What does it mean to kill yourself, to kill your “self”? What is being attacked and/or escaped from? There is no consensus about what a self is. Its contours change or even vanish depending on your particular perspective—philosophical, psychological, or neurobiological. Is the self an illusion or something real? Is it an aspect of our consciousness? An intense conscious feeling-state of some kind seems to be necessary to trigger the act of suicide, but that doesn’t mean unconscious forces are not at work in the suicidal person. What actually goes on in a person who wants to die? I am not possessed by a desire to kill myself. I am afraid of death by accident or illness. I hope to live a long time, and I find it excruciating to think about what my sudden death or slow demise would mean for the people who love me. I have had to work hard to understand how a person comes to decide that death is preferable to life. The will to survive is a Darwinian principle that seems to have gone off course. From this perspective it is not strange that some theorists believe there must be some constitutional explanation, some biological secret that can be uncovered to solve the problem.
It is a sign of the times that neuroscientists are looking for the genetic causes of suicide. Their research has not addressed what it means to turn against one’s self and how this might be related to genes. This is too subtle a question to ask. The findings that suicide victims have reduced levels of the neurochemical serotonin and its major metabolite (5-HIAA) as opposed to those who died for other reasons have drawn the most attention.4 Because there is evidence that the serotonergic system is partly under genetic control but no specific knowledge of how this works, the research remains speculative.5 Despite newspaper articles trumpeting the discovery of a suicide gene, “Suicide Gene Identified,” researchers have proposed only candidate genes.6 The chosen endophenotypes (the measurable biological or behavioral markers for a particular disease) for suicide are impulsivity and aggression. But as the psychiatrist Gustavo Turecki points out, not all suicides are impulsive or aggressive.7 Can the act of suicide or a succession of suicide attempts be called a disease, and if it can, what exactly do we mean by classifying suicide in this way? Notably, in these studies that search for a gene or genes for suicide, self-harm is not distinguished from harm to other people and, while there are countless animal studies on the role of genes and environment in aggression, self-aggression is rare in the animal kingdom, which makes routine study impossible. In the case of suicide, we cannot rely on animal studies for information about human beings, who are far more likely than other animals to hurt themselves on purpose.
What we do know is that environmental influences on an animal, including social ones, such as maternal care and isolation, have been shown to produce chemical alterations around the DNA molecule that modify gene expression.8 Some studies have found that these chemical changes can be inherited by offspring who have never been subjected to the same stress.9 Much of the work in epigenetics is done on mice and rats, but it is not unwarranted to extrapolate to human beings if one proceeds carefully. Repeated shocks or deprivations to an animal affect its stress regulatory system (the hypothalamic-pituitary-adrenal, HPA, axis) and hormone levels—corticosterone in rats, cortisol in human beings—which have been linked to changing gene methylation.10 A human postmortem study by Patrick McGowan and his colleagues found increased cytosine methylation in suicide victims who had been abused but not in suicide victims who had not been abused.11 This study suggests that abuse affects methylation but is not necessarily a predictor of suicide. “Stress,” that vague and now ubiquitous word for myriad forms of assault that come from outside the organism, is a vehicle by which environment is transmuted into biological being, although not one of us is conscious of how our cells are adapting to the particular conditions around us.
Human beings are surely made of cells, but as a species we have produced a broad range of cultures, organized in myriad ways, and we have generated ideas about how to live that have been articulated in hundreds of languages, and this thickening of complexity in the human realm defies simplistic reductions to genes, neurochemicals, and synapses. Genes, neurochemicals, and synaptic connectivity are all important, but they cannot tell us anything about a person’s thoughts when she makes the decision to kill herself. The suicidal poet in my class may have been subjected to repeated emotional stress that altered his gene expression. He may have been impulsive and aggressive, but if we truly want to understand what had happened to him, we would have to try to take his point of view. We have to enter a first-person perspective.
In his 1973 article for Encyclopaedia Britannica, Edwin Shneidman writes, “It is probably accurate to say that suicide always involves an individual’s tortured and tunneled logic in a state of inner-felt, intolerable emotion.”12 “Better a terrible end, than terror without end,” wrote one man at the end of his suicide note.13 These two aspects of conscious experience—unbearable feeling and an internal argument for the deed—must be present in the suicidal person, and I think Shneidman is right to distinguish them. Neither “inner-felt, intolerable emotion” nor “tortured and tunneled logic” can be understood without an examination of a person’s unique, subjective perspective on the world.
In chapter 10 of his Psychology, William James describes several selves—material, social, and spiritual—but his “self of selves” is “felt.” He calls this “empirical” and embodied self “Me.”14 James’s Me resembles what phenomenologists call the prereflective, minimal, or core experiential self. Some neuroscientists have proposed a form of a primal or core self, a motor-sensory, affective bodily self with a neural location in the brain, which is responsible for a primary form of self-awareness in many creatures.15 What other animals don’t have, at least not to the degree human beings do, is what James called the “I” or knower, a self that remembers its past and anticipates its future. Suicide is an intentional conscious act. Before you do it, you have to picture it, think about it, test it out in your mind, and articulate it in language. It requires reflective self-consciousness, an active projective imagination in which the person sees himself or herself dead. The Me can experience terrible suffering, but only the I can form an argument for killing.
In The Sickness Unto Death, Kierkegaard’s meditation on despair, the pseudonym Anti-Climacus asks what the self is: “The self is a relation that relates itself to itself or is the relation’s relating itself to itself in the relation; the self is not the relation but is the relation’s relating itself to itself.”16 The famously complicated philosopher further complicates this definition, but I shall seize on something essential. For Kierkegaard, the physical body takes in and records the immediate reality of the senses, which the psychical then interprets in reflection. Kierkegaard’s self is a synthesis. This is a fertile idea that can be rephrased as follows: the conscious human self is not a static thing but an active relation between the motor-sensory-perceptual life of bodily experience and psychic ideas or thoughts and their linguistic representations. In the Phenomenology of Perception, Merleau-Ponty argues that the person “as concrete being is not a psyche joined to an organism but the movement to and fro of existence which at one time allows itself to take corporeal form and at others moves toward personal acts.”17 For every suicidal person there is consciousness of suffering—a prereflective but intensely felt bodily state—and there is a tortured logic or story the person tells herself that makes death seem right and necessary, her reflection. And yet, as Merleau-Ponty justly points out, her feeling and her language are enmeshed in a single phenomenal reality.
William James writes with particular eloquence about the social self.
No more fiendish punishment could be devised, were such a thing physically possible, than that one should be turned loose in society and remain absolutely unnoticed by all the members thereof. If no one turned round when we entered, answered when we spoke, or minded what we did, but if every person we met “cut us dead,” and acted as if we were non-existing things, a kind of rage and impotent despair would ere long well
up in us, from which the cruelest bodily tortures would be a relief; for these would make us feel that, however bad might be our plight, we had not sunk to such a depth as to be unworthy of attention at all.
James goes on to say, “A man has as many social selves as there are individuals who recognize him.”18 James is surely right that the most terrible thing of all is to live unrecognized, to feel invisible among others. Invisibility can quickly come to feel like annihilation. No one can live without feeling that he or she is seen by other people.
In his passionate, if rambling, defense of suicide published in 1976, two years before he killed himself, Jean Améry maintains that what all people who kill themselves share is not a cry for help but the message. “This message, which does not have to be written down, cried out, defined by any kind of sign, but is instead given along the way in the silent act, means that we ourselves at the moment of stepping over the line, when we have issued our refusal to the logic of life and the demands of being, still have in a part of our person something to do with the other, right up to our last flicker of consciousness.” “Because the other,” he continues, summoning Sartre, “with his glance, his project, his fixing of my ego, is both murderer and Samaritan. The other is the breast of my mother and the helpful hand of the nurse. The other is more: the ‘you’; specifically, without which I could never be an ‘I.’ ”19
Améry’s view of suicide is dialogical. It can occur only in relation to that other. The real other person may be missing from the death scene, but an imaginary other haunts the proceedings until the final message is delivered. If Améry is right, then it is not strange that people who have lost beloved others to suicide are haunted by the idea of a message and its emotional content, whether a note exists or not. They are left feeling guilty or angry or at the very least terribly confused. Many suicidal people deliver messages, drop hints, or make some sign of their intention to others. In the last play Sarah Kane wrote before she killed herself in 1999, 4:48 Psychosis, the nameless character says, “Don’t switch off my mind by attempting to straighten me out. Listen and understand, and when you feel contempt don’t express it, at least not verbally, at least not to me.”20 The heartbreaking anxiety of the “I” in relation to the “you” in the play, the terror of being shamed and belittled, the aggression and the abjection are so raw that when I read the text, I felt as if I were listening to a scream.
Suicide and suicidal behaviors may be seen as fundamentally communicative. They are intersubjective or interpersonal. Even though the message is not necessarily spoken or written, it is always embodied in the act itself, and it is always directed at another person or persons, who can be, as Améry points out, both murderer and Samaritan. Kane’s I want you and I don’t want you is such a message. The “you” is at once desired and feared. None of us begins life with a knowing “I,” but an experiencing “Me” is present from the start, and that early self develops through intimate others—the “you.” As Améry contended, there is no I without a you.
In his landmark work Attachment and Loss, John Bowlby understood that human beings and other primates are inherently social beings that actively seek connection with others to survive and that our early experience with those others shapes us for life. Through these early interactions, a person develops what Bowlby called “internal working models,” representations of the self and of others that mediate his or her response to social encounters through adulthood.21 Neglect, trauma, and erratic care in infancy can have a dramatic impact on the grown-up the child becomes. Mary Ainsworth gave attachment research a working taxonomy through “the strange situation.” By watching twelve-month-old children separated from and then reunited with a parent in a laboratory, Ainsworth was able to specify different styles of attachment: secure, anxious, and avoidant.
Secure children are upset when the parent leaves the room, but when he or she returns, they seek out the parent and are easily comforted. Anxious children are often uneasy in the parent’s presence, become desperate upon separation, and are not easily comforted when the parent returns. They may also punish the parent for leaving. Avoidant children don’t seem distressed by a parent’s absence and upon reunion actively avoid the parent. Mary Main and Judith Solomon proposed a further category they called “disorganized” or “unresolved” to explain child behaviors that did not fit well into the other three. A child appears torn between approaching the parent and avoiding him, caught in an emotional limbo. A little girl cries in panic when her father leaves, but upon his return, she forcefully holds back her tears and remains silent despite his attempts to engage her and turns away to play with toys.
Strict codification of any human behavior is difficult, and there are always children who fall outside these rubrics, whose actions resist classification. Nevertheless, an increasing number of studies have connected insecure attachment to suicide and suicidal behaviors. In an overview of the literature, Mario Mikulincer and Phillip Shaver note, “Attachment insecurities, mainly anxious and disorganized,” have been consistently linked “to suicidal thoughts and behavior.”22 Some researchers understand suicide as an extreme attachment behavior.23 Anxious and disorganized attachments create a highly charged zone between self and other in which intense desire for closeness mingles with a terror of rejection. Recognition, vital to the social self as James understood it, is at once hoped for and feared as toxic. Kane’s character speaks to this at the end of the play: “The vital need for which I would die / to be loved.”24 This strange sentence expresses a mad logic: I am willing to die to be loved, even though my death will make the love I crave impossible to experience.
Interestingly, both secure and avoidant attachment styles appear to protect a person from suicide.25 The boundaries between me and you are more clearly defined in both. The securely attached person can negotiate intimacy and distance. An avoidant person has sealed himself off from others. He actively protects himself from all intimate involvement with others, which may create an internal working model of the other that is less volatile. From an attachment perspective, then, suicide is a relational drama that often involves a precarious sense of both one’s self and others, which is unconsciously and consciously coded and may be described in both biological and psychological terms.
Borderline personality disorder, or BPD, is the only psychiatric diagnosis to include suicidal and self-harming acts as part of its diagnostic criteria. As a classification it is quite new. Although the term “borderline” (or “borderline personality organization”) had been used in a number of ways in psychoanalysis to identify patients who at times seemed to slip into psychotic states, it made its first appearance as a diagnostic category in the DSM-III in 1980.26 Both the criteria for its diagnosis and treatment for it have evolved considerably since then, but the illness has always been linked to difficulties in interpersonal relations, to what one group of researchers call “ambivalent and erratic feelings in close relationships.”27 It is also now viewed as an illness for which disturbed attachment in infancy “is a major etiological factor.”28 In other words, a baby who finds himself with an unreliable caretaker or one who gives him confusing, mixed messages may grow into a person who cannot control his precarious, turbulent emotions, a person similar to Kane’s character for whom a need for love is so desperate it may end in self-killing. The complexities of such feelings are immense.
Biochemistry is obviously involved. The pituitary hormone oxytocin, crucial to birth and lactation, dubbed the “love” and “trust” hormone in the popular press, has been implicated as an important hormone in social bonding. A much-cited paper published by Nature in 2005, “Oxytocin Increases Trust in Humans,” appeared to demonstrate that if you spray oxytocin up your nose and play a game, you become more trusting.29 The simple equation, oxytocin = trust, has worn thin since then, but more interesting is that if you administer oxytocin to people with BPD who have been identified as insecurely attached, it seems to have exactly the opposite effect, despite the fact that the neurobiological prof
ile in normal controls and people with BPD is the same. The hypothalamic-pituitary-adrenal axis in healthy people and people who have been diagnosed with borderline personality disorder is similarly activated. Why the difference in their feelings? A possible explanation was articulated in an article by Kenneth Levy and his colleagues: “For healthy individuals, feelings of closeness and intimacy associated with oxytocin are generally seen as positive. However, individuals with BPD may view the same feelings of closeness as threatening, thus experiencing decreases in trust and collaboration after receiving oxytocin.”30 This single example must serve as a prime illustration of the dangers that turn up if you believe a psychological or emotional state can be instantly reduced to neurobiology. The dramas of attachment surely involve the nervous system, but they are also part of a personal narrative of becoming over time, one that involves the social self and turns on recognition.
The term “nonorganic failure to thrive” has been used for infants who lose weight and don’t develop normally. They are in peril for no known “organic” reason. These cases are usually linked to deprivation, to babies who may not be starving for food but are starving for touch and care. In truth, there is nothing nonorganic about it. Social animals require social interactions. All mammals depend on bonds with others. Some monkeys and other primates that have been isolated, especially during early life, repeatedly show self-injuring behaviors.31 An ostracized chimp in the wild may creep off alone and eventually die, but I don’t believe the animal’s self-injury and withdrawal can properly be called suicidal. Similarly, the infant who fails to thrive is not killing himself on purpose.
A Woman Looking at Men Looking at Women Page 51