The deadliest choice
Private Practice, June 2021

You erase yourself. You rub yourself out. That’s what suicide is – arguably a higher form of self-censorship, an admittance that the forces around you have become too much. You don’t necessarily want to die, yet living is no longer bearable, no longer comforting or something you wish to keenly embrace. Nobody seems to listen anymore. Nobody seems to really delve into your inner workings. You go days, weeks even, without expressing what you feel. All of a sudden, there seems to be no outlet, no sponge for your thoughts, no one that truly gets you.

The curse of suicidal ideation is that it often pushes you down to zero. Zero paths. Zero stability. Zero optimism. Zero faith. It is a shudder inside you. Everything you imagined life would be now looks a little ragged, impossible, torn, broken, different, incomprehensible. Stability – what did that look like? What did it feel like? Because life was once good, this voice believes. There were glimmers of happiness, nothing too heavy, a natural unthinking grace.

Could it be that too many lived years are simply not healthy? Better to sail away at a young age and not feel the chasm and difficulties of a harder reality, a troubled perspective, a stained and worn mind? Or can a beautiful anchor or connection sustain you – a special person/people invested in you, worried about you, concerned, wanting to cheer you, encourage you, love and support you? I personally miss simplicity; the smile and respect of my daughter, seeing her laugh naively at a family birthday party. Without that, life feels like an avalanche at times. Like its beauty has been chiselled away. Like the sun is beating down on me, but I can’t feel its warmth.

We age and things fall away. What was once recognisable to some now feels, in the blink of an eye, daunting and derelict. The sides of the world don’t seem to fit. People pass each other and only seem to indulge in pleasantries and puff. Is it this enormous disappointment which shackles the mind and leaves it bereft, which makes us wonder where the hell we are heading and why those politicians at the ‘top’ seem to be on a constant loop?

Examples of good intention, decency and benevolence are vital to wellbeing. We look around and see smatterings of these, but then we cast our eyes once more on the bruising treadmill in the foreground, of being made to feel like we are nothing more than economic units, that reaching the finishing line after 50 years’ hard labour should be done with the minimum amount of fuss. Is it any wonder that somewhere along that road we crack up, feel demoralised, unloved, exploited, incredibly, incredibly vulnerable and in need of an escape hatch? Isn’t that… normal?

Beliefs around suicide

Fontenelle, Augustine and Kant would have us believe that suicide is an irrational act – fickle and crazed. They respectively lend their words to our ears:

• The Cowardice of an uneasie Spirit that cou’d bear Life no longer, when attended with Disappointment.’¹
• ‘Suicide is a sin – the gravest crime against the Creator.’²
• ‘If [man] disposes of himself, he treats his value as that of a beast. He who so behaves, who has no respect for human behavior, makes a thing of himself.’³

Marx and Montaigne are more forgiving:

• ‘[Suicides are] victims of their Society, and only when that Society has been radically transformed, and the original self-determination of the human species restored to all its members, would such symptoms of social disease be eradicated.’⁴
• ‘Life is slavery if freedom to die is wanting.’2 From cowardice, sin and disrespect to recognising a diseased society and form of slavery. I know who I’m inclined to believe. And Marx’s point about self-determination is a key component if we are to figure out the oppression which often drives suicide. Choice – does it really exist, or is it a construct designed to manipulate and appease us? Sartre talked a good game, even about a prisoner being free to try to escape,⁵ but beyond this ludicrous scenario, aren’t we weighed down by the repetitiveness of work, the randomness of life and the unreliable nature of relationships?

The deadliest of choices

Biology, mental illness, life events, personality traits and genetics are all relevant to choice and the deadliest of choices: suicide. But a startling fact still manages to unhinge the classic stereotype around suicide of it seemingly being synonymous with gloom and selfishness: ‘Since the Golden Gate Bridge opened, in 1937, more than 1,200 people have committed suicide from it, making it the most “popular” place to kill oneself in the world. Ninety percent of those suicides plunge to their deaths from the San Francisco side of the bridge, with its views of the city. Only a small portion choose to spend their last moments on the Pacific side of the bridge, with its endless void of water and what Jack Kerouac called an “end of continent sadness”… It seems to me that these figures indicate the persistence of an essential human characteristic. Even in their final, desperate act, soon-to-be suicides yearn to be connected to people, to society, to all those myriad human influences.’⁶

Connection. So vital. And yet when people are down, dispirited, despondent and disillusioned, society tends to walk away. Sadness is not permitted. It is discouraged, turned into a jovial sketch, rushed off stage, treated as foreign (that other), and associated with shame and weakness. If the remnants of a stiff upper lip former British Empire were not evident before, then they certainly reappear in the form of flag-waving jingoism not at all compatible with darkness or depression or difference.

This is society’s crime – censorship, the prohibition of emotions. And so a self-censorship takes over. It dutifully informs you of the accepted standards, the real interplay between people (often very different from documented ideals).

Stigma and judgment

Tired of this restraint, Stacey Freedenthal ‘outed’ herself in 2017 via an article in the New York Times titled, ‘A Suicide Therapist’s Secret Past’. In a similar manner to a gay person coming out at the turn of the millennium (very much post Oscar Wilde, a century after his ‘gross indecency’), Freedenthal expressed her relief: ‘It felt good to come into the light. I don’t think I’d realized how exhausting it was to hide that significant piece of myself, especially given that my career is in suicide prevention. I feared that if people knew my history, they might question my competence. I feared stigma and judgment, so I often muted myself in contexts where it could’ve been useful for me to share my story. But I’m living more authentically now by not keeping this secret.’⁷

Exhausting is very much the word, as other minorities have felt; playing a defined role in society for fear of stepping out of line, or being judged. And this leads to the interesting subject of how therapists sometimes behave in the company of those with suicidal ideation – the common perception of having to ‘…balance therapeutic work with legal peril’⁷ being not at all helpful. It often, in fact, ensures a cold, bureaucratic, guarded exchange – the last thing a client requires in their hour of need.

The definition of an ‘outpatient therapist’ (effectively those not working within a psychiatric ward or mental health hospital residence) can reduce or lessen one’s fear around feeling responsible for a client at risk of suicide. Ultimately, we cannot control what clients do 24/7 or how they behave, but we can be very open about the subject of suicide, when present, in the knowledge that research shows this does not increase its likelihood or chances of happening.⁷

Freedenthal conjures up some very effective imagery around suicide and considers ‘What you would say to the person on the roof’ versus ‘How you would listen to the person on the roof’. There is a tendency to always want to act rather than truly showing regard and understanding initially. There is a tendency to want to solve the riddle before us in a hurried manner through fear of that opportunity passing.

Suicide and the law

But suicidal individuals are not a homogenous group. They cannot be directed to a playbook of strategies on how to overcome such thoughts, particularly when those thoughts often calm them because they picture something else… away from the current malaise, the imperious demands around them, the daily fragility and upset.

We have come a long way since the Suicide Act (decriminalisation) was given Royal assent on 3 August 1961: ‘An Act to amend the law of England and Wales relating to suicide… The rule of law whereby it is a crime for a person to commit suicide is hereby abrogated.’⁸ We at least now seemingly recognise that suicide (or attempted suicide) is sufficient on its own to warrant concern rather than incarceration and condescension, perturbation rather than patronisation.

World-weary hangman, John Ellis, who turned a gun on himself in 1924,⁹ but failed, was met with the words: ‘Your life has been given back to you [so] turn it to good use in atonement’¹⁰ upon being discharged at Rochdale Police Court. Making amends for a wrong or reparation – is that what someone suffering really wants to hear?

That they have done wrong, that they are to be cursed or judged. Sheila Moore, in January 2000, made an exceptionally compelling case that the Suicide Act – which was a Government, not a Private Member’s, Bill – ‘…far from being… a relinquishing of state control over a deviant behaviour, stands as an unusually explicit example of a transfer of responsibility for control of a deviant behaviour from criminal justice to medical jurisdiction in the interests of establishing more effective control’.¹¹ This is a useful aside in that it identifies ‘… that the true nature of the reforms was not to loosen control, but to restructure it in an attempt to make it more effective’.¹¹

Coming at a time when mid-century measures and changes in the law (labelled ‘permissive’), under the veneer of liberalisation, at least gave the impression of a more tolerant and understanding society – the Street Offences Act (1959), Abolition of Death Penalty Act (1965), Abortion Act (1967), Sexual Offences Act (1967),¹² Divorce Reform Act (1969) – Moore is keen to point out that ‘Clause II of the [Suicide] Act dealt with, and formally criminalised for the first time, one of the most controversial issues of modern times: assisted suicide’.¹¹ Not everything is as it seems, in other words. Life is a daily fight for a modicum of control, wondering if evidently well-intentioned words are genuine or manipulative. This is the human condition – of wanting to trust, but being guarded due to certain happenings and experience.

What’s life about?

A character called Jim, in David Vann’s incandescent Caribou Island, muses: ‘The question, really, was what his life was about. He didn’t believe in God, and he wasn’t in the right field to become famous or powerful. Those were the three biggies: faith, fame and power. They could justify a life, perhaps, or at least make you think your life meant something.’¹³ The hesitation is interesting: perhaps. That is all we mostly have. Not certainty or guarantees or undying loyalty, but a wavering, often bumpy ride to the grave. And those who aren’t religious, well known or well off can feel slighted or more susceptible to emotional landslides, turmoil and a sense of pointlessness. Those without love and purpose can feel dismantled or destroyed. ‘The act of suicide itself, the grand gesture, is significant and interesting only in relation to every little defeat and difficulty that came before,’¹³ Ian Sansom perceptively notes. Every. Little. Defeat. How simple, yet acute. Indeed, why shouldn’t suicide, attempted suicide or thoughts of suicide be linked to a multitude of pain, humiliation and jealousy? Depression is loss and failure. Suicide is the cranked-up reckoning and questioning of life.

Ernest Hemingway’s psychiatrist Howard Rome put it this way in a letter to Hemingway’s widow, Mary, in July 1961: ‘Our conversations repeatedly got back to the future: what were the pros and cons of a permanent residence in Idaho against someplace in Europe or Africa? I was convinced that the suicidal risk was minimal. It was this that prompted me to say to you that I felt I had to trust him, that if he were ever to get back to work, which was life for him, he had to get to it free of doctors, nurses, and all of the encumbrances which were a perpetual reminder of sickness. I felt that he was being absolutely frank with me; particularly was I convinced of this when he freely talked about his fears. They weren’t the usual kind. For the most part they centered on a deep concern about doing things the right way.’¹⁴

The whole letter is one of the most touching things I’ve ever read. And the fact that we are privy to its private contents is both disturbing, yet deeply enlightening. Two things leap out at me, two things grapple with my emotions: the future and doing things the right way. 

How do we live?

We are enough in this world by the time we hit 40 or 50 to fully see how it imposes itself on us, how it adds to our travails, how it undutifully pardons itself for wrecking a part of us, the person we thought we were. We then consider the future with the remaining faculties we have and decide to continue or rub ourselves off the face of the earth. But doing things the right way – that is central to everything. We are too old to cheat ourselves. We are too old to take or bend to the gummed-up logic of a younger person who has more power. So how do we live? How do we have that reckoning with our mind? Calculating, estimating, avenging, punishing.

Daphne Merkin describes a woman ‘…standing in her kitchen, making a pot of coffee… before the dark thoughts [come] tumbling in: You shouldn’t, you should have, why are you, why aren’t you, there’s no hope, it’s too late, it’s always been too late...’¹⁵ In those last five words, I think, is the unadulterated despair of a mind plagued with no direction. In their exaggeration, distortion and misplaced reasoning, we see a new template, which somehow represents an out-of-town mind; one no longer inhabiting the centre, one chased from the familiarity of its normal cerebral neighbourhood.

How can it, after all, always have been too late? Before we ventured into this world properly. Before we saw nature, spoke to people, felt satisfaction and experienced heartache or disappointment. In that misshapen philosophy is not farce, however, but rather ‘…intractable feelings of thwarted belongingness and perceived burdensomeness [and] social problem solving deficits’.¹⁶

Suicidal individuals might have ‘…about one-third fewer presynaptic serotonin transporters and about one-third more postsynaptic serotonin receptors’⁶ (which suggests they are desperately trying to compensate for low serotonin levels), but this cannot be the whole picture. Biology, mental illness, life events, personality traits and genetics – as alluded to earlier – all play their part. The presence of serotonin, particularly in the pre-frontal cortex (the source of the brain’s executive functions, which help make a person more balanced and less impulsive), undoubtedly acts as a calming influence and can prove advantageous to those with greater stores of this neurotransmitter.⁶ Shouldn’t we elevate life events and personality traits though and try to find a way out of this morass? Shouldn’t we try to find a path that is better than the stifled and suppressed trench imagery of ‘shove myself forward’?¹⁷

Three types of suicide

It is said that in decadent and disintegrating empires, suicide rates rise.¹³ It is also said that despair results from a lack of charity in social relationships.⁴ If we can fix such pernicious and malignant ways, then surely we can begin to restore the beauty of the world.

Émile Durkheim claimed that there were three types of suicide:

• the egoistic (a self-centred person who is cut off from the mainstream)
• the altruistic (over-integration: widows, for example, who mount the pyre to accompany their dead husbands)
• the anomic (social instability and thus alienation caused by erosion of standards and values).

In Le Suicide, one of the founding texts of sociology, Durkheim writes: ‘The victim’s acts which at first seem to express only his personal temperament are really the supplement and prolongation of a social condition which they express externally.’¹³ Thomas Masaryk, on the other hand, states that ‘…the number of suicides is a direct mathematical measure of the real mood of society… its soul excited, perturbed, sick.’¹³ Life is a battle, a struggle – of that we are aware. But it is anchoring or mooring ourselves to meaning and love, or trying to be irrepressible when the weariness sets in, that ultimately shapes us. Merkin observes that she ‘…can no longer figure out what it is that moves other people to bustle about out there in the world’, but then quickly realises that if we are ‘…possessed of the necessary illusions’¹⁵ then everything might just be OK. Maybe illusion is all we have. Myth. Pretending. Believing. In among the clamour of the world. But is that so bad?