Working in the Dark

Understanding the pre-suicide state of mind

Donald Campbell, Rob Hale

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317552147
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Working in the Dark focuses on the authors' understanding of an individual's pre-suicide state of mind, based on their work with many suicidal individuals, with special attention to those who attempted suicide while in treatment. The book explores how to listen to a suicidal individual's history, the nature of their primary relationships and their conscious and unconscious communications.

Campbell and Hale address the searing emotional impact on relatives, friends and those involved with a person who tries to kill themself, by offering advice on the management of a suicide attempt and how to follow up in the aftermath. Establishing key concepts such as suicide fantasy and pre-suicidal states in adolescents, the book illustrates the pre-suicide state of mind through clinical vignettes, case studies, reflections from those in recovery and discussions with professionals.

Working in the Dark will be of interest to social workers, probation officers, nurses, psychologists, counsellors, psychotherapists, psychoanalysts and doctors who work with those who have attempted suicide or are about to do so.

Chapter 1

---

Attitudes about suicide over the ages

 

 

 

 

---

 

A glimpse of the history of suicide reveals the changing attitudes and conceptual frameworks. Suicide is as old as history and ubiquitous. Throughout the ages it has been variously regarded as an altruistic act, a crime against the state, a sin against religion and an immoral act. As Robin Anderson (2000), a psychoanalytic colleague, points out:

In Europe during most of the Christian era, suicide was regarded with even greater condemnation, and therefore presumably fear, than murder. The unsuccessful suicide was not only punished severely, but the successful suicides could not be buried in an ordinary cemetery. They had to be buried at a crossroads either with a stake through the heart or with stones on top of the body to prevent their spirit rising and haunting the living.

Shakespeare (1914) refers to this in A Midsummer Night’s Dream (Act Three, Scene II, 380–7) where Puck says:

And yonder shines Aurora’s harbinger,

At whose approach ghosts, wand’ring here and there,

Troop home to churchyards. Damned spirit all,

That in crossways and floods have burial,

Already to their wormy beds are gone,

For fear lest day should look their shame upon;

They wilfully themselves exil’d from light,

And must for aye consort with black-brow’d night.

Here Shakespeare refers to the burial of murderers and suicides at crossroads and the ‘floods’ in which people had drowned themselves and are left permanently excluded from society even after their deaths. The fear seemed to be that such a terrible act would come back and infect the living. (We will return to this early recognition of the impact of the suicide on others.)

Although we have now done away with these barbaric and superstitious practices, suicide was illegal in the United Kingdom until 1961, and it was still possible to be sent to prison for attempted suicide. Perhaps the law, without realising it, for a long time understood the unconscious intention of suicide. It is noteworthy that attempted suicide is still an offence in Singapore and people may still be sent to jail.

Until the end of the eighteenth century, suicide was seen as a crime against God. In the early nineteenth century this gave way to a model of disease in which suicide was seen either as a disease in itself – a special form of insanity or as a manifestation of a more general mental disorder not to be found in sane persons (Bourdin and Esquirol as cited in Berrios & Porter, 1995). Later, Durkheim (1951) introduced the first sociological perspective in his monumental work Le Suicide, which viewed suicide as a collective phenomenon, influenced by specific factors characterising the society in which it appeared – where social solidarity was strong, there would be little suicide, where it was weak, there would be more.

Modern medicine and psychiatry have studied the epidemiology, genetics and biology of suicide together with the influence of life events both personal and societal; also the impact of various forms of treatment – pharmacological, physical and psychological – on suicidal ideation and behaviour. Each is important but outside the scope of this book. There are excellent and compendious books, often multi-authored (e.g. Hawton & van Heeringen, 2000), which cover those various views of suicide. We restrict our task to a psychoanalytic study of suicide, and recommend Essential Papers on Suicide (1996) by Maltsberger and Goldblatt for those who are interested in the psychoanalytic papers that have influenced our thinking.

As a consequence of their study and treatment of suicidal individuals, psychoanalysts are in a position to extend and also to challenge various assumptions and part-truths that other professionals and laymen have made about suicide. As we hope will become clearer in this book, the psychoanalytic process gives us the opportunity to study in minute detail the many component parts of the self-destructive process, and its waxing and waning control over a person’s life. Psychoanalytic theory has as its cornerstone the concept of the unconscious, which differentiates it from all other theories. It is in the unconscious that the fundamental suicidal fantasies reside; it is the purpose of analysis to make those fantasies conscious and thus more within the person’s control. Obviously psychoanalytic treatment is time consuming and not available to many people, but the insights psychoanalysis provides can be extended and integrated into the management and treatment of any suicidal individual. It is our hope that this book will convince you, the reader, of the usefulness of the psychoanalytic model, both in general mental health settings and in specialist psychotherapy services.

Suicide is commonly held to be part of a depressive state in which the person feels that life is not worth living and that death is preferable. Certainly, sadness and pessimism are often present, but they do not in themselves account for the major drive towards suicide. A second assumption is that suicide is a cry for help. This is a view that may be influenced as much by the professional’s need to help as it is by the patient’s crying out for it. A third assumption is that suicide is a means of manipulating others. Again, this is in part true. A fourth assumption is that suicide can be a solitary or solipsistic act in which the person rationally decides to take leave of life. This has also been referred to as the rational suicide, or the suicide of anomie. Although such acts may occur, they are, in our experience, extremely rare. Each of these assumptions is only partly true, and, if taken as the whole truth, is misleading because they fail to recognise the complexity of the act and the centrality of the violence inherent in the suicidal act.

If a self-destructive act is examined superficially, the patient’s conscious intentions may well confirm one of the popular assumptions about suicide. However, closer scrutiny of unconscious processes reveals the less acceptable face of suicide as an act aimed at destroying the self’s body and tormenting the mind of another. The contradiction between a benign view of suicide and the perception of the act as violent or cruel may be apparent to the observer but is unlikely to be acknowledged by the patient. Usually, aggressive wishes are so unacceptable to the patient that they are relegated to the unconscious by repression. The patient, therefore, continues to deal with the contradiction between his conscious view of the suicide attempt and unconscious wishes by resisting any attempt to bring anger, sadism or aggressive intentions into consciousness.

Ambivalence and contradiction are at the centre of the suicidal act. A patient reported that he had taken 199 aspirins. One had fallen on the floor and he refused to take it because it might have germs on it. It would be potentially dangerous for a clinician to respond only to the patient’s conscious wish to live, that is, to protect himself from germs, and not to pursue the intent behind swallowing the other 199 pills.

In the authors’ opinion, therefore, to identify any self-destructive act as either suicide or parasuicide is both simplistic and incorrect. The most useful term is a suicidal act with the outcome unstated. Our working definition of the suicidal act is the conscious or unconscious intention at the time of the act to kill the self’s body. We are proposing the concept of a split between the self and the body regarded as a separate object. Later, we will contrast this with acts of self-mutilation in which the intention is not to kill but to torture the body.

Although we have not studied the cross-cultural aspects of suicide in any detail, it is our experience that the fundamental dynamics are remarkably constant, although the precipitants and methods will be influenced by cultural and social phenomena. Much of the literature in other books and journals is devoted to this topic, so we will not dwell on it here.

Our purpose, then, is to provide a psychoanalytic view of the purposes, courses and impacts of suicidal acts. Our source material is our clinical experience to which we have sought to give our own theoretical structure, and our goal is to integrate this theory into that of other psychoanalysts. We start, however, by comparing the psychoanalytic view with that of mainstream psychiatry.

References

Anderson, R. (2000). Assessing the risk of self-harm in adolescents: A psychoanalytic perspective. Psychoanalytic Psychotherapy, 14(1), 9–21.

Berrios, G. E. & Porter, R. (1995). A history of clinical psychiatry: The origin and history of psychiatric disorders. New York, NY US: New York University Press.

Durkheim, E. (1951). Le Suicide. New York, NY US: Free Press.

Hawton, K. & van Heeringen, K. (2000). The international handbook of suicide and attempted suicide. New York, NY US: John Wiley & Sons Ltd.

Maltsberger, J. T. & Goldblatt, M. J. (1996). Essential papers on suicide. New York, NY US: New York University Press.

Shakespeare, W. (1914). A midsummer night’s dream. London: Oxford University Press.

Chapter 2

---

Suicide and mental illness

---

In this chapter we want to look at some of the statistics of suicidal behaviour as well as some of the many descriptive profiles of the lives of those who attempt or succeed in suicide.

According to the World Health Organisation (2014), suicide is the eleventh most common form of death worldwide, accounting for about one million deaths per year. Add to this the fact that suicide rates in both US and UK are continuing to rise (particularly in middle-aged men) and the importance of the study of such acts is obvious; all this despite the development of extended suicide prevention programmes. Whether the statistics would have been even worse without these programmes is impossible to say. A recent commentary by Kamerow (2012), written from what would appear to be a very medical perspective, highlights these statistics and concentrates on risk factors and prevention strategies – both very important. What is missing, however, is any concept of an understanding of the suicidal act.

Although many psychiatric texts pay scant attention to the dynamics of suicide, a psychoanalytic book such as this should not diminish, by turn, the importance and usefulness of conventional, psychiatric and descriptive approaches. Unfortunately, professional identities often determine an all too narrow lens through which a suicidal act is viewed – to the detriment of the patient. The organic psychiatrist sees it in medical terms as the result of or as a by-product of an illness, a disturbance of brain biochemistry. The treatment is drugs which correct the imbalance. The sociologist sees it as the result of social pressures relating to economics, culture, religion, ethnicity, social deprivation and disadvantage. The remedy lies in altering, where possible, the social circumstances and pressures that a person is encountering on an individual basis or the disadvantage experienced by a group of people – for example, the loneliness of old age or financial adversity. The cognitive psychologist sees suicide as the result of the individual distorting or misperceiving interpersonal experiences, always giving them a negative connotation. The treatment is cognitive behavioural therapy or dialectical behavioural therapy. As for the psychotherapist or psychoanalyst, it is the dynamic approach set out in this book which we would espouse. Overall we would encourage a multidimensional approach, which attempts to integrate biological, social and psychological theories, since, if they represent part of the truth, they must ultimately be reconcilable. This is a tall order since each of us has chosen a profession or professional identity which makes sense of the world for us and to which we fall back often to the exclusion of other theoretical frameworks.

Let’s look at the contribution of descriptive (organic) psychiatry, which aims to establish the presence or absence of defined mental illnesses on the basis of symptoms experienced by the patient or signs indicated to the observer by their behaviour. The way that these phenomena fluctuate throughout a person’s lifetime is an important part of this assessment. Psychological autopsy, the process of making a retrospective diagnosis by examining all the known facts from whatever sources, has been widely used to establish diagnostic categories for those who kill themselves. The range of figures for individual suicide is high – with the incidence of depressive disorders varying between 37 percent and 90 percent. One wonders whether the diagnosis of depression is in the eye of the beholder. As Braithwaite (2012) observes, in response to Kamerow’s article mentioned above:

As depressive disorder is hugely over diagnosed in life (Aragonès, Piñol & Labad, 2006) what is there to suggest the same is not true in death? Recent prescription of antidepressants to a deceased subject or retrospective reports of insomnia, lethargy an...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• Introduction
• 1 Attitudes about suicide over the ages
• 2 Suicide and mental illness
• 3 Psychoanalytic understanding of suicide
• 4 The Core Complex
• 5 Suicide fantasies and the pre-suicide state of mind
• 6 How learning from the patient generates theory
• 7 The role of the father in the pre-suicide state
• 8 Pre-suicide states in adolescence
• 9 Implications for the professional
• 10 Self-mutilation
• 11 A patient’s account
• 12 Conclusion
• Index