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Archive for October, 2013

Even after eighteen years, the thought of my daughter Mary’s suicide can shock me. It isn’t that I’m not used to her absence, because I am. What continues to shock is that my teenage daughter arrived at a moment in her life when she was capable of lethal self-injury and seemed proud of it. Just after swallowing several dozen antidepressant pills, she wrote in her suicide note, “For once, I’ve done something decisive.”

I finally understand about suicidal “psychache” and its roots in perceived burdensomness and failed belongingness (see October 10, 2013 post). After many years, I accept those responses to the “why” question that haunts all of us who are left in the wake of suicide.

What I’ve had a harder time dealing with is the how: “How on earth did my gentle
daughter ever bring herself to destroy her own healthy body?” That’s the question that floats just beneath awareness only to surface occasionally with a jolt of anger and disbelief.

However, in the past several years, psychologist and clinical researcher Thomas Joiner has provided an insight about the “how” of suicide which goes some distance in explaining Mary’s final act: her acquired ability for serious self-harm. “My view [of suicidal behavior] involves habituation, or getting used to the fear and pain involved in self-injury,” Joiner writes. “This . . . leads to an acquired ability for serious suicidality, which, when combined with burdensomeness and disconnection produces high risk for suicide.”

Far from being an act of bumbling cowardice, suicide requires a certain kind of competence and courage, according to Joiner. “How does one get used to and become competent and courageous regarding suicide? In a word, practice. People who have hurt themselves (especially intentionally but also accidentally), who know how to work a gun, who have investigated the toxic and lethal properties of an overdose drug, who have practiced tying nooses, and who can look someone in the eye and show resolve about following through with suicide, are viewed here [in Joiner’s theoretical framework] as at substantial risk for suicide” (Why People Die By Suicide, Cambridge, MA: Harvard University Press, 2005, 40, 50-1).

With Mary, there was an arm-cutting incident nine months before her death that raised substantial fear in her father and me and brought psychiatric intervention. There was the moment Mary was seen looking through Physicians’ Desk Reference to learn, I think, about the toxic properties of her andipressasant medication. There was the moment at dinner a few hours before her overdose that she looked me in the eye for an instant. There was sadness in her eyes, but also, I now see, undeniable resolve.

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On the topic of psychological pain that underlies most suicides, the late Edwin Shneidman wrote: “In almost every case, suicide is caused by pain, a certain kind of pain–psychological pain, which I call psychache.”

In Shneidman’s view, the root of psychache is thwarted psychological needs, some of which are the need for achievement, affiliation, autonomy, deference, nurturance, order, play, shame-avoidance, succorance, and understanding (The Suicidal Mind, New York: Oxford University Press, 1996, 4, 20).

Within the last decade, another researcher, Thomas Joiner, has begun to refine Shneidman’s concept of psychache. “I believe that Shneidman’s answer [regarding the cause of psychache] is too general, because most of us identify with one or more of these thwarted needs from time to time. What in particular . . . are people feeling psychache about?”

For background: Shneidman was a psychologist and pioneer in the study of suicide. He was a professor at the UCLA School of Medicine and founded the American Association of Suicidology in 1968. Joiner, whose father died by suicide in 1990, is a psychology professor and clinical researcher at Florida State University.

To the question of what exactly causes psychache, Joiner answers, “Perceived burdensomeness and failed belongingness.”

“People who are contemplating suicide perceive themselves as a burden, and perceive that this state is permanent and stable, with death as a solution to the problem.” Helping them requires pointing out how mistaken their perceptions are.

As for failed belongingness, Joiner notes that the human need to belong is fundamental. “The fact that those who die by suicide experience isolation and withdrawal before their deaths is among the clearest in all the literature on suicide.”

To illustrate, Joiner cites the example of a man in his thirties whose suicide note was found in his apartment: ” ‘I’m going to walk to the bridge. If one person smiles at me on the way, I will not jump’ ” (Why People Die By Suicide, Cambridge, Mass: Harvard University Press, 2005, 37-8, 38, 98, 122, 120).

In 1995, my teenage daughter Mary left a suicide note which spoke of her sense of failed belongingness: “I say hello to kids in the hall at school, but that’s about where it ends. I don’t know why they’re laughing or why anyone would want to laugh. I am so alone.” I did not grasp the depth of my daughter’s sense of isolation, and even if I had grasped it, I doubt I would have recognized its danger.

I have also wondered over the years whether Mary perceived herself to be a burden to her family. There was no indication of it in her suicide note, and I’m glad for that, because she was the last person ever to be a burden. Still, Joiner’s reevaluation of psychache provides at least a partial answer to the enduring question of why.

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