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Ira Israel


Contemplating Suicide

Posted: 07/06/2013 1:11 pm

Fascinating article last Sunday in the New York Times Magazine regarding suicide rates and researchers trying to determine specific correlates that would help predict suicide in particular populations.

Professor Matthew Nock of Harvard says, "It's easy to generate explanations. It's much harder to test out these different explanations and see whether the data support them or not." Excellent point. Maybe looking for a gene that predicts suicidal tendencies is like trying to measure milk with a ruler? Maybe the best that we can do is generate (unverifiable) theories?

Well, here is my theory regarding suicidality and suicidal ideation:

In "Mindfulness for Urban Depression" I say, "I've never heard a patient say, 'I feel loved, respected, and appreciated by my family, friends and co-workers... and I'm depressed.'" Similarly - and I realize that I'm going out on a limb here - I have never heard a patient say, "I feel truly HEARD and UNDERSTOOD by my family, friends, and co-workers and I know that they care about my well-being and love me deeply... and I want to blow my brains out."

Thus, I equate suicidal ideation - for anyone not dealing with an inescapable, imminent, painful death - with terrorism. For those diagnosed with pancreatic cancer or another unavoidable, insufferable, drawn-out demise, I would rename suicide as "self-euthanasia" or "auto-euthanasia." For everyone else, I believe that suicide and suicidal ideation is tantamount to terrorism.

Please follow this intentionally incendiary analogy: for 25 years or so, terrorist nonpareil Osama Bin Laden would occasionally issue edicts stating his belief that America had undue influence in the Middle East. He did not feel that he was being heard so he decided to turn up the volume. Terrorism, in my humble opinion, represents the terrorist's desire to be heard, to pay his suffering forward, to inflict his suffering on others, to have his or her emotional experience validated and understood, and to possibly gain some empathy. However, once one resorts to terrorism s/he is immediately branded as an "evil-doer" and whatever message he had is instantly lost in the medium. (Think of Timothy McVeigh or any other fundamentalist if you feel that Osama Bin Laden didn't have the right to political opinions. Moreover, if twenty minutes ago someone came up to you and asked, "What was Osama Bin Laden's message?" I imagine you would reply something like, "I don't know, I don't care, and it doesn't matter!" Right?)

Similarly, when people attempt suicide, the message is lost in the medium as we believe that only someone "crazy" or profoundly unwell would end his or her own life. But what do we hear if we are able to glean a message from the supposed madness? Usually, I hear something like, "I do not feel loved and appreciated in the manner I deserve to be loved and appreciated as a sentient being. All I ever wanted was to be loved unconditionally and I was forced to jump through hoops like a dancing bear for a few meager crumbs of affection and positive feedback. I do not feel as if people love and appreciate the real me. And I have never truly been able to properly grieve my loss of innocence - finding out that the world was unsafe - when someone I trusted betrayed me and violated me and there was nobody around to protect me, that I was all alone and that if I didn't learn how to protect myself (maybe even by isolating), I would be abused again and again. I have been trying to gain empathy and understanding for many years with the only tools I have available... and I don't feel that other people truly hear me or care about me. Right now it feels as if my only hope at being heard and understood is to commit an outrageous act of self-destruction. Then it will be impossible for them to ignore me."

Thus, when I visit patients in the psych ward who have tried to end their lives - after calmly and serenely expressing as much empathy as humanly possible - once they know I'm doing my best to authentically understand what they were thinking and feeling, that I don't think they are crazy, and that I am genuinely interested in what they have to say - I ask them to close their eyes and walk me through their imaginary funerals. Who is standing around the grave? Who is speaking? What are they saying?

I did not come across this theory willy-nilly. In graduate school many years ago, Professor Richard Corum explained Ophelia's final act by stating (if I remember correctly from 1999) that "Suicide always involves two people." A good parallel would be resentment, which we now often refer to as "Poking yourself in the eye and waiting for the other person to go blind." Corum added that Ophelia is pregnant with Hamlet's baby but he rejects her (while possibly feigning madness) when he says, "Get thee to a nunnery! Why wouldst thou be a breeder of sinners?" Meanwhile, her father has told her that she is naive if she believes the supposed "tenders" of Hamlet's affection and that she should stay away from him - however, she is already pregnant with Hamlet's baby. She is trapped and her only escape - her only means of agency - other than passively endure the horrific shame of being an unwed mother in that day and age, is to kill herself.

Secondly, I would like to make a distinction between pain and suffering. You may be familiar with the expression, "Pain is unavoidable. Suffering is optional." My friend Noah Levine teaches that pain does not cause suffering; it is our intolerance of pain that causes suffering. This is a very provocative idea that resonates with me as a psychotherapist. For we live in a society that has a very slim bandwidth for emotions. As I say on my DVDs and in my lectures, grieving and bereavement get in the way of productivity so we limit that process to a week or two. But can you ever fully grieve the death of a child? Or the death of a partner or parent or even a dear pet? What about the death of your marriage? Or the death of your job? What about the death of a dream or aspiration or hope?

The psychiatrists who wrote the latest version of the Diagnostic and Statical Manual of Mental Disorders (DSM 5) eliminated the Bereavement Exception from the diagnosis of depression. Previously, if your child was murdered in front of you, your boss would say, "That's really awful. You should take two weeks off of work." But now the Bereavement Exception has been eliminated and you would soon be diagnosed with depression and medicated if you didn't "get over" the murder of your child quickly.

All of us will experience the deep pain of losses and betrayals and violations and we need trustworthy, intimate, compassionate, loving relationships with people who empathize with our pain to create a space for us to process our losses in our own healthy, individual manners. There is no "One-Size-Fits-All" regarding grief. Without a safe space to process our emotions - assuming one doesn't numb oneself out with television, alcohol or drugs - our pain transmutes into suffering. And when suffering exists in isolation it can seem insufferable; sometimes the only solution appears to be turning up the volume.

Instead of looking for the orchestra in the radio, maybe scientists should ask high-risk populations such as war veterans (more of whom died by suicide last year than in combat) questions such as, "Do you feel like anyone can really understand the horrors that you witnessed? What did you do to grieve the loss of your best friend who was blown up by an IED next to you? Do you feel that what you went through - losing your legs in Iraq - is appreciated by your fellow Americans?" Or maybe scientists should ask suicidal teenagers how much they enjoy living on somebody else's schedule, living by somebody else's ideals, being forced to study swaths of knowledge that seem completely useless to them, competing against their friends, and being relentlessly tested, judged, scored and categorized?

Yes, I agree, my theory of suicide and suicidal ideation as terrorism is scientifically unverifiable. However, I think that there are better uses of time and research money than looking for a gene that correlates with suicidal tendencies. So the next time you or someone you love begins to eye that third rail or bridge with lust, try to discern the message that would be sent before it gets lost in the medium.

Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.