Choosing life or death
Therapy Today, July/August 2022

In 2020, a few months after the first UK lockdown, a client of mine took her own life. Zoe* was 28 and a lead nurse in an intensive care unit (ICU). She had first come to counselling in a state of suicidal crisis and we worked together for two years, until the month before her death.

Thirty years earlier, in 1990, my brother Ben had died by suicide at the age of 35. It was one of the reasons why I decided to train as a counsellor.

Zoe’s death left me feeling deeply shocked and upset. As her counsellor, I was not able to be part of the rituals that allow the grief to be shared and held by family and friends. COVID-19 restrictions made everything feel even more disconnected. My supervisor was wonderful – he listened and supported me, while I tried to manage all the feelings and questions that were sometimes overwhelming.

Now, two years on, there is a need for me to look at the issue of counselling and death by suicide in a more empirical way, in order to deepen my processing of what happened and perhaps explore some of the more problematic aspects of this subject in relation to our work.

This article will take a look underneath the dominant discourse about suicide – ‘It must be stopped’ – and invite a more open and curious exploration of an issue that has largely been managed with risk assessment tools, and a large helping of apprehension and disquiet for many practitioners. My aim is ‘to nibble at the puzzle of human self-destruction’.¹

I will also explore what has changed since my brother’s death in 1990 in the way that society behaves in response to death by suicide (DBS), and more specifically about the role of the counsellor when faced with a client like Zoe who is openly trying to decide whether she should continue living in the world.

Being heard

Ben was from the ‘boys don’t cry’ generation of men; he found it difficult to talk about his feelings, and in those days men were not invited to discuss their mental health. I was a young mother with three children under seven, always busy when he called to say hello. He did, however, leave a suicide note, which showed some of his workings out and was enlightening in terms of his state of mind. Ben had written that he intended to ‘try my luck in the next world’.

Zoe, on the other hand, had my complete attention for every appointment, and she fully engaged with her weekly counselling sessions. I regularly talked about her in supervision and explored the echoes and transference that came up for me. As Mark Twain, the US writer, said, ‘History doesn’t repeat itself but sometimes it rhymes.’ It was a demanding and difficult piece of work, which somehow felt authentic despite my concerns, or perhaps because of them.

Zoe’s presentation was distinctly different from the client who comes to counselling with an ‘integrated’ level of suicidal ideation – ‘I would be happy not to wake up tomorrow’ – which is a relatively common occurrence in the therapeutic field.

Zoe spent two years experiencing what US suicidologist Edwin Shneidman describes as ‘psychache’. This would vary in intensity, with occasions where it seemed to have subsided completely. When she decided to make some radical changes in her life, a choice that did not go down well with those close to her, the psychache returned with a vengeance. Her decision to die by suicide seemed to be her way to put a stop to the emotional torment that gripped her and would not let her go.

Psychache is a complex tapestry of emotional, social and spiritual pain, which can be exacerbated by external events or family disruption. When psychache becomes intolerable, the idea of death is primarily a relief to stop the agonising pain of getting through each day. Both Zoe and Ben indicated in their final letters to family that they believed they would feel relief in death. In this sense, suicidality has a lot to do with different individual thresholds for enduring psychological pain. Perhaps counselling can sometimes act like an ‘escape lane’ on a busy dual carriageway?

Three elements

Psychologist and suicide expert Thomas Joiner talks about ‘perceived burdensomeness’ – the thought that ‘my death will be worth more than my life to friends, family and society’ as a key element of suicidality.² Joiner views this ‘a misconception, a piece of skewed thinking’. But to this type of client, it seems perfectly logical.

Joiner then describes the equally significant factor of alienation, which can be present even when an individual seems to belong to a family or friendship group. He points out that there must be both a feeling of failed belonging (alienation) and perceived burdensomeness, combined with a third element, which is the ability to enact lethal self-injury (fearlessness), and only when these three elements combine, like a Venn diagram, is there the potential for death by suicide. In this context, fearlessness does not mean the absence of fear, but rather the ability to override it in order to carry out DBS. All human beings are driven by a primal desire to remain alive, but some manage to surpass it.

There are certain categories of people who are more inured to the ‘violence’ required to take one’s own life. They would include those who are addicted to dangerous levels of substance abuse, vets who euthanise animals, doctors who are used to witnessing pain and death, and those who intensify or repeatedly escalate their attempts at DBS. For these people, the gap between life and death is smaller.

Shame

We cannot examine DBS without recognising the role of shame. No other form of death carries with it such a deep-rooted sense of disgrace. Being close to someone who takes their own life is a uniquely disturbing experience. Suicide is so commonly associated with shame that many families and friends suppress the fact and prefer to describe it as ‘sudden death’ or ‘accidental’. There are good reasons for this in terms of cultural beliefs about the sanctity of life.

In ancient Greece, suicide was considered a disgraceful act. A person who had died by suicide did not receive the death rites accorded to common citizens. The recently published Global Mental Health report found that attempted suicide is still a crime in 20 countries, resulting in legal action against individuals and their friends or families.³

There are still consistent messages from the main religious groups regarding the sanctity of life. The Anglican Synod only voted as recently as 2017 to remove the ban on Christian funerals for those who died by suicide, although many Anglican clergy had chosen to ignore this rule for some years.

The Catholic faith teaches that life is given by God and can only be taken away by him; therefore it is the most serious of sins to do so of one’s own volition. In Hinduism, murdering one’s own body is considered as sinful as murdering another. Like other Abrahamic religions, Islam views suicide strictly as sinful and detrimental to one’s spiritual journey. Judaism also regards suicide as one of the most serious of sins.

Given the faith-based messages that DBS is shameful, it is no wonder that so many families do not wish their loved one to be tarnished with the label of ‘suicide’.

Post-DBS guilt

Guilt is a close neighbour to shame, and the guilt associated with DBS is very common, if not universal. It’s as if someone living must pay the price for not stopping the person who has died, even though that person chose to end their life and acted on that choice. Shneidman says: ‘The most important question to a potentially suicidal person is not an enquiry about family history or laboratory tests of blood or spinal fluid, but “where do you hurt?” and “how can I help you?”’ But what if we as therapists help with the hurts and still, for some people, death is the better alternative? Should we always try to persuade someone to remain alive?

In the myth of Orpheus and Eurydice, Orpheus is given an extraordinary musical talent by his father, Apollo. Orpheus falls in love with Eurydice, but on their wedding day she is bitten by a snake and dies. Orpheus takes his lyre to the gates of Hades and plays his exquisite and poignant music to anyone who might be listening on the other side. Eventually Pluto, King of the Underworld, invites Orpheus to enter and tell his story. Pluto is touched by Orpheus’ grief and gives permission for him to return to life with his beloved Eurydice, but on one condition – on the journey Orpheus must not turn back to look at her until they reach the living world.

As they make their way out of the underworld, Orpheus manages to keep looking ahead until the last few steps, but then his excitement gets the better of him, he turns to look at Eurydice, and she disappears forever.

This myth is predicated on the idea that the Underworld is a terrible place – somewhere from which we need to be rescued. Paintings often depict it with violent imagery of fire and dark shadows, populated by fearsome creatures or terrifying spirits – a place that would preclude any kind of tranquillity or calm.

Some people experience the living world in exactly this way. Therefore, who are we to insist that they remain here? What is the counsellor’s responsibility if the client has capacity and still is focused on DBS as the most effective solution? If we wouldn’t try to persuade someone with terminal cancer to have treatment if they chose not to, could we also manage ‘terminal suicidality’ in the same way?

Warning signs

Joiner and colleagues define suicide risk as ‘The presence of any factor empirically shown to correlate with suicidality, including sex, age, psychiatric diagnosis, and past suicide attempts.’⁴ Clearly there will be many clients who could be described as having risk factors for suicidality, but not all of them will attempt DBS. This assessment differs from a ‘suicide crisis’, which is time limited and indicates imminent risk of a suicide attempt, regardless of the number or type of risk factors present.

Joiner and his colleagues suggest that warning signs must be looked at in terms of the individual, rather than applying a template or ‘one-size-fits-all’ assessment. The counselling relationship enables the practitioner to develop an understanding of the complexities for each client, and the counsellor may occupy a unique position in terms of witnessing and diagnosing a ‘suicide crisis’.

How do we distinguish between the client who wants to explore the benefits of not being alive as a ‘compare and contrast’, and the person who is planning an exit, which they see as an act of true independence that they believe will lead to a feeling of relief? There are four factors to which we must pay attention:

1. ‘I might as well be dead’
For many, the expression of suicidal ideation is a way of defining the level of emotional pain that they feel. The declaration from a person that they would be happy not to wake up in the morning has a passivity that could indicate a risk factor but not a warning sign.

2. Suicide-anxiety loop
A common scenario is the client who regularly brings a drama of suicidal intention into the counselling room, which activates the counsellor into safety planning, perhaps contacting various agencies and generally exhibiting a high level of concern, which allows the client to become calm, having passed her/his overwhelming feelings onto the practitioner. If this transaction begins to happen regularly, it may develop into an obstructive cycle for client and practitioner in terms of the counselling work.

3. Unable to adapt
Psychotherapist Joseph Lee talks about another, slower, suicidal trigger as ‘a failure of adaptation’.⁵ It could be said that, from infancy, we are in a permanent process of adapting to life and what it brings to us as individuals. When a life event becomes too much to manage – bereavement, redundancy, loss of partner to another – there are some for whom the adaptation is simply too arduous.

At this point, if the client cannot get purchase on the world and the suffering (psychache) becomes intolerable, the counsellor can offer a safe, secure attachment while the client regains a sense of agency.

4. Suicide as an archetypal idea
Therapist and social worker Katherine Best suggests approaching this with a series of questions: ‘What really does need to die? A relationship? A false belief? A social mask or role? Physical power? Your shame? Is it possible to have a symbolic suicide and to surrender that which needs to be released?’⁶ In this Jungian approach, the therapist may invite the client to connect with the unconscious by using suicide as a metaphor.

Above are some examples of the varied ‘suicidal’ presentations that we might see in the counselling room, requiring the practitioner to hold a constant hypothesis about the degree of suicidality in front of them while addressing the issues that the client might bring. It is this dilemma that can be mitigated by understanding the distinction between risk factors and warning signs, as outlined above.

Survivors

The Golden Gate Bridge links San Francisco to Marin County, and is the most used suicide site in the world. The fall from the bridge into the deep strait below takes four seconds. In the film The Bridge by Eric Steel, a camera crew was positioned discreetly at either end of the bridge for a whole year in 2004. They recorded 24 deaths and one survivor.

The film caused much controversy when it was released in 2006, and it is certainly harrowing to watch. The film crew would regularly call the emergency services, and many times members of the public would try to dissuade the ‘jumpers’ from climbing over the barrier, sometimes successfully. Often the ‘saved’ person would return later and attempt the jump again.

With no voiceover, the documentary intersperses images of those who jumped to their deaths with the words of relatives and friends, who speak directly to camera and give an insight into the challenges and complexity of being in the life of someone who dies by suicide.

The only survivor in the film is Kevin Hines, a young man who endured the 243-foot fall, and who discloses to the camera that he had changed his mind about wanting to die just before he hit the water. Kevin now believes that he survived the perilous fall through intervention from a ‘higher power’. His story validates the dominant discourse that a suicidal person really wants to live, and therefore we must always stop them from following through.

However, another speaker talks about how the alternative for his brother who ‘successfully’ jumped would have been to find himself restrained in a secure psychiatric unit on heavy medication, and that this would have been unbearable for him. Here we see an alternative discourse, albeit a much less palatable one. Many of the 24 who died seemed, like my client, to have reached the centre of Joiner’s Venn diagram whereby living was more painful than the idea of dying.

These two competing perspectives illustrate the complexity and dissonance that can arise for the practitioner when they find themselves trying to navigate this uncomfortable, largely uncharted territory, where the only clear guidelines are about risk assessment and prevention.

The choice to die?

Perhaps there is a link here with another emerging discourse about what choices we should have when we become old and frail. David Jarrett, who was a geriatrician for 40 years, makes an interesting observation in his book 33 Meditations on Death: ‘It is not that we are living longer, but that we are taking longer to die.’⁷

Jarrett believes that there is a collective avoidance of any discussions about how and when to have a good death, and instead we are preoccupied with longevity at any cost. Clearly there is a distinction between the urgent psychache experienced by Ben and Zoe and the more natural process of ageing, but the question about our use of personal agency is the same.

Where better to safely talk about choices for death in all its forms than in the counselling and therapy arena? During our two-year therapeutic relationship, Zoe asked extraordinary and courageous questions about the nature of existence, the reckless, wasteful way we treat the planet, and the purpose of life itself. She also made beautiful artwork from recycled materials, was part of a drama group, and shared an allotment with a friend from college. Some would say that should have been enough to bind her to this life.

As a result of the work that Zoe and I did together, something has rooted itself in me about the nature of counselling that I did not know before. Occasionally, and I hope very rarely, all that I can do for a client is use my unique position of ‘compassion with boundaries’ to walk alongside them, but in the opposite direction to Orpheus – to the edge of this living world, so that they have someone to whom they can safely say goodbye.

*Client name and identifiable details have been changed