Once … he wrote a poem.
And he called it “Chops,”
Because that was the name of his dog, and that’s what it was all about.
And the teacher gave him an “A”
And a gold star.
And his mother hung it on the kitchen door, and read it to all his aunts …
Once … he wrote another poem.
And he called it “Question Marked Innocence,”
Because that was the name of his grief, and that’s what it was all about.
And the professor gave him an “A”
And a strange and steady look.
And his mother never hung it on the kitchen door because he never let her see it …
Once, at 3 a.m.… he tried another poem …
And he called it absolutely nothing, because that’s what it was all about.
And he gave himself an “A”
And a slash on each damp wrist,
And hung it on the bathroom door because he couldn’t reach the kitchen.
PSYCHOLOGICAL PAIN or stress alone—however great the loss or disappointment, however profound the shame or rejection—is rarely sufficient cause for suicide. Much of the decision to die is in the construing of events, and most minds, when healthy, do not construe any event as devastating enough to warrant suicide. Stress and pain are relative, highly subjective in their experiencing and evaluation. Indeed, some people thrive on stress and are at sea without it; chaos and emotional upheaval are a comfortable part of their psychological lives. Many individuals at a relatively high risk for suicide—for example, those with depression or manic-depressive illness—function extremely well between episodes of their illness, even when in situations of great pressure, uncertainty, or repeated emotional or financial setbacks.
Depression shatters that capacity. When the mind’s flexibility and ability to adapt are undermined by mental illness, alcohol or drug abuse, or other psychiatric disorders, its defenses are put in jeopardy. Much as a compromised immune system is vulnerable to opportunistic infection, so too a diseased brain is made assailable by the eventualities of life. The quickness and flexibility of a well mind, a belief or hope that things will eventually sort themselves out—these are the resources lost to a person when the brain is ill.
We know that the brain’s inability to think fluently, reason clearly, or perceive the future with hope creates a defining constellation of depression. We also know that depression is at the heart of most suicides. Neuropsychologists and clinicians have found that people when depressed think more slowly, are more easily distracted, tire more quickly in cognitive tasks, and find their memory wanting. Depressed patients are more likely to recall negative experiences and failure, as well as to recall words with a depressive rather than a positive context. They are also more likely to underestimate their success on performance tasks.
Most of the impaired cognitive functioning in depression is also apparent in highly suicidal patients, including those who have recently tried to kill themselves. Suicidal patients, for example, are less able to generate possible solutions when presented with a series of problems to solve. Their thinking is more constricted and rigid, their perceived options narrow dangerously, and death is seen as the only alternative. Occasionally death is seen not just as the only alternative but as a highly seductive and romantic one. A nineteen-year-old college student illustrates this in drawings she gave to her psychologist, which portray suicide as a tranquil surcease of pain, a lulling alternative to the problems of life.
When suicidal patients undergo psychological testing, the experiences they describe tend to be negative, vague, and diffuse, and they see the future with futility and despair. When asked to think of things they are looking forward to, suicidal patients come up with far fewer than nonsuicidal people do. Often only a sense of responsibility to other family members or concerns about the effects of suicide on their children keep some people alive who otherwise have a strong desire to commit suicide.
In short, when people are suicidal, their thinking is paralyzed, their options appear spare or nonexistent, their mood is despairing, and hopelessness permeates their entire mental domain. The future cannot be separated from the present, and the present is painful beyond solace. “This is my last experiment,” wrote a young chemist in his suicide note. “If there is any eternal torment worse than mine I’ll have to be shown.”
Drawings by a nineteen-year-old college sophomore
This sense of the unmanageable, of hopelessness, of invasive negativity about the future is, in fact, one of the most consistent warning signs of suicide. Aaron Beck and his colleagues at the University of Pennsylvania have shown, in an extensive series of studies, that hopelessness is strongly related to eventual suicide in both depressed inpatients and outpatients. So, too, has Jan Fawcett of Chicago’s Rush-Presbyterian Hospital in his long-term prediction studies of suicide. People seem to be able to bear or tolerate depression as long as there is the belief that things will improve. If that belief cracks or disappears, suicide becomes the option of choice.
ON OCTOBER 29, 1995, twenty-year-old Dawn Renee Befano, a talented Maryland freelance journalist who had suffered from severe depression for years, killed herself. She left behind twenty-two journals, which are now in unpublished manuscript form. Excerpts from the journal written in the weeks leading up to her death show how unbearable her world had become, how her sense of her options had constricted them to nonexistence, and how an agonizing, suffusing hopelessness pervaded all reaches of her mind:
October 9th.
I will not last another month feeling as I do now. I do not question that my eyes are brown, and I do not question my fate: I will die a suicide within the next month if relief does not come relatively quick. I am growing more and more tired, more and more desperate. I am dying. I know I am dying, and I know it will be by my own hand.…
I am so bone-tired and everyone around me is tired of my illness.
October 10th.
Outside the world is crisp and blue, refreshing fall weather, beautiful weather. I feel like hell, trapped in a black free-fall. The contrast between the two makes both seem more extreme.
In a strange way, however, I feel at peace, resigned to my fate. If I do not feel better by the end of November, I have decided to choose death over madness. I know, one way or another, that this will all be over with by the end of next month. This will all be over and done with.…
I feel everything and all is pain. I do not want to live, but I must stick it out until my deadline.
October 11th.
I’m terrified. What’ll it be, death or madness? In all honesty, living like this for another two weeks is difficult to imagine. I can only take so much of this punishment. When I die, all I leave behind are these journals.… I don’t think I’ll leave a suicide note, these journals will be more than adequate.
October 17th.
I can’t think. All is muddled. I want to sink into sleep, to escape. I am so tired. To care about anything takes such a tremendous effort. The fog keeps rolling in.
I simply want the world to leave me alone, but the world slips in through the cracks and crannies. I cannot help that. The goddamn fog keeps rolling in.
Insane. This waiting is truly testing my endurance. I cannot handle it for much longer. I don’t want to have to handle it. Nobody around me does either. Nobody.
October 20th.
Behold, I am a dry tree.—Isaiah 56:3
October 23rd.
I want to die. Today I feel even more vulnerable than usual. The pain is all-consuming, overwhelming. Last night I wanted to drown myself in the lake after everyone in the house had gone to sleep, but I managed to sleep through that impulse. When I awoke, the urgency had vanished. This morning, the urgency is back. I live in hell, day in and day out. Every day, I break down a little bit more. I am eroding, bit by bit, cell by cell, pearl by pearl. I am not getting any better. “Better” is alien to me, I cannot get there. They can try acupunctu
re, they can try ECT, they can try a frontal lobotomy, none of it will work. I am a hopeless case. I have lost my angel. I have lost my mind. The days are too long, too heavy; my bones are crushing under the weight of these days.
October 24th.
I am sick, so sick. Impossibly sick.…
October 28th.
So this is what the Tibetan Book of the Dead calls “bardo,” the time between lives. I don’t have any taste for life because I am between lives. A more optimistic way of putting things, instead of simply, I don’t want to live.…
I will not go back into a hospital. I will simply take a walk into the water.
The pain has become excruciating, constant and endless. It exists beyond time, beyond reality, beyond endurance. Tonight I would take an overdose, but I don’t want to be sick, I just want to be dead.
The next morning Dawn woke early. She sat at the kitchen table, ate cold cereal, and worked on the crossword puzzle from the newspaper. After a short while, she left the kitchen and was not seen alive again.
The bed in her room was made neatly, according to her mother. There was “a stack of thirteen library books on the floor, and the contents of her backpack, including keys, cash, and her driver’s license, stowed in a large envelope. Her great-grandmother’s crystal rosary beads were spread out on the bed.”
Her body was found months later, floating in a lake.
CHAPTER 4
The Burden of Despair
—PSYCHOPATHOLOGY AND SUICIDE—
One forgets emotions easily. If I were dealing with an imaginary character, I might feel it necessary for verisimilitude to make him hesitate, put the revolver back into the cupboard, return to it again after an interval, reluctantly and fearfully, when the burden of boredom and despair became too great. But in fact there was no hesitation at all.
—GRAHAM GREENE
“MISERABLENESS IS like a small germ I’ve had inside me as long as I can remember,” wrote Graham Greene. “And sometimes it starts wriggling.” When the miserableness became intolerable, Greene reached out first for a knife, then for poison, and finally for a gun. Pathological despair came to him early and often throughout his life, cycling—as manic-depression will—with a dangerous, alcoholic, and suicidal ferocity. In his memoir A Sort of Life, Greene described his early encounters with suicidal depression and his escalating attempts to numb or die his way out of it. While still at school,
I tried out other forms of escape after I failed to cut my leg. Once at home on the eve of term I went into the dark room by the linen-cupboard, and in that red Mephistophelean glare drank a quantity of hypo under the false impression it was poisonous. On another occasion I drained my blue glass bottle of hay-fever drops, which, as they contained a small quantity of cocaine, were probably good for my despair. A bunch of deadly nightshade, picked and eaten on the Common, had only a slightly narcotic effect, and once, towards the end of one holiday, I swallowed twenty aspirins before swimming in the empty school baths.
Were these “real” suicide attempts, desperate gestures, or simply dramatic responses to the usual glooms of childhood? This is an inevitable question in light of actions taken by a precocious and sensitive schoolboy: How much of what he did was due to his temperament (and, in this case, the quick and finely wired temperament of a child who went on to become a great writer), how much was in response to painful or difficult circumstance, and how much was due to his underlying mental illness, the manic-depression openly acknowledged by Greene and an illness that also ran in his family?
Certainly, thoughts of suicide did not pass as Greene grew older. When he was nineteen, he removed his brother’s revolver from the cupboard in their bedroom—“I felt nothing,” he said. “I was fixed, like a negative in a chemical bath”—and walked toward the beech woods:
I slipped a bullet into a chamber and, holding the revolver behind my back, spun the chambers round.…
I put the muzzle of the revolver into my right ear and pulled the trigger. There was a minute click, and looking down at the chamber I could see that the charge had moved into the firing position. I was out by one.…
This experience I repeated a number of times.… The revolver would be whipped behind my back, the chamber twisted, the muzzle quickly and surreptitiously inserted in my ear beneath the black winter trees, the trigger pulled.
Greene did not, in the end, kill himself. But the possibility of suicide was a recurring presence in his life and, as for many with depression, the seeming best and final response to bale and weariness. He continued to wage war against his black depressions, “the hopeless misery of the years,” as he put it, using alcohol, the perverse exhilaration and risk of Russian roulette, and dangerous travels abroad into war zones and other areas of high political and social volatility, as antidotes to a bled-out state.
Suicide, at once the most individual of acts, is also a numbingly stereotypic and common end point for many who suffer from severe psychiatric illness. While no one illness or set of circumstances can predict suicide, certain vulnerabilities, illnesses, and events make some individuals far more likely than others to kill themselves.
The most common element in suicide is psychopathology, or mental illness; of the disparate mental illnesses, a relative few are particularly and powerfully bound to self-inflicted death: the mood disorders (depression and manic-depression), schizophrenia, borderline and antisocial personality disorders, alcoholism, and drug abuse. Study after study in Europe, the United States, Australia, and Asia has shown the unequivocal presence of severe psychopathology in those who die by their own hand; indeed, in all of the major investigations to date, 90 to 95 percent of people who committed suicide had a diagnosable psychiatric illness. High rates of psychopathology have also been found in those who make serious suicide attempts.
Work done by Clare Harris and Brian Barraclough in England, shown here in an adapted form, gives a general notion of which kinds of mental illness place an individual at risk. The researchers analyzed the results of 250 clinical studies and compared the number of suicides in people suffering from specific mental illnesses with the number of suicides expected in the general population. To determine suicide risks in schizophrenia, for example, they reviewed thirty-eight studies from thirteen countries; altogether, the suicide rate in more than thirty thousand schizophrenic patients was compared with that of the general population. The patients with schizophrenia, as can be seen in the graph, were more than eight times as likely to die by their own hand.
A history of a serious suicide attempt turned out to be the single most powerful predictor of subsequent suicide, placing an individual at thirty-eight times the expected risk. Mood disorders and substance abuse also carry with them very high rates: those who suffer from depression, or from dependence upon prescription drugs (sedatives, sleeping medications, antianxiety medications), are twenty times more likely to kill themselves than the general population, and individuals with manic-depression (bipolar disorder) are fifteen times more likely. Although people who are dependent upon prescription medications have a higher rate of suicide than people dependent upon alcohol, alcohol is, because far more people use it, responsible for many more suicides. This is in part because there are more individuals who are alcoholics than who are prescription drug abusers; in part because depressive disorders are frequently—and lethally—accompanied by alcohol dependence; and in part because alcohol is often used in conjunction with other methods at the actual time of suicide.
Suicide risk in selected psychiatric and medical conditions
What is perhaps most striking about this summary of studies, however, is how many more suicides are linked to psychiatric illnesses than are to serious medical disorders such as Huntington’s disease, multiple sclerosis, or cancer. It seems strange that the latter illnesses, so often tied to pain, disfigurement, diminished dignity and independence, and death, are as little associated with suicide as they are. Most nonpsychiatric medical illnesses, however, are not accompanied by an increas
ed rate of suicide; even though physical illnesses are common in people who commit suicide, they are also common in people who do not kill themselves. In one study of psychiatric patients, for example, researchers found that one-third of the patients who committed suicide suffered from nonpsychiatric physical illness; when they looked at the prevalence of such illnesses in psychiatric patients who did not kill themselves, however, they found that nonpsychiatric physical illnesses were as common or more so.
Two things seem to be true: First, although there are exceptions, almost everyone who has a physical illness and subsequently commits suicide also has a psychiatric illness. Second, most of the medical conditions that do show a significant increase in the rate of suicide—temporal lobe epilepsy, Huntington’s disease, multiple sclerosis, spinal cord injury, HIV/AIDS, head and neck cancer—originate in or strongly influence the brain and the rest of the nervous system. These medical disorders can cause extreme mood swings and, in some instances, dementia. Other illnesses, such as heart and lung diseases, may be painful, disabling, or life-threatening, but they do not make suicide more likely (some treatments for these illnesses, however, such as coronary bypass surgery and certain medications used to treat high blood pressure, may cause severe, even suicidal depression in vulnerable individuals).
The focus of this book is on suicide in the relatively young and otherwise physically healthy, and therefore the issues surrounding suicides committed in the context of terminal illness are not as relevant as they would be in a discussion of suicide in the elderly. Still, it is important to underscore the fact that even in those with medical illnesses, most suicides or severe attempts are due to coexisting depression. The only condition that actually seems to protect against suicide is pregnancy, a condition of youth or relative youth. During pregnancy and the first year afterward, there is a three- to eightfold decrease in the risk of suicide.
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