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David Zigmond
It is fortunate that the frequency of successful suicides is falling, but in contrast that of attempted suicides is rising, particularly those due to self-poisoning, which today are in excess of 100,000 per annum. What do the Statistics Mean? The decline in the number of successful suicides may be attributed to a number of factors. Some psychiatrists might claim that improved medical techniques and services have made a large contribution, but this is doubtful for two reasons. First, relatively few people who attempt suicide can be treated successfully by strictly medical methods. Second, our psychiatric services are still extremely rudimentary and remain little improved, unfortunately. Nevertheless, the use of medical therapies has saved the lives of many who would have sunk relentlessly into a state of intolerable anguish. However, depression as an illness, which can be treated unequivocally by medical methods alone, is much less common than depression as a reaction or life-position, where medical methods are evidently inadequate and unsuccessful. We all consider problems according to our personal training, skills and temperament; psychiatrists, of course, are no exception. It follows, therefore, that psychiatrists who work mainly within the medical model will think of depression as an autonomous illness, rather than a reaction or life-position in which the person maladaptively uses a submissive, suffering and helpless role to gain recognition, care and security from others. Statistics about depression, therefore, are very difficult to trust or interpret. Different people mean different things by this word, and our tools for measuring these phenomena are crude and inadequate. Considering these factors, there still remains a certain amount of evidence that the growth of non-medical helping organisations, such as the Samaritans, has helped to reduce the number of suicides. Unfortunately it is difficult to be sure of this, because certain practical aspects have changed in the community coincidentally which make suicide far more difficult. First, the nationwide conversion to natural gas has made this kind of self-poisoning much less successful, and second, the prescription of dangerous drugs has been vastly reduced. In the last ten years doctors have become much more aware of the self-poisoning and addictive dangers of such drugs as barbiturates, methaqualone (Mandrax) and glutethimide (Doriden). The latest tranquillisers and hypnotics are far safer, and must be responsible for some of the reduction in suicidal deaths. Perhaps because the drugs are safer, they are taken more impulsively by those who wish to demonstrate anger and frustration towards the self and others, but have not yet reached the stage of wanting death unambivalently. This would account for the paradoxical increase in attempted suicide and the decline of successful suicide. The Question of 'Trivial' Suicidal Gestures Not all self-destructive acts have the same motives or intensity of motivation. It is extremely difficult to devise any reliable method of assessing the severity of suicidal gestures, because of the inevitable intrusion of all kinds of subjective material from the person attempting to make such an assessment. As a simple example, it is very likely that we would tend to underestimate the seriousness of self-destructive behaviour in people we do not like, because we tend to shut out those imaginative and empathetic qualities which we find highly effective with people we warm to more easily. Indeed, we may even collude with a person's masochistic behaviour, because of the aggressive feelings we have towards them. Nevertheless, in spite of such distortions, it is sometimes clear that one person has really attempted to end his life, while another has made a theatrical gesture to evoke care, recognition, sympathy, guilt or hostility from others. It is often argued that the former present a `real' problem and should be helped, while the latter do not have a 'real' problem, are manipulating our time and resources and should not be pandered to. There are a number of objections to this viewpoint. Such an attitude may indicate the serious limits of our own rigid value-system, which seeks to judge and dispose of a problem, rather than to understand or alleviate it. Because of this we often fail to recognise the importance of the 'trivial' overdose as an early warning signal of relentlessly self- destructive behaviour. It is clear that people who have taken small and safe overdoses as a cry for help are very much more at risk of taking a subsequent fatal overdose than people who have not given these earlier signals. Although the threat to life from `pseudocide' may be negligible at the actual time of this gesture, the future is less certain and may well involve far more extensive damage. All self-damaging behaviour indicates that the sufferer can only communicate some vital need by a language that puts at serious risk the security of his life-structure and the integrity of his physical functions. With such stakes as the final payoff, no suicidal gesture is 'trivial': in the long term, unchecked, every one is a potential suicide. Self-damaging Behaviour: The Suicidal Spectrum Suicide is only one dramatic example at the most extreme end of the whole spectrum of self-destructive behaviour. In this respect suicide differs only in acuteness and intensity from other patterns of behaviour, which cause damage to the self and to personal relationships. Clear examples of more chronic and more common types of self-damage include drug abuse, alcoholism, obesity, heavy cigarette smoking and dangerous driving. More covert and subtle suicide-equivalents are suggested in chronically compulsive unhappy relationships, a proneness to illnesses requiring surgery, and the choice of employment where an element of danger is involved. In all these there is a compulsive tendency towards recurrently hurtful relationships, activities and lifestyles. The origin and complexity of these masochistic life- plans will be explored later. Varieties of Suicide and its Attempts It has already been suggested that suicidal actions may result from many different kinds of life situations and anticipated payoffs. Consequently, in attempting to help a person who indulges in self-destructive behaviour, it is important to attempt to understand the motivation and payoff. I have found that patients who have taken an overdose of drugs fall into the following categories: 1. The unambivalent option of death. 2. Stress reactions in vulnerable personalities. 3. Masochistic personality disorders. 4. Mental illness. This scheme is not watertight and faultless. Nevertheless, it provides a useful. tool for description, effective action and prognosis. The Unambivalent Option of Death The unambivalent option of death implies a genuine, deeply motivated and often thoroughly premeditated decision to end life, because of a dilemma that is truly intractable and without tolerable solution. Most commonly they can be assigned to one of three groups. 1. The isolated, depressed elderly with poor family contacts and failing bodily functions and sensory faculties. They perceive, quite correctly, that life now offers only progressive deterioration of bodily and social functions. The physiological aspects of this syndrome may, in time, be solved by technical geriatrics. Unfortunately, nothing short of a revolution in our ecology, family life and social norms will ever reverse the increasing isolation of the elderly. 2. Younger people with progressive incurable physical disease such as aggressive forms of disseminated sclerosis or cancer. Fortunately they are a fairly small group but, as with older people, they perceive correctly the tragedy of their future. We can do little except offer short-term practical props and platitudes. 3. Those with longstanding and severe relationship and personality disturbance who have sufficient insight and intelligence to understand their dilemma, but are too damaged to have the resources to change radically. Such people have often been heavily involved with multiple caring agencies, but often these provide little more than temporary support, ritualised care or asylum. Knowing that the bulk of their problem continues inexorably and unchanged, they have often earlier sought solace in self-damaging 'solutions' such as alcohol and dangerous drugs, which are both suicidal warnings and equivalents. These three groups present the caring professions and the community as a whole with their most difficult ethical decisions. It is implicit in the problem that there is nothing further we can do to improve the quality of existence. If a person, knowing this, chooses death, are we right to counter this with resuscitation and various forms of religious dogma? Suicide has often been called an act of aggression, but in certain circumstances it may be more aggressive to go on living. To burden others with the experience of protracted and inevitable disintegration of the mind or body may be more damaging to those who love and must care for the receding and decaying person than an unambivalent option for death. For those of us who are trained to cope and provide solutions, such an alternative makes us feel threatened and inadequate. It is a reflection of the understandable bias and inadequacy of our medical training that we are trained neither to examine nor to cope with the problems that inevitably arise in us. Case No. 1 Mr E.A. is 84 years of age. He has made three attempts at suicide since his wife died two years ago. His wife had been a very domineering woman, and because of his dependence on her he is now emotionally unable to cope with life alone. A married daughter lives abroad, but has never, in any case, been close. In the last five years he has suffered from increasingly troublesome breathlessness from cardiac and respiratory disease, which has responded only moderately to competent medical treatment. His eyesight is also insidiously failing, but nothing can be done to help him in this respect. Considerable discomfort from his osteoarthritic hips and knee keeps him awake at night and housebound. Although he is extremely unhappy and given to despair, he is not depressed in a way that can be helped medically. In spite of full involvement by competent doctors, psychiatrists, social workers, day centres, home-help and meals-on-wheels, this man has not regained his will to live. He sees his existence as being uncomfortable, futile and parasitic. His survival now depends on whether or not he is able to outwit his medical and welfare attendants. Stress Reactions In Vulnerable Personalities People who are vulnerable to stress probably make the majority of suicide attempts, although because the attempt implies a mixture of motives, it is usually ambivalent and therefore unsuccessful. Generally the self-damager is a young adult who reacts impulsively to an immediate stress, threat or loss. The fact that they react in this way implies that they are particularly vulnerable to specific kinds of stress, and also tend to react by self-damaging behaviour. Although a large part of their lives may appear fairly orderly and satisfactory, it is evident that this stability is precarious in the face of difficult periods, which those who are more secure adapt to with greater realism. The suicidal act here has a number of contributory components. First, the stress is seen as disproportionately large, and all good parts of experience are temporarily eclipsed, so that life is seen transiently as a mere source of pain and suffering, which should be ended. Second, there is a strong aggressive reaction to any experience, which represents a loss or frustration. This anger may either be turned inwards against the self (‘1 hate myself, I may as well be dead’1) or outwards against others (`See what you made me do! You'll be sorry now'). Underlying this runs a basic lack of security and autonomy which makes these people prone to, but not bound to, self-destructive reactions. Fortunately this group is the most amenable to support, practical suggestions and limited psychotherapy. Often the attempted suicidal act will bring about the immediately desired change and solution, by altering family dynamics and decisions. One must always be aware, however, that all these short-term counter-measures alter the person's ecology, rather than his self-image and his predisposition to self-damaging responses, which may well prove decisive in the long run. Case No. 2Mrs B.A., 27 years of age, made an ambivalent and impulsive suicidal gesture with tranquillisers. She knew she would be hospitalised and would probably recover. This was a gesture of anger against her husband, who had a brief and casual liaison with another woman. He is the more dominant and autonomous of the two, and she tends to passivity and dependence. Generally he has been supportive and reliable with her, but she has been unable to withstand any deviation from this. Whenever things do not go her way she sulks and 'acts hurt'. Importantly, she is unable to assert herself or show anger directly. Much of this probably stems from her family background. Her father left her mother when she was four years of age. Not only is she, therefore, especially vulnerable to loss, but she has modelled herself on her mother who also uses a martyred, submissive and hurt role to evoke the protection of others. During her stay in hospital Mr B.A. solemnly promised to end his other relationship. They are, at present, happily reconciled. The immediate injury has been healed, but her predisposition to self-damage continues. Masochistic Personality Disorders People with masochistic personality disorders fall at the extreme end of the suicidal spectrum. They are more disabled than the previous category, in that they are not merely inclined to self-destructive behaviour, but are bound to it as a way of life so that self-damaging responses occur relentlessly, often ending tragically. This endpoint may not be actual suicide. There are many variations, ranging from alcoholism to recidivism, from crippling psychosomatic illness to drug addiction. The core of this problem lies in the individual's basically faulty and negative view of himself and, therefore, how he may relate to others. Because of his lack of security, trust and confidence, he is unable to establish liaisons that are based on emotional equality and positive bonds. He can relate only via manoeuvres of control or submission—an equal and trusting relationship is unprecedented and hazardous. In many ways these people must be viewed as suffering from a grave deficiency syndrome. Such a defect stems from childhood, but often the formative events are too distant or too subtle to be reconstructed accurately by the adult many years later. What we may infer is that, as children, they could only gain essential care and recognition by arousing either pity or anger from otherwise inaccessible adults. Positive responses are not forthcoming, and negative ones are at least some form of care, and so are chosen as a very unsatisfactory alternative to parental oblivion. The colic of Periodic Syndrome may hurt, but the concern it evokes from mother makes it worthwhile. Playing-up with father is bound to make him aggressive, but at least then he shows he cares. The adult outcome of this childhood programming is one of an unhappy and destructive pattern of social and intimate relationships. Because of the core of suspicion, mistrust and feared disaster this person will turn every kind of encounter and relationship into some kind of testing-out situation in which they invite, and thereby precipitate, rejection and humiliation. They then react with the expected components of bewilderment ('Why does this always happen to me?'), depression (‘I always knew I was no good') and retaliation (`I'll teach you to hurt me like this!'). It is clear how this has all the ingredients of suicide, and its equivalents of the acute and chronic varieties. Although support and care may help these people contain and get through their crises, another crisis is always imminent. It is probably true that only intensive and long-term psychotherapy can radically change their distorted and negative self-image with its sequel in disrupted and painful relationships. Of all those coming to the psychiatrist, they belong to the group most difficult to help. They are indeed fortunate if they are cared for where the requisite time and expertise is available, but even with this the outcome is often unpredictable. Case No. 3 Mrs M.C., 23 years of age, was admitted to hospital after taking her complete stock of antidepressants after a violent and drunken row with her second husband, to whom she has been married for three months. Like her first husband he either ignores her or hurts her—moments of positive intimacy are almost non-existent. Her medical and social history indicates the depth and breadth of her emotional deprivation. She escaped the conflictual relationship with her adoptive father at 16 years, by becoming pregnant by, and then marrying, a man whose sadism matched her masochism. Within a year her anger and depression led to her slashing her wrists. This act heralded the first of three fruitless admissions to a psychiatric unit. This was followed by three consecutive convictions for bomb hoaxes and one for theft. In each case she deliberately left trails, so that a game of 'Cops and Robbers' could be played with the police before her welcome and inevitable terms of imprisonment ensued. As with hospital, she saw prison as a place of security and negative care, corresponding to her own sense of worthlessness. After her stay in prison she was placed in a succession of aftercare hostels, but found these too unstructured and lenient, despite her testing-out behaviour. Her medical history then erupted into a variety of painful physical complaints, and she visited her general practitioner frequently. He, in turn, referred her to various hospital departments. In the last three years she has had four laparotomies for suspected appendicitis, salpingitis, an ovarian cyst and 'adhesions'. She has been investigated neurologically, and negatively, for headaches and has had two D and Cs for menstrual dysfunction. She was admitted as an emergency case with a suspected but feigned pulmonary embolus and was equally convincing to the cardiac arrest team who attended an episode of collapse. It might be added that she is a heavy smoker, and has abused a variety of drugs. Her family background indicates that she knows nothing of her natural parents. She was adopted by a married couple, who had been told they could not have any more natural children, although this was later disproved: there were three natural sons by this marriage. Her adoptive father is a rigid, domineering man who has definite and now outdated ideas about sex roles. M.C. was always restricted and disciplined far more than her adopted brothers, who have not shown her negativistic and self-damaging traits. The adoptive parental marriage is not a happy one because of father's compulsive dominance, but mother is sufficiently submissive and placatory to ensure a resentful and depressed truce. Much of father's controlling and punitive behaviour towards M.C. may have stemmed from his incestuous feelings. In adolescence this seemed more overt and only added to the predominantly negative identity she was forming of herself. In spite of her high intelligence, capacity for insight and (perhaps surprisingly) likeable nature, her self-damaging traits may yet hinder all attempts to help her. Mental Illness There has been much discussion about the definition and boundaries of mental illness, which is important though necessarily complex and inconclusive. This article will not enter into this debate and my definition in this context is clear and pragmatic. By mental illness, I mean those disorders of mental life and consequent behaviour that create distress and can be demonstrably treated by medical measures, with an effectiveness that can in no way be guaranteed by other approaches. People who suffer from mental illness so defined provide the caring professions with extremely gratifying results, so long as the problem is correctly recognised and allocated. Unfortunately the number of people who fall within the suicidal spectrum who are mentally ill in this sense is relatively small. Nevertheless, it is one of the prime responsibilities of all who undertake care and decision-making for unhappy and self-damaging people to ensure that there is not a problem that needs medical assessment and therapy. The penalty of such neglect is the possible suicide in a person who could have been salvaged effectively and rapidly by medical expertise. Commonest among such problems are severe depression (usually of the endogenous kind) and psychotic syndromes (usually schizophrenia). It is impossible to deal adequately with these illnesses within the length of this article, but it is essential for all who are involved in this type of work to be cognisant with these areas of conventional psychiatry. Conclusion Suicide should be considered not in isolation, but against the background of behaviour which is harmful to the self. Suicide is thus the most acute and dramatic form of this and represents the 'absolute' in the suicidal spectrum. Other forms of self-destructive behaviour may presage later and more serious forms of suicide. Such patterns of behaviour indicate a kind of deficiency syndrome, where the person maladaptively learns that he can relate only by being hurt. The earlier this is countered the more hopeful the outcome, but some personalities seem so damaged and disordered that all help seems inadequate. Sometimes suicide represents a rational decision taken from a position of mental health. This creates grave problems of ethics and management. However, some people are driven to suicide by a genuine mental illness where medical treatment is fortunately effective and mandatory. Correct diagnosis and referral of these people is a foremost priority. 1Strategic statements appear in parentheses throughout this article. David Zigmond, MB, CH.B, DPM, is Senior Registrar in the Department of Psychological Medicine at University College Hospital, London WCI. He is also a member of the Institute of Transactional Analysis. SEPTEMBER 1977/UPDATE
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