A psychodynamic perspective on suicide can help us all reckon more honestly with the interconnectedness of psychic pain
In many societies today, thinking around suicide is mostly compassionate, and rightly so. There’s widespread acceptance that a person who seeks to end their own life must be suffering desperately. However, what this well-intentioned focus on the individual misses is that suicide does not only reflect a crisis point of one person’s suffering. Rarely acknowledged is that suicide is also an act of terrific violence – against the victim’s body and against those around them.
To find the body of a loved one who has taken their own life is deeply and irreversibly disturbing. The suicidal person knows this, and so if we – the relatives, friends and mental health professionals – are to develop a fuller understanding of how to support a suicidal person, we must attempt to reckon honestly with the powerful relationship dynamics that are operating within, and around, the suicidal person, leading them to act with such violence towards themselves and those who will be affected by their death.
Engaging in this reckoning is incredibly challenging. The closer you get to the frightening emotional reality of suicide, the more your mind tries to defend itself. To encounter a suicidal person is to come into contact not only with death, but also with deep suffering and emotional pain – pain that you can’t help but identify with in some way. I’m not suggesting that everyone will experience suicidality, but that we all experience psychic pain and, when we’re unable to resolve this pain within ourselves, we are all vulnerable to acting out that pain in and through others. This is why responses to suicide can be as much about the onlooker – whose mind is desperately trying to distance itself from any recognisable element of a suicidal state – as it is about the suicidal individual.
As a clinical psychologist working with suicidal patients, I’ve experienced first-hand how difficult it can be to hear about the trauma, the loss and the intense self-loathing that often accompanies a person who is feeling suicidal. In the therapy room, my mind may try to wander away from their distress, turning the discussion towards the parts of their life they enjoy – their so called ‘protective factors’ – as mental health professionals are often taught to do. Or I might otherwise feel tempted to try to reduce my patient’s experience, to convince myself that the situation is not so serious because they seem to demonstrate ‘futuristic thinking’ (that is, they’re able to talk about the future, which is usually taken as an indication that there is less of an immediate risk) or because of I’ve noticed some other possibly tenuous hopeful sign.
While these conversations focused on the positives have merit and may help the suicidal patient to remain connected to those parts of themselves that want to continue living, I am sure that another function is to help the therapist reduce his or her own anxiety. But at what cost? Will I leave enough space for my patient’s distress, their anger or their disappointments?
I am torn between conflicting aims of listening to the patient to support them through their pain, versus seizing control of them
Suicide is a kind of last bastion of control for people who have had little control over what has happened to them in life. Expressions of suicidality are, in part, an attempt to garner, and gain control over, the care that the patient (knowingly or not) longs to receive. My professional response to this is important, and there are often institutional procedures and protocols for ‘managing’ risk that can inadvertently miss the patient’s need. Any mention of suicidal intentions can trigger a sequence of important questions or actions that are intended to prevent the patient acting on those intentions. In a moment, a therapy session can move from a space for the patient to be understood – to process, to grieve, to take back some control – into a space where, suddenly, their last bastion is arrested. My task as a therapist is also arrested, and I am torn between conflicting aims of listening to the patient to support them through their pain, versus seizing control of them.
The factors that contribute to a person feeling suicidal are numerous and complex, but there will usually be a history of terrific adversity, loss, trauma or abuse. Even where there are no obvious signs of these adversities, the patient will inevitably have experienced growing up in an environment where their unique personhood was ignored – or they felt it was. Those deeply important elements of ‘good enough’ care – upon which one’s sense of self is grown – were likely absent. Without a safe outlet for the powerful emotional effects of these experiences, the devastating result is that the patient’s mind begins to turn its distress inwards and the body becomes a vessel for it.
In killing the body, the fantasy for the patient is that their suffering may also die – as if there is a part of them that will continue to live, but without the suffering. The upsetting reality, which the mind ultimately denies, is that this is not true. All that death gives is death, and in my role as therapist I believe it is crucial that I convey this reality.
When a suicidal act results in death, the suffering is pushed outwards like an explosion, felt most immediately by those who care. In the wake of a death, those very feelings that drove the patient to suicide are experienced by their loved ones and by the professionals who were tasked with looking after them. There’s something tremendously functional about this exchange, as if the patient’s unconscious is inflicting the pain that they have suffered back onto their primary caregivers, or indeed the substitute figures such as loved ones, friends or healthcare professionals.
The violence of the suicide reverberates throughout the system, and clinicians hope their records reflect that they are not responsible for the death
For those caught in the blast, feelings of intense guilt, regret, anger, confusion and denial are commonplace. I’m surprised how often I hear ‘I wish [the patient] would have just said what they were going through so that they could have been helped’ – a comment laced with guilt, and perhaps the wish that the outcome could have been controlled if only something were different.
In healthcare settings, reactions of this kind are experienced throughout the entire system. Friends and family of the deceased might deny their own sense of responsibility, seeking answers from outside of themselves by taking aim at the mental health service who ‘failed’ to keep their loved one alive. The service – accountable to a jury of the public and to its commissioners – must provide an account of why the suicide was allowed to happen. The violence of the suicide reverberates throughout the system, and clinicians – whose professional integrity may be examined – hope anxiously that their records reflect that they are not responsible for the death. Whether responsibility is attributed or not, clinicians must reckon with their own personal devastation that their task of ‘helping’ people has been apparently unsuccessful.
Around the world, there are organisations whose existence is premised upon the omnipotent ideological fantasy that ‘zero suicide’ is an achievable target – many of them are members of the UK-based charity Zero Suicide Alliance. This is a seductive promise that’s difficult to argue with because, after all, no suicide feels acceptable. But I wonder if the idea of ‘zero suicide’ is another manifestation of the same denial and longing for control that reside deeply within the patient. These movements are arguably in denial of the pain that the patient is acting upon and communicating with their body, and in denial of the control that would ultimately be required to save every one of them.
The difficult reality for those supporting a suicidal person is that the solution is not straightforward. The interpersonal milieu surrounding someone who is suicidal will be fraught with projections, in which the patient projects their own feelings outwards onto others. This psychoanalytic idea comes from object relations theory, which proposes that we see others not as they are, but as we are. In other words, our early experiences of care shape the way we later experience the care offered (or not) by others. Consistent with this perspective, the suicidal person will often experience the people caring for them – albeit often unconsciously – as if they are the ones who contributed to their distress.
As a society, something we can take from this is to consider the ways in which each of us is inclined to deny the painful parts of our experiences: the disappointments, the wounds or the traumas that have caused us suffering and for which we feel understandable anger. These experiences connect us all, and I believe we need a cultural shift that recognises anger and despair are acceptable and often understandable. A wider cultural shift of this kind would mean fewer individuals feeling a need to turn their anger inwards, where the body becomes the vehicle, and those closest becoming the target.
When it comes to supporting suicidal individuals, I believe a vital message for everyone involved is to learn to listen more carefully, as the psychoanalysts Donald Campbell and Rob Hale argue in more detail in their book Working in the Dark (2017). This means really listening to the patient’s story and resisting the temptation to deny the reality of the pain that they have endured. It means listening to the nature of the patient’s relationships and accepting that suicide is very rarely an individual act, but one that is meaningfully connected to those around them. Listening not only to what the suicidal person says, but also to what they do not say, or to what their behaviour and suicidal fantasies might communicate. Also, listening to the pain experienced by those in contact with a suicidal person, who are tasked with ‘helping’ or ‘preventing’ suicide.
Last but not least, it means listening to our own unconscious: to our reactions, our honest feelings about ourselves, our resistance to or denial of pain – and, when necessary, acknowledging our own need to access support, to help us think clearly when confronted with the weight of these realities. A more honest relationship with the parts of ourselves that we find painful is important because we take all of ourselves everywhere, knowingly, or not.
