Towards an Understanding of Suicide
– Te Mohio ki te Whakamomori
In the six months to February 2018, five young people (and one parent) within my children’s social group took their own lives. Whenever I was able to attend their funerals I realised I was listening for clues as to why these five talented young people had decided on a permanent solution to what may have been a temporary problem. In my grief I risked jumping to conclusions, but I think perhaps there were three intersecting threads that led to these tragedies:
First, in each case there was a sense of rage without a home;
Connected, but different, they all needed to put up a front to the world;
Lastly, I believe they lacked a capacity to be alone.
I want to think about each of these in turn by reference to psychoanalytic thought, in particular the work of the British psychoanalyst and paediatrician Donald Winnicott. I hope to bring these threads together as I endeavour to make sense both of these six tragic deaths and my own journey through life to my practice of psychotherapy today.
As I begin to write I am aware that when I am anxious I have a tendency to come across as if I know what I am writing about! I don’t. One of the difficulties of psychotherapy becoming professionalised and taught in universities is that it links the practice with a need to know. The work of ignorance is neglected. In the face of a threat of suicide we often know nothing and this always evokes terrible anxiety. We do need to be scared and bear to believe it might happen.
We all have our reasons for taking up the practice of psychotherapy: I remember as a child my desire to end my own life would alternate with a desire to murder my father. I consider myself fortunate not to have succeeded in either project, and also not to have become floridly psychotic. Over the years the threat to my own life has waned and very rarely haunts me now; although I know I have not entirely laid this ghost to rest.
I remind you we are all born utterly helpless: I believe the way our helplessness is received by the world shapes the rest of our lives. Piri Gal, a neuro-developmental therapist on Waiheke, introduced me to a saying of Urie Bronfenbrenner:
In order to develop normally, a child requires activity with one or more adults who have an irrational emotional relationship with the child. Somebody’s got to be crazy about that kid. That’s number one. First, last, and always.
A Sense of Rage Without a Home
In a long tradition of psychoanalytic thought I will begin with Freud. In this Age of the SSRI I think Freud’s formulation of depression and suicide in his 1917 paper “Mourning and Melancholia” is sadly neglected:
We have long known, it is true, that no neurotic harbours thoughts of suicide which he has not turned back upon himself from murderous impulses against others, but we have never been able to explain what interplay of forces can carry such a purpose through to execution.
The analysis of melancholia now shows that the ego can kill itself only if, owing to the return of the object-cathexis, it can treat itself as an object—if it is able to direct against itself the hostility which relates to an object and which represents the ego’s original reaction to objects in the external world.
Thus in regression from narcissistic object-choice the object has, it is true, been got rid of, but it has nevertheless proved more powerful than the ego itself.
Freud reminds us how, when for some reason we are not able to feel murderous angry feelings towards someone who we are closely identified with, the hatred and loathing can be turned on ourselves, with disastrous consequences. I find this really useful. It is a hard job as a parent to receive a child’s love and hate with equanimity. When our own parental ego needs propping up by our child’s we may tend to favour love over hate: Which sometimes leaves a child’s rage without a home.
A patient Richard turned up to his first appointment after an unusually long break of six weeks, looking sheepish. In his early fifties, Richard was the youngest of five. He had been the outsider both in his family and in the context he grew up in. Richard’s father had killed himself. Slouching on the sofa, Richard told me he was feeling guilty. We had been meeting for almost fourteen years, mostly once a week, but twice a week for the previous two years.
Despite a stellar career, he had suffered with depression and thoughts of taking his own life for as long as he could remember. I waited, wondering what he was feeling guilty about. Richard wanted to own up that he had gone to see his doctor whilst I was away because he was feeling so miserable. He had come away with a prescription for antidepressants. He related how they had had an immediate effect and he had woken up the next day feeling much better.
I am much more interested in the symbolic value of anti-depressants than their neuropharmacology. I believe they may be mislabelled: All SSRI’s list as one of their “side-effects” a reduction in libido. I wonder how the drug companies decide what is a side-effect and what a main-effect. Darian Leader in his book ‘The New Black, Mourning, Melancholia and Depression’ argues the diagnosis of depression was created by pharmaceutical companies to make a market for their products. I believe the main effect of the SSRI’s may be this reduction in libido they list as a side-effect, which in turn has the side-effect of abating the ferocity of the ego’s attacks on itself. I also know the SSRI Richard had been prescribed, takes somewhere between one and three weeks to have a physiological effect, so I was very curious.
Over his next few appointments Richard kept coming back to how guilty he was feeling about taking medication. At first I had tripped up and been reassuring (always rather useless) but I recovered my mind and remained interested but neutral. His continuing insistence on how bad he felt about taking the antidepressants gave me the feeling I was missing something important. As I listened to him recount how much better he was feeling and how he was finding it so much easier to say “no” to other people’s demands, I found myself thinking about how hard he finds it to be angry with me. I was reflecting on how I had not only been away for six weeks, but I had also moved my practice from the rooms we had met in for fourteen years. Yet Richard had not said a word about either. I began to wonder if taking the medication was a symbolic act of aggression against me – hence Richard’s guilt.
I apologised to Richard that I had been away for such a long break and wondered aloud if he might have unconsciously sought out the medication as a way of punishing me for being away so long, in the fantasy that I would be quite upset by this. Now he kept bringing his guilty feelings to me because part of him imagined I would be upset. Perhaps his guilty feelings were less about the action of taking the medication than about the symbolic value of this action. Speaking about his guilt served a double purpose, both aggressive in repeating the attack on me and also attempting to assuage his feelings of guilt. Richard considered what I had just said. He asked me to repeat my words and was able to connect with a glimmer of recognition that something about what I was saying might be true.
I went on to think about how this unconscious attack on his internal objects of me and the therapy, in fantasy, might have freed his aggression up in other ways, so he felt more able to use it in the service of saying “no” to others and protecting himself. Neither Richard’s mother or father appear to have been available to Richard’s aggression when he was a child and his several siblings used to ridicule him as the little brother. If he had expressed his anger and aggression this would have been made fun of, leaving Richard feeling ashamed and helpless. He learned to turn his hatred back on himself.
A Need to Put Up a Front to the World
When I read references to families and early childhood in the media and in politics, I am often struck by how we seem to have forgotten the conclusions of the research done by John Bowlby and the Robertsons in the 1950’s: How much a child needs someone to be crazy enough about them to make them a priority. I think being crazy about a child means what Winnicott sometimes called “ordinary devotion” and other times “primary maternal preoccupation”.
In New Zealand at least, it seems children are still often second class citizens who have to be accommodated to the needs of the adults around them. Rather than supporting adults to parent their children, we support adults to return to the workforce, the economic imperative, and children to grow up as quickly as possible. We measure and evaluate and forget the inestimable value of play.
When I first met my patient Susan, I had an overwhelming sense of her looking at me to discover who she should be. A middle aged woman with a lifelong interest in personal growth, she was living a comfortable life working part-time in a helping profession, with her children on the cusp of leaving home and a husband who had found success in his career. Her reason for seeking psychotherapy was not immediately clear, but I suggested it had something to do with this sense I had of her looking at me to find out who she was supposed to be.
In his paper “Ego Distortion in terms of True and False Self” Winnicott begins by saying the idea of a “false self” is not in itself new, but that it deserves more thought and necessarily implies a corresponding idea of a “true self”. Right at the start he links back to Freud as follows:
It would appear to me that the idea of a False Self, which is an idea which our patients give us, can be discerned in the early formulations of Freud. In particular I link what I divide into a True and a False Self with Freud’s division of the self into a part that is central and powered by the instincts (or by what Freud called sexuality, pregenital and genital), and a part that is turned outwards and is related to the world.
Susan’s father had been a highly educated successful professional with an interest in child development. Her mother had been a full-time mother to Susan and younger siblings until Susan was about nine at which point she trained and began to work as a teacher.
Susan’s mother was passionate about parenting and read many how-to books and was actively involved in parenting groups and Playcentre. However Susan’s description of her mother made her sound histrionic and not very motherly.
Susan cried a lot in her appointments with me, and sometimes I felt as if I was in a kind of Victorian melodrama. She seemed to become very dependent disarmingly quickly; but there was something odd about this, something uncanny. I felt as if I was being enrolled in something, perhaps seduced, and I was often disarmed by how quickly she could transition from seeming utterly distraught to a composed thoughtfulness.
About three years into her psychotherapy Susan moved onto the couch. I felt relief as I was no longer subject to her rather controlling gaze and I hoped she might find the space to become more self-reflective without her preoccupation with the image of me.
Gradually I became aware of a visceral sense Susan was trying to climb inside my mind when she was with me. I had always assumed Susan had a well developed internal world because of her work and her interest in personal growth, but I started to become aware she did not. In fact she was dismayed by the very idea of having an internal world, it was a foreign concept to her. I started to wonder how autistic Susan might be, and this was reinforced by how difficult she would find the journey from her car to the couch. I was also connecting with Donald Meltzer’s thoughts on Adhesive Identification and the children he wrote about who would draw a house on one side of a page, turn the page over, and the doors would line up. Susan’s house had no interior.
I was also wondering about Susan in terms of true and false self. Winnicott connects his thinking about a false self to early infancy:
In seeking the aetiology of the False Self we are examining the stage of first object-relationships. At this stage the infant is most of the time unintegrated, and never fully integrated; cohesion of the various sensori-motor elements belongs to the fact that the mother holds the infant, sometimes physically, and all the time figuratively. Periodically the infant’s gesture gives expression to a spontaneous impulse; the source of the gesture is the True Self, and the gesture indicates the existence of a potential True Self. We need to examine the way the mother meets this infantile omnipotence revealed in a gesture (or a sensori-motor grouping).
Winnicott links the idea of a True Self with the spontaneous gesture: If this is met by a mother who repeatedly “… meets the omnipotence of the infant and to some extent makes sense of it” something begins to have life that might become a True Self “… through the strength given to the infant’s weak ego by the mother’s implementation of the infant’s omnipotent expressions.” Thus the True Self becomes a reality through the mother’s ability to be preoccupied with her infant in a “… specialised relationship, one which might be described by a common word: devotion.”
He contrasts this with a mother who “… repeatedly fails to meet the infant gesture …” and “… instead substitutes her own gesture which is to be given sense by the compliance of the infant.” The tables are turned and rather than the mother making sense of her infant’s gestures, the infant must give some sense to its mother’s gesture through its compliance.
I often felt as if Susan was seeking to comply with my requirements and unable to give expression to anything convincing about herself.
When Susan was not quite eighteen months her next sibling was born. She was left with friends of her father for about a week. She had no narrative memory of this event but the experience of this separation endured in both my mind and Susan’s. She used to call my voicemail regularly between appointments as listening to the sound of my voice was a way of soothing herself.
Winnicott alluded to a way in which a False Self structure might be a particular problem for people in the fields of therapy and social work. Over the years I began to understand Susan’s career helping others as a ’sinthome’ or a way of holding her world together.
’Sinthome’ is the way Jacques Lacan referred to something that binds together the three registers of the imaginary, the symbolic and the real. He developed this idea thinking about James Joyce and how writing performed this function for him. Unlike a symptom, Lacan considered the sinthome as unanalysable. Susan had made a career out of shaping herself to others requirements in the hope that this offers them relief. She was beginning to wonder about stopping her work and I believe this may have reflected a growing sense of the possibility she might start to live her own life.
Her overwhelming memory of her childhood was of ‘being good’ for her parents – trying to find the right shape for them. She arrived at appointments wondering what to talk about today, but it seemed she was always trying to work out what I would like her to talk about. She also idealised everything relentlessly.
One day Susan came to see me and spoke of feeling like she was coming to see me to be persecuted and to persecute herself, as if I was there to tell her everything she was doing wrong. However she said she also knew sometimes she came to therapy and it was a tender loving experience. My association to this was to a seminar I attended some years ago with the psychoanalyst Vamik Volkan. He was given money to set up a multi-disciplinary team at a university in the USA to go into conflict zones and find ways to get the conflicting parties to work through their differences. He had worked with Israelis and Palestinians, Serbs and Croats amongst others. Vamik said he had learned that the times to be really worried were both when people were refusing to talk to each other and also when everybody was getting on marvellously.
I believed this association was connected to Susan so I suggested that both of the experiences she was speaking about were problematic, both when she was feeling she came here to be criticised and also when she felt therapy was a tender loving place. I thought perhaps she was having a growing experience of herself as a someone, a someone separate from me with all the difficulties that brings. Susan was quiet and thoughtful about this in a way that is quite new for her.
Winnicott is clear that there are real dangers associated for a personality constellated around a false self:
The False Self has as its main concern a search for conditions which will make it possible for the True Self to come into its own. If conditions cannot be found then there must be reorganized a new defence against exploitation of the True Self, and if there be doubt then the clinical result is suicide. Suicide in this context is the destruction of the total self in avoidance of annihilation of the True Self.
When suicide is the only defence left against betrayal of the True Self, then it becomes the lot of the False Self to organize the suicide. This, of course, involves its own destruction, but at the same time eliminates the need for its continued existence, since its function is the protection of the True Self from insult.
Whilst this has never been an issue for Susan, I kept a weather eye on her as she began to live her own life with all the grief this brought.
Lacking a Capacity to Be Alone
In his paper “The Capacity To Be Alone” Winnicott suggests that the capacity to be alone “… is one of the most important signs of maturity in emotional development”. It is a paradox because it is “… the experience of being alone while someone else is present.”
Winnicott is clear that this capacity to be alone has nothing to do with the experience of defensive withdrawal or solitude. I believe he is referring to a capacity to be connected with oneself, to have a space inside oneself that is private and personal, irrespective of whether in the company of another. He traces the development of this capacity to early infancy:
… the capacity to be alone is based on the experience of being alone in the presence of someone, and that without a sufficiency of this experience the capacity to be alone cannot develop … Being alone in the presence of someone can take place at a very early stage, when the ego immaturity is naturally balanced by ego support from the mother. In the course of time the individual introjects the ego-supportive mother and in this way becomes able to be alone without frequent reference to the mother or mother symbol
I often find myself remembering a drawing I was told John Bowlby made when he visited New Zealand:
Apparently he drew this and asked his assembled audience what they thought it was. He explained it was two mothers chatting on a park bench and the petals of the daisy were the tracks their children made around them as they played. The children would wander off apparently blissfully unaware until at a certain point they would hurriedly return to rediscover themselves in their mothers’ minds. Then, reassured, they would adventure forth again to play.
I suggest this may be an illustration of children practicing their capacity to be alone in the company of their mothers. If the child returned to find their mother preoccupied with some task on their mobile telephone, or deeply engrossed in a conversation that excluded them from their mother’s mind, they would not be able to venture forth again in the same way. Similarly if the mothers were obsessively monitoring their children’s play, even following them around like helicopter’s, the child would respond to their mother’s anxiety and not be able to be absorb themselves in their play.
Winnicott puts it like this:
Here is implied a rather special type of relationship, that between the infant or small child who is alone, and the mother or mother-substitute who is in fact reliably present … It is only when alone (that is to say, in the presence of someone) that the infant can discover his own personal life. The pathological alternative is a false life built on reactions to external stimuli.
Here we can see the link with the development of a False Self. Without a capacity to be alone there is no safe haven for the True Self and we are required to protect ourselves with a front to the world whose main purpose is to ensure the True Self is not exposed to the shadow of early disappointments. Winicott clarifies this by differentiating between ego-relatedness and id-relatedness: Ego-relatedness refers “to the relationship between two people, one of whom at any rate is alone; perhaps both are alone, yet the presence of each is important to the other” and links it to the experience of liking. In contrast id-relatedness concerns bodily impulses in their raw and sublimated forms.
Jamie was in his early forties and had just begun a psychotherapy with me. He was highly ambivalent about the whole process, threatening to stop unless I reduced his fee. He always arrived in a hurry, flung himself on the sofa and stared at me, everything about him tense. He could not make his mind up whether what I was offering him was an elaborate scam or if there might be something useful about it. When I waited for him to speak he wondered if we were engaged in some sort of competitive staring match. I helped him out, asking what was on his mind this morning, or perhaps said something about how I was experiencing him today.
Like several of my patients he was dismayed by the idea that he could ignore me when he was in my room. This was simply an impossibility. That he could follow Freud’s Fundamental Rule and read off the surface of his consciousness, putting himself:
… into a state of quiet, unreflecting self-observation, and to report … whatever internal observations he is able to make” taking care not to “exclude any of them, whether on the ground that it is too disagreeable or too indiscreet to say, or that it is too unimportant or irrelevant, or that it is nonsensical and need not be said.
I believe this capacity to free associate is intimately related to a capacity to be alone in the company of another. Jamie prepared for a trip overseas by setting up three Tinder dates before he left New Zealand so he knew he would not feel lonely when he arrived. He knew he could not bear being alone. He rationalised these as “cheap tour guides”.
I sometimes think my capacity to be alone is the thing most tested in my work. Being able to bear unbearable states of mind without acting them out, being able to think, being able to observe my thoughts and allow reverie, none of this could happen without a capacity to be alone.
Jamie grew up with a father in the military and was sent away to boarding school at nine. He remembers being miserable for about a year but was bright and athletic and soon found a way to fit in well. However his late teenage years were a descent into drink and drugs. Despite this he went to a prestigious university where he felt lost and alienated. He dropped out at the end of his first year. Reading Marlon Brando’s autobiography on the plane home, he decided this sounded a much more interesting life to lead.
The capacity to be alone is a close cousin to our development of “negative capability” as Keats wrote in his letter to his brother, “… when man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.”
Jamie drank and smoked his way through life, alternating between lying in bed in his room with a joint and booze watching a stream of movies and masturbating, or manically engaging with his flatmates or the occasional friend. Every moment was literally filled with Kipling’s “sixty seconds of distance run”. He said running was the only thing that calmed him down. I surmised Jamie had a very limited capacity to be alone. As soon as he entered the room and sat down he experienced me as a demand and if I failed to be sufficiently demanding he also experienced this as difficult. He knew how to respond to others’ demands and how to be demanding but nothing in between.
I found myself imagining the shadow of early experience of his mother falling on me. Jamie was still close with his mother and had visited her abroad to take care of her recently after an operation. However Jamie was careful to pick and choose what he said to his mother as she had always been very anxious and he did not find her a source of comfort.
His father wanted nothing to do with any of the family.
My experiences have led me to recognise that dependent or deeply regressed patients can teach the analyst more about early infancy than can be learned from direct observation of infants, and more than can be learned from contact with mothers who are involved with infants.
Whilst most of Jamie was not deeply regressed, if I listened carefully, the echoes of his early experience were there to be heard. I found it hard to remember to breathe when I sat with him and even harder not to be pulled into a kind of undertow that required me to engage in conversation about his life, as if I had some useful advice to offer. I like Adam Philips’ idea that any benefit that comes from a psychotherapy is necessarily a “side-effect”. As soon as I notice I am trying help a patient I believe I have become rather useless. I understand my job is to make myself available to be made use of by them and their unconscious and endeavour to understand something about the emerging process which Ogden has described as the analytic third. I think I am trying to offer a “frame of ego-relatedness” within which “id-relationships occur and strengthen rather than disrupt” what is often a fragile ego. “Gradually, the ego-supportive environment is introjected and built into the individual’s personality, so that there comes about a capacity actually to be alone.”
Jamie seemed perpetually dissatisfied with life, seeking one id satisfaction after another. Winnicott again:
The so-called normal child is able to play, to get excited while playing, and to feel satisfied with the game, without feeling threatened by a physical orgasm of local excitement. By contrast, a deprived child with antisocial tendency, or any child with marked manic-defence restlessness, is unable to enjoy play because the body becomes physically involved. A physical climax is needed.
I worried that Jamie’s need for a physical climax was leading to dangerous acting out, and without a safe haven for his true self there may have been a serious risk of suicide, accidental or intended.
How My Patients Teach Me
Desire: It begins and ends with desire: ‘Tihei Mauri Ora!’
My desire, my patients’ desire and the ways in which our desire can be linked with love, hate, and knowing.
Richard has taught me how I need to offer a home for rage, even when that rage is so distant it can’t be thought. How useless it is to reassure, and yet how vital it may be to find a way to offer a hundred horizons, both in the past and the future. He reminded me, when someone wants to kill themselves, how important it may be to recognise the rage within them that can find no home. To free up their culturally encouraged identification as ‘suffering from depression’, explore their misdirected hate and aggression and attempt to know the unthinkable, the forbidden and forgotten targets of their rage.
Susan has taught me how to sit with love, hate and knowing and treat those three imposters just the same: Mine and my patient’s. How easy it is to waste time sitting with a patient’s false self, imagining I am doing something useful. How useless I am if I become another “milkmaid of human kindness” forgetting the aggression hidden in being the Good Samaritan. She helped me understand how killing oneself might just be a last ditch attempt at preserving something essential about oneself that has given up ever being welcome in the world. How the gnawing knowledge that one is not really living one’s own life may prove too much to bear.
Jamie taught me how all I really have to offer my patients is my capacity to be alone in their company. How unbearable this can feel sometimes. He reminded me how much my patients need to know that each time they return for another appointment they will find themselves already there in my mind. He did not let me forget how hard life is when there is no refuge within, no sense of a place of one’s own, a sanctuary where one can discover oneself free from the intrusion of others. How killing oneself might just be a way of finding peace when one lacks the capacity to be alone in the company of others.
For those five young people and the one parent, it is too late. There is no coming back from suicide – although death cannot exist as an “unthought known” in our unconscious, it certainly does exist in the real.
However, I have found being able to think about these three threads …
- Misdirected rage and aggression,
- Needing to hide something essential and vulnerable, and
- Lacking a capacity to be alone,
… help steady me when I find myself sitting with someone wanting to end their life.
I hope perhaps you might find this useful too.
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Article posted 26 April 2019