The Aeschi Working Group

MEETING THE SUICIDAL PERSON

The therapeutic approach to the suicidal patient:   New perspectives for health professionals

Antoon A. Leenaars, Ph.D.

SUICIDE:  A MULTIDIMENSIONAL MALAISE

No one really knows why human beings commit suicide. The goal of this paper is to provide a psychological point of view on the topic, among the many other perspectives that are needed. It addresses the question by providing a theory of suicide, arguing that it is theory that allows us to sort out the "booming buzzing mess of experience" (Wm. James). Suicide is a multidimensional malaise. Methaphorically speaking, it is an intrapsychic drama on an interpersonal stage. As sound theory must be empirically observable, the theory is next applied to research of suicide notes, studying such factors as age, sex, method of suicide, cross-culture, and cross-time. Next, since all theory must have clinical applicability, a clinical case study of Goethe's Werther is provided. Overall, it is concluded that we need to continue to develop models to understand the suicidal mind.

No one really knows why human beings commit suicide. One of the most frequent questions asked about suicide is, "Why do people kill themselves? or, more specifically, "Why did that individual commit suicide?" People are perplexed, bewildered, confused, and even overwhelmed when they are confronted with suicide. Indeed, the very person who takes his/her own life may be at the moment of decision, the least aware of the essence of the reasons for doing so. Understanding suicide, like understanding any complicated human act, is a complex endeavor, involving knowledge and insight drawn from many points of view. This is true for all people working in suicidology. My goal here is to provide a point of view on the questions, based on my studies over the years of perhaps the most personal document-suicide notes. My hope is that the perspective will be useful whether one is doing research, answering the crisis line, counselling the suicidal patient, surviving a loved one's suicide and so on.

Most frequently, people identify external causes (e.g., ill health, being abandoned by a lover, losing one's income) as to why the person killed him/herself. This view is too simplistic, although often the suicidal person holds that perspective. This is not to suggest that recent traumatic event (e.g., drop in income, a change in work, a divorce, a grade of F) cannot be identified in many suicides. However, although there are always situational aspects in every suicidal act, they are only one aspect of the complexity.

Suicide is a multidimensional malaise (Shneidman, 1985). There are biological, psychological, intrapsychic, logical, conscious and unconscious, interpersonal, sociological, cultural, and philosophical/existential elements in the suicidal event. It thus seems reasonable that we would be perplexed and bewildered about answering the question, "Why?"

Any element of the malaise is a legitimate avenue to understanding suicide. Studies of serotonin have a place. Studies of the effect of gun control have a place. Studies of cultural diversity have a place. In fact, I oppose any reductionistic model in studying suicide. Much of current thought about suicide is, from my view, too mechanistic. Suicide is a multifaceted event and is open to study by multiple disciplines. However, let me state that I agree with Shneidman (1985) that the psychological dimensions of suicide are the "trunk" of suicide. Shneidman (1985), using an arboreal image, wrote:

An individual's biochemical states, for instance, are the roots. An individual's method of suicide, the contents of the suicide note, the calculated effects on the survivors and so on, are the branching limbs, the flawed fruit, and the camouflaging leaves. But the psychological component, the problem solving choice, the best solution of the perceived problem, is the main "trunk" (p.202-203).

From a psychological point of view, I would like to offer a few observations on the question, "Why?" Of course, one should understand that these ideas are not exhaustive. They are ideas gleaned from the 10 most significant suicidologists in our psychological history that have some empirical support. Specifically, the clinicians are the following: A. Adler, L. Binswanger, S. Freud, C.G. Jung, K.A. Menninger, G. Kelly, H.A. Murray, E.S. Shneidman, H.S. Sullivan, and G. Zilboorg.

As a crucial final point of introduction, there are, of course, views that theory should not play a role in understanding suicide. Suicidology should only be tabular and statistical. However, I believe that theory, explicit and implicit, plays a key role in understanding any behavior. Theory in science is the foundation (Kuhn, 1962). Newton, Einstein, and all great scientists are great because they were theorists. It is only through theory, as one of my consultants - Edwin Shneidman - to this paper, noted, that we will sort out the "booming buzzing mess of experience" (Wm. James). In fact, it can be argued that "sciences have achieved their deepest and most far reaching insights by descending below the level of familiar empirical phenomena" (Hempel, 1966, p. 77). Theory may well be in the eye of the beholder (Kuhn, 1962), but it is pivotal in scientific understanding whether one is a researcher, crisis worker, clinician, etc. There is nothing as useful as good theory. And I would go further: I believe that we can only have our constructions. People must make formulations about things to understand them (Husserl, 1907/1973). Thus, it would be wise to borrow the ideas of our leading theorists to answer the question, "Why?"

Suicide Notes

How can we answer our initial questions? How do we look at suicide? Our answers, whether theoretical or not, should be based on logical and empirical fact (Ayer, 1959). Shneidman and Farberow (1957), Maris (1981) and others have suggested the following alternatives at scientifically answering these questions: statistics, third-party interviews, the study of nonfatal suicide attempters and documents (including personal documents). All of these have their limitations. Statistics reflect by themselves only numbers and are, at best, only a representation of the true figures. A third party interview, sometimes called a psychological autopsy, can only provide a point of view which is not the suicide's. Nonfatal attempters may be different from completers. Documents may provide, to use Maris's words (1981), only a snapshot of an event that requires a full-length movie. But sometimes they provide a vignette of sufficient length so that some essential essences of the entire movie can be reasonably inferred. Indeed, all the alternatives have their limitations and strengths.

Of course, there is the problem of obtaining any of these data: statistics, interviews, reports by attempters, and personal documents. The data base for potential explanations of suicide is conspicuously absent. Maris (1981), points out that this is because "most researchers have been trapped by either the Scylla of official or 'vital' statistics or the Charybdis of individual case histories."

A related (if not embedded) problem is the one that is the ubiquitous issue of psychology itself: the mind-body problem; or, the admissibility of introspective accounts as opposed to objective reports. This resonates to Windelband's (1904) division of two possible approaches to knowledge between the nomothetic and the idiographic. The tabular, statistical, arithmetic, demographic, nomothetic approach deals with generalizations, whereas the idiographic approach involves the intense study of individuals - the clinical methods, history, biography. In this latter approach personal documents are frequently utilized - personal documents such as letters, logs, memoirs, diaries, autobiographies, suicide notes. Let us, before addressing the topic at hand, explore the views on the idiographic approach in more detail; the other - the nomothetic approach -- is well engrained in psychology and science in general.

Allport (1942) has provided us with a classic statement on the advantages of the idiographic approach, noting that personal documents have a significant place in psychological research. Shneidman (1980), in Voices of Death (a book about letters, diaries, notes, and other personal documents relating to death), has stated that such "documents contain special revelations of the human mind and that there is much one can learn from them." Although Allport (1942) cites some shortcomings in the use of personal documents in psychological science - unrepresentativeness of sample, self-deception, blindness to motives, errors of memory -- he makes a clear case for the use of personal documents, citing the following: learning about the person, advancing both nomothetic and idiographic research, and aiding in the aims of science - understanding, prediction, and control. As an interesting footnote to his trailblazing work (Shneidman, 1980), Allport wrote about diaries, memoirs, logs, letters, autobiographies, but it did not occur to his capacious mind to think of perhaps the most personal document of all: suicide notes.

My study of suicide is not defensive about the use or pleading for the occasional admissibility of personal documents. On the contrary, it emphasizes their special virtues and their special power in doing the main business of psychology - the intensive study of the person.

Furthermore, the use of personal documents does not mean that the essential method of science - i.e., Mill's method of difference - has to be abandoned, as the comparison between genuine and simulated suicide notes clearly illustrates. I believe that personal documents provide a unique place in human science where maximum relevance can be mated with acceptable precision. There are not many marriages like that in psychology.

Suicide notes are the ultrapersonal documents. They are the unsolicited productions of the suicidal person, usually written minutes before the suicidal death. They are an invaluable starting point for comprehending the suicidal act and for understanding the special features of the people who actually commit suicide and what they share in common with the rest of us who have only been drawn to imagine it. Suicide notes are a way through the looking glass to suicide although, unlike Alice, we will not find "beautiful things" there, but unbearable pain.

Early research (e.g., de Boismont, 1856; Wolff, 1931) on suicide notes largely utilized an anecdotal approach that incorporated descriptive information. Subsequent methods of study have primarily included classification analysis and content analysis. Only a very few studies, however, have utilized a theoretical-conceptual analysis despite the assertion in the first formal study of suicide notes, that such an approach offered much promise (Shneidman & Farberow, 1957). Almost twenty years ago, I applied a logical, empirical analysis to suicide notes. The method permits a theoretical analysis of suicide notes and augments the effectiveness of controls.

The method has been previously described in detail (Leenaars, 1988a; Leenaars & Balance, 1984a). It treats the notes as an archival source. This source is subjected to the scrutiny of control hypotheses, following an ex post facto research design (Kerlinger, 1964). Suicide notes are recast in different theoretical contexts (hypotheses, theories, models) for which lines of evidence of each of these positions can then be pursued in the data, utilizing Carnap's logical and empirical procedures (1931/1959) for such investigations. These positivistic procedures call for the translating of theoretical formulations into observable (specific) protocol sentences in order to test the formulations. The protocol sentences express the meaning of a given theory as they are matched empirically, by independent judges, with the actual data. Next, one introduces the method of induction from the available verified protocol for the discovery of general ideas and to allow further theory building to occur.

A Theory of Suicide

Theory should begin with definition. Thus, to begin, let me offer a formal definition of suicide by Shneidman (1985):

Currently in the Western world, suicide is a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution (p.203).

Suicide is a multidimensional malaise. It is not simply a psychopathological entity in the DSM-IV (American Psychiatric Association, 1994). I do not agree, as I noted earlier, with those who point to an external stress as the cause of suicide. I also do not agree that it is only pain. I tend to place the emphasis on its multideterminant nature of suicide. Suicide is intrapsychic. It is not simply the stress or even the pain, but the person's inability to cope with the event or pain. The issue of any scheme about human personality, i.e., personology (Murray, 1938), is one that makes an individual an individual. It should be the study of the whole organism, not only the stress or pain. People do not simply commit suicide because of pain, but because it's unbearable; they are mentally constricted; they cannot cope and much more.

However, from a psychological view, suicide is not only intrapsychic, it is also interpersonal. Individuals are interwoven. We live in a world. I disagree with those who point to only some intrapsychic aspects such as anger turned inward or primitive narcissism. Suicide occurs between people (or relationships to some similar ideal). Methaphorically speaking, suicide is an intrapsychic drama on an interpersonal stage.

Two concepts that have been found to be essential and helpful in understanding the malaise are lethality and perturbation (Shneidman, 1973, 1980, 1985, 1993). Lethality refers to the probability of a person killing him/herself, and on quantification scales ranges from low to moderate to high. It is a psychological state of mind. Perturbation refers to subjective distress (disturbed, agitated, sane-insane), and can also be rated from low to moderate to high. Both concepts are needed to frame the following theory. It is important to note that one can be perturbed and not suicidal. Lethality kills, not perturbation.

To begin: Suicide can be clinically understood from at least the following concepts (Leenaars, 1988a, 1989a, 1989b, 1995):

I. INTRAPSYCHIC

1. Unbearable Psychological Pain

The common stimulus in suicide is unendurable psychological pain (Shneidman, 1985). The enemy of life is pain. The suicidal person is in a heightened state of perturbation, a psychache (Shneidman, 1993). It is the pain of feeling pain. Although, as Menninger (1938) noted, other motives (elements, wishes) are evident, the person primarily wants to flee from pain experienced in a trauma, a catastrophe. The fear is that the trauma, the crisis is bottomless - an eternal suffering. The person may feel any number of emotions such as boxed in, rejected, deprived, forlorn, distressed, and especially hopeless and helpless. It is the emotion of impotence, the feeling of being hopeless-helpless that is so painful for many suicidal people. The situation is unbearable and the person desperately wants a way out of it. The suicide, as Murray (1967) noted, is functional because it abolishes painful tension for the individual. It provides relief from intolerable suffering.

2. Cognitive Constriction

The common cognitive state in suicide is mental constriction (Shneidman, 1985). Constriction, i.e., rigidity in thinking, narrowing of focus, tunnel vision, concreteness, etc., is the major component of the cognitive state in suicide. The person is figuratively "intoxicated" or "drugged" by the constriction; the intoxication can be seen in emotions, logic, and perception. The suicidal person exhibits at the moment before his/her death only permutations and combinations of a trauma (e.g., business failure, political scandal, poor health, rejection by spouse). The suicidal mind is in a special state of relatively fixed purpose and of relative constriction. In the face of the painful trauma, a possible solution became the solution. This constriction is one of the most dangerous aspects of the suicidal mind.

3. Indirect Expressions

Complications, ambivalence, redirected aggression, unconscious implications, and related indirect expressions (or phenomena) are often evident in suicide. The suicidal person is ambivalent. There are complications, concomitant contradictory feelings, attitudes and/or thrusts, often toward a person and even toward life. Not only is it love and hate but it may also be a conflict between survival and unbearable pain. The person experiences humility, submission, devotion, subordination, flagellation and sometimes even masochism. Yet, there is much more. What the person is conscious of is only a fragment of the suicidal mind (Freud, 1917/1974). There are more reasons to the act than the suicidal person is consciously aware of when making the final decision (Freud, 1917/1974; Leenaars, 1988a, 1993). The driving force may well be unconscious processes.

4. Inability to Adjust

People with all types of problems, pain, losses, etc., are at risk for suicide. Although the majority of suicides may not fit best into any specific nosological classification, depressive disorders, manic-depressive disorders, anxiety disorders, schizophrenic disorders, panic disorders, borderline disorders, psychopathic disorders, have been related to some suicides (Sullivan, 1962, 1964; Leenaars, 1988a). Yet there are other disorders not specified that may result in risk. Varieties of depression, however, may well be the most frequent disorders; however, it must be understood that not all suicidal people are depressed, and that not all depressed people are suicidal. Suicidal people experience unbearable pain, not always depression. Indeed, suicidal people see themselves as unable to adjust. His/her state of mind is incompatible with accurate discernment of what is going on. Considering themselves too weak to overcome difficulties, these people reject everything except death -- they do not survive life's difficulties.

5. Ego

The ego with its enormous complexity (Murray, 1938) is an essential factor in the suicidal scenario. The OED defines ego as "the part of the mind that reacts to reality and has a sense of individuality." Ego strength is a protective factor against suicide. Suicidal people, however, frequently exhibit a relative weakness in their capacity to develop constructive tendencies and to overcome their personal difficulties (Zilboorg, 1936). The person's ego has likely been weakened by a steady toll of traumatic life events (e.g., loss, rejection, abuse, failure). This implies that a history of traumatic disruptions - pain - placed the person at risk for suicide; it likely mentally handicapped the person's ability to develop mechanisms (or ego functions) to cope. A weakened ego correlates positively with suicide risk.

II INTERPERSONAL

6. Interpersonal Relations

The suicidal person has problems in establishing or maintaining relationships (object relations). There frequently is a disturbed, unbearable interpersonal situation. A calamity prevailed. A positive development in those same disturbed relationships may have been seen as the only possible way to go on living, but such development was seen as not forthcoming. The person's psychological needs are frustrated. Suicide appears to be related to an unsatisfied or frustrated attachment need, although other needs, often more intrapsychic, may be equally evident, e.g., achievement, autonomy, dominance, honor. Suicide is committed because of thwarted or unfulfilled needs, needs that are often frustrated interpersonally.

7. Rejection-Aggression

The rejection-aggression hypothesis was first documented by Stekel in the famous 1910 meeting of the Psychoanalytic Society in Freud's home in Vienna (Friedman, 1910/1967). Adler, Jung, Freud, Sullivan, and Zilboorg have all expounded variations of this hypothesis. Loss is central to suicide; it is, in fact, often a rejection that is experienced as an abandonment. It is an unbearable narcissistic injury. This injury is part of a traumatic event that leads to pain and in some, self-directed aggression. In the first controlled study of suicide notes, Shneidman and Farberow (1957) reported, in fact, that hate directed towards others and self-blame are both evident in notes. The person is deeply ambivalent and, within the context of this ambivalence, suicide may become the turning back upon oneself of murderous impulses (wishes, needs) that had previously been directed against a traumatic event, most frequently someone who had rejected that individual. Suicide may be veiled aggression - it may be murder in the 180th degree (Shneidman, 1985).

8. Identification-Egression

Freud (1917/1974, 1920/1974, 1921/1974) hypothesized that intense identification with a lost or rejecting person or, as Zilboorg (1936) showed, with any lost ideal (e.g., health, youth, employment, freedom) is crucial in understanding the suicidal person. Identification is defined as an attachment (bond), based upon an important emotional tie with another person (object) (Freud, 1920/1974) or any ideal. If this emotional need is not met, the suicidal person experiences a deep pain (discomfort) and wants to egress, i.e., to leave, to be gone, to be elsewhere. The suicidal person wants to leave, to exit, to get out, to get away, to be gone, to be elsewhere ... not to be ... to be dead. Suicide becomes the only egression or solution and the person plunges into the abyss.

Psychotherapy with Suicidal People: A Person-Centred Approach
Antoon A. Leenaars JOHN WILEY & SONS, LTD, Chichester 2004

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