Chapter Three: Suicide and Self-Harm

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Self-harm and suicide are often conflated together particularly when undertaking risk assessments within mental health and psychological work but also within health policy initiatives. However, I was pleased to see this comment in the latest government suicide prevention document (Preventing Suicide in England: A cross government outcomes strategy to save lives): “We also have to be clear about the scope of the strategy. It is specifically about the prevention of suicide rather than the related problem of non-fatal self-harm. Although people with a history of self-harm are identified as a high-risk group (of suicide) we have not tried to cover the causes and care of all self-harm” (DoH, 2012, p. 4). What is important in this statement is a recognition of the difference between self-harming behaviour and suicidality. They are not mutually inclusive and for the most part self-harming and suicide do not have the same quality or intentionality although they may have aspects of self-aggression in common.

 

Chapter Four: Myths, Misrepresentations, and Fallacies

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If we look at suicide historically, in a way it can be seen as a narrative of denouncement, suspicion, and opprobrium within the context of changing social and cultural norms. For the most part, suicide is either excused, appropriated, accounted for, or reviled within a number of prevailing orthodoxies—be they religious, political, cultural, or territorial. It is rarely simply allowed to be the human, individual experience that it is. It is more often misunderstood, misrepresented, and treated with great suspicion within wider society. It remains suspect. As such, there abound a great many competing pronouncements, explanations, theories, and excuses for suicide, historically and contemporaneously. They range from the sympathetic, the scientific, the sociological, the psychological, to the indignant and the dismissive. Many ideas about suicide contain part truths and part understandings. In Chapter Two we spent some time in the shark-infested waters of what is or is not a mental illness. Reducing suicidality to a mental illness is one such example of a part truth—it can be partly helpful, partly miss the point, and partly unhelpful. But there remain other fallacies and myths and responses to suicide which bear further examination in order that we may better understand what we are dealing with.

 

Chapter Five: The Suicidal Condition

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In the introductory chapters we have examined some of the ideas, common constructs, understandings, and misunderstandings about suicidality. Now we will look further into the condition of the suicidal mind and examine it in some depth. The hope is that we may then have both a better understanding of this condition and also perhaps be relieved of some of the terror, rejection, guilt, or disdain, or other strong feelings, that may arise when we are asked to think about suicide. That which is able to be faced is better able to be accepted than that which is not. To accept that the condition of suicide might always be with us as part of the human struggle is not the same as ignoring it with a phlegmatic/dismissive “People kill themselves so we should just let them”, nor is it the same as trying to stop it happening, but rather it is about our decision and our ability to tolerate it. This of itself is a helpful act, perhaps the most helpful act in relation to the suicidal person: for us to try to tolerate what the suicidal person believes cannot be tolerated by them or about them.

 

Chapter Six: The Suicidal Fantasy

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We are now beginning to see the suicidal condition and the suicidal act are complexities that can feature and take hold in any individual. Suicide, in my view, is a standalone condition which needs its own careful analysis and understanding. It is in no particular way connected with conventional thinking about mental illness but bears better scrutiny if it is considered in and of itself. There are common aspects to suicides but it always, or nearly always, has a meaning for the individual suicide which is theirs alone. Knowing as we do that in the UK as many as seven people per day, on average, kill themselves at present recorded rates, it is important that we extend our understanding of something so deathly as suicide beyond a conventional medical view of mental illness or a socio-economic analysis of deprivation, so that we may better grasp its psychological roots and meaning and hence have more of a chance of approaching it.

Perhaps the reason why we associate suicide with illness is that it is easier for us to think of suicide in terms of pessimism and depression. If someone takes his own life then it must be because he thinks his life is not worth living. Maybe he has had an insurmountable degree of difficulty to face, a lousy start in life, unparalleled losses to deal with. All of this may well be true of certain suicides. But what these well-meaning assumptions about suffering and depression fail to appreciate, and in a way this is as the unconscious intends, is the aggression behind the act. Suicide is an act of killing and destruction. The intention at the time of the act is to both save the self and destroy the self. To kill the self's body but—and here is the deathly clincher—to keep part of the self's mind alive. As I put it at the beginning of this book, as stated by Campbell and Hale (1991), suicide is an act both for and against the self. The suicidal person is in the ultimate position of ambivalence, with life and death balanced on a knife edge. There is a wish to live and a wish to die. In the moments of suicide the hostility, rage, despair, hopelessness are all felt to be too much, but there is also a very active wish and desire to live without the pain. However, at the fatal moment of suicide the person appears to view herself almost as another person, to separate out herself from herself and hence to take out on her own body, and on the continuing lives of others, the hostility and despair that relates to past and present injuries felt to have been experienced.

 

Chapter Seven: Working Through

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In the previous chapter I explained that suicide, as I have come to see it, is largely a standalone condition. That is to say that while in some ways suicide may be connected to aspects of what we commonly think of as illness, it remains primarily, in and of itself, a drama of the mind; a peculiar condition into which the mind twists itself. The soil for suicidality is usually deep and the causes are often unclear and unknown to the person involved, having a largely unconscious aspect. And one of the most important unconscious elements in play in any act of suicide is aggression or the acting out of hate.

Consequently suicidality is often hard to spot, hard to fathom, and hard to treat. Combine these factors with its notorious qualities of dissembling, impulsiveness, and lethality, and it is not surprising that so many people are able to successfully kill themselves. Sadly those who do take their own lives are not confined to the untreated—a high proportion of those in the UK who do take their own lives are, at the time of their death, in some sort of mental health treatment or in the care of a general practice or mental health team. And while we can argue about what might be the right or wrong treatment for those who are suicidal it might be more helpful to come at ideas about treatment in a way that is geared towards the individual state of mind. There are a great many health professionals—doctors, psychologists, psychotherapists, and counsellors who could be well placed to work with the suicidal in ways that will have a greater impact than is currently realised if they are enabled to contain and think about suicide with the person at risk. All too often clinicians are trained and instructed to assess suicidality by means of questionnaires or inventories but then left floundering with very inadequate resources and support when a suicide is identified. When it comes to suicide it is the better part of valour and of helpfulness to move beyond debates about treatment models and instead to fully take on what this suicide means for this person, and to work through the suicidality of the person with that person as an individual.

 

Chapter Eight: Exploring the Consequences

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“It will generally be found that as soon as the terrors of life reach the point where they outweigh the terrors of death, a man will put an end to his life. But the terrors of death offer considerable resistance.” So wrote the nineteenth-century German philosopher Arthur Schopenhauer in his essay, “On Suicide”, in his Studies in Pessimism (1891). It seems manifestly true that because we are able to think, it follows that we are able to think of suicide as a solution to the unbearable pain or insurmountable challenges and burdens that we all face in life. However, despite our ability to contemplate suicide, not many of us actually go on to kill ourselves. As we have seen, the conditions that lead someone to take their own life are far from simple, straightforward, or understandable; nor is suicide easy to carry out. As Schopenhauer went onto say, “Suicide is the destruction of the body; and a man shrinks from that because his body is the manifestation of life.” In some ways Schopenhauer is echoing Freud's puzzle over the pleasure principle—how, if we are driven to pursue our needs and our pleasures, do we understand the drive to destruction? In understanding suicide as both an act of the self and against the self, as an act of destruction turned against the self, we can begin to understand its hold over us. We have faced the reality of suicide throughout the ages and across cultures and enough of us continue to die by suicide for it to be worthy of our inquiry. Despite out best efforts, and some not so good efforts, suicide is determinedly with us. We do not seem to be able to stay its hand.

 

Chapter Nine: Final Thoughts

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Any discussion about suicide is going to be difficult. Suicide is never going to be a neutral or mild subject. Suicide is about extreme feeling or feeling extreme. It is a strong response to life and, consequently, it arouses strong responses in others. Suicide is “over the top”. It is out of proportion—it is “out–rage-ous”. Suicide is not a proportional response to anything. It is a rageful act about something felt to be too much. It is a desperate act of escape, of getting away from all that is felt to be unbearable, unmanageable, and unfair. Suicide is an unbearable solution to unbearable feeling. It leaves behind something unbearable for the bereaved.

However, we do talk of rational suicide, by which we appear to mean a suicide that makes sense to and about the person involved, and presumably to others. The arguments for rational suicide are supported by the notion of autonomy, namely that we must be able to act according to our own desires and beliefs without interference from others. Following on from such ideas the right to die is seen as an expression of autonomy, in extremis: we have the right to choose the time and manner of our dying. Arguments in support of rational suicide also rely on the belief that an individual has the ability to make a rational assessment of their utility or “good” in living, of the quality of their life as opposed to ending their life. Suicide in this way is seen as a way of deciding to cease painful and hopeless disease, feelings, pain, or circumstances. However, this reasoning is based on an assumption that autonomy, as the exercise of independent thought, independently derived, free from culture, society, relationship, psychological turf, etc., is possible. But as we have seen throughout this book, to be able to conclude that an act or intention of suicide is reasonable, rational, is not a straightforward matter. Also, since the experience of being dead is entirely unknown—regardless of any religious belief—it is highly questionable whether it is possible to “know” what the outcome will be. So the question which remains in my mind is not “Are there any conditions in which suicide is a reasonable response?”, but rather “Why are so many suicides carried out with respect to what are in fact inevitable and ordinary life experiences (albeit tough ones—loss, deprivation, shame, isolation)?” Why do some of us manage life, with all its vicissitudes, and others do not? Suicide, it seems, contrary to appearances, is largely an internal problem not an external one. The concept of suicide as understandable within the context of the individual's psyche is more meaningful than any concept of it being a rational act. And it is within an understanding of the person's internal world that the clue to helping a suicidal person ultimately lies.

 

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