In this second part of our topic on suicide (click here for part 1), I would like to discuss the more intimate factors associated with suicide. Perhaps we could reframe it by asking, “Why people kill themselves”?

The answer, as I mentioned in the first posting, is complex. There is no one single answer that would explain that tragic behavior. However, in my many years working with very distressed and hurting people as well as reading and thinking on this subject, I have come to see four factors, which seem to be present in one way or another in the mind of those who are contemplating suicide.

The Four Factors

• Hopelessness. Many years ago, a very prominent American Psychiatrist, Dr Aaron Beck, who is also known as the ‘father” of Cognitive Therapy, noticed that an item in his depression questionnaire highly correlated with likelihood for self-harm, including completed suicides. This item dealt with a sense of hopelessness. Later, he developed a whole questionnaire known as the Beck’s Hopelessness Scales to evaluate this very important construct. The person who is at high risk for suicide is the person who has lost the sense of the future, who develops strong pessimistic attitudes, has very low motivation to do anything, and has limited expectations regarding life and others. In working with very depressed people over the years, I have seen repeatedly that it is not the degree of adversity in the person’s life, but the loss of hope that is critical. It reminds me of the quote from Nietzsche “give a person a why and he can deal with any how”. No matter how much pain and suffering a person experiences, if hope exists, if there is a point to everything (a “why”) then he can deal with the greatest of difficulties. On the other hand, once hope is lost, life tends to go the same way. The beautiful, courageous and tragic story of Ann Frank reminds us of this principle. This young Jewish adolescent hid with her family is an attic of a house in Amsterdam during WWII. Her diary shows despite her precarious situation, she was hopeful and joyful. She kept hoping for the day of liberation, and her future life. Sadly, they were betrayed and the Nazis sent them to concentration camps, and there she fought on, resisted this evil with all her might, until her older sister died. Ann, who had so gallantly and courageously battled fear, horror, hunger, and disease, felt there was no more hope and let go of life; she stopped fighting and surrendered herself to despair. Just four weeks later, the allied forces liberated her concentration camp.

• Pain. Edwin Shneidman, in his seminal work on suicide, created the term “psychache” to describe the depths of psychological pain, hurt, and anguish a person experiences when contemplating suicide. While in sadness and depression, we always feel a level of pain, this is a more intense, despairing and alienating type of pain. As a Psychologist dealing with people in this state, I always felt this huge emotional divide when trying to reach out, to succor, and to bring hope. This is not only a hurtful pain, but also an alienating type of pain, which cuts people off from others. A person who suffers this type of pain, feels no one understands or can understand. This person feels alone, desperate and hopeless.
• Anger. Sigmund Freud in his pioneering work in Psychoanalysis theorized that one prominent reason why people developed depression was through an unconscious mechanism in which anger, initially felt against other people, is introjected (turned inward) against the self. This is possible because we carry within ourselves our histories and the image of important people in our lives, even those who have hurt us. Therefore, the anger we feel towards them we direct it to their internal representations in our minds. At some point, this anger, or better-said “rage” is let loose and becomes murderous rage against the self. When I was in training I had a supervisor who used to say that suicide was the ultimate “fuck you”, referring to this concept in which the act of killing oneself is a defiance, a message, towards others whom have hurt us and whom we hate. Independently of the veracity of this theory, the person who is suicidal is typically very angry as well, although as frequently, this anger is not acknowledged.
• Guilt. The final horseman of this apocalyptic self-destruction is guilt. This emotion, as all emotions, carries within itself, a set of consequences. A person who is guilty feels the need to be punished. It is only through punishment that guilt can be released, paid for, and the emotional debt, be once for all, finally settled. When guilt is unbearable and the hope for forgiveness is not available, suicide becomes the ultimate and proper method of paying that debt. A common misconception in PTSD is that people develop symptoms due to witnessing or living through horrific images of horror or destruction. While it is true that witnessing experiences of this nature will affect us in emotional ways, most people will, with time, feel better and return to normal functioning. In most severe cases of PTSD, the dynamics are very often consistent with feelings of guilt regarding what the soldier did or failed to do, which resulted in pain, suffering or loss of life. Now this guilt does not have to be “logical, real” so to speak, it only needs to exist in the person’s psyche as a constant reality and accuser of his actions. Sometimes this guilt takes unusual form such as the well-known “survivor guilt” in which the soldier feels guilty not because his actions (or lack of) but just because he survived and the common expression of this existential dilemma is “why me, why was I spared”? Another interesting twist to this guilt is the man who becomes horrified to find he had the capacity to enjoy killing and destroying the lives of other people. I have seen variations of these themes in almost all of the cases I have treated with severe PTSD, and this is a very difficult obstacle to overcome.

Where do we go from here?

There is very little doubt that the person experiencing these kinds of emotions, needs to find professional help. The good news in this tragic story is that people do recover and hope flourishes again in the desert of our hearts. War changes people, but beyond the horrific consequences of battle, the person you become is not dependent on the events themselves but on the choices you make, in the face of those events. Who you are at any given time in your life, is not the sum total of all your experiences, although those are indeed primordial. Who you are and who you become is who you choose to be; we are our existential choices.  An old priest told me of his experiences counseling those who were about to die in a firing squad (this was right after a revolution in a Latin American country). Some men had to be dragged and tied to the post, while they cried and begged for their lives, while others walked to their deaths with defiance, refused the blindfold and died yelling at their executioners or praying and singing to God; same fate, different attitude. I was a young adolescent when I heard this story, and throughout my life I always wondered if placed on that situation how would I die. Most importantly, this story always reminded me that I am and I become my choices, even when those choices may just only be the choice of my attitude.  

If you or someone you know is facing these demons, seek out help. The very first step in any type of recovery is the acknowledgment of the problem and the decision to do something about it. The road to recovery may not be easy, but good and wonderful things do not come easy, they take work and commitment. You need to realize the need to open up the old wounds and face them, talk about them, tell them to another human being who will be there for you. You need to find in your heart to forgive yourself for real or imaginal wrongs you did or for the failure to act; to forgive others, to let go of the guilt and the anger you have been harboring for years. You need to find new purposes and goals, new meaning, to renew hope, to heal the pain and to find the path you will walk for the rest of your life. You will not forget your memories, those will always be there, but your understanding of them, your relationship to them and your reaction to them, that will change, and that change will make you free.

Many aspects of this process are not only psychological but spiritual as well. Long before we had psychiatrists and psychologists, people would come to their parishes and spiritual leaders for healing and guidance; it worked for them and it can work for you as well. Confession, forgiveness, and renewal, ancient practices that are never too old or outdated for us to use them.

Galgano Guidotti was a knight who fought bravely in the Crusades and upon his return, he carried with him the invisible wounds of the soul. The story is told that in his despair, he stuck his sword in a rock and turned to God for healing, changing his life forever. Today there is a small chapel in the Galgano Monastery in Montesiepi in Tuscany, Italy where that sword can be seen. It still stands as a reminder of a warrior who found peace and a new purpose in his life; if he did it, you can also do it.

-Spartan

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