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At the wake following my daughter Mary’s suicide in 1995, a high school teacher said with apparent bewilderment, “But she handed in a paper just last Thursday!”

“It makes no sense,” I said. “Why would she be doing homework if she was planning to do . . . this?”

Another teacher explained that perhaps Mary had been ambivalent to the end, that possibly her resolve to die had wavered along the way. Overwhelmed by the brute fact of her suicide, however, I silently brushed off that theory. My daughter must have carefully planned and then moved directly to her own self-destruction without hesitating. The way I saw it on the night of her wake, the handing in of a school paper was her attempt not to arouse suspicion; that’s all.

But psychologist and clinical researcher Thomas Joiner argues that those contemplating suicide usually are torn between their desire to die and their innate will to live. “The suicidal mind is characterized by ambivalence,” he writes, “with competing forces tugging at the suicidal individual from the sides of both life and death.”

To illustrate, Joiner writes of several people who have gone over Niagra Falls or jumped from the Golden Gate Bridge and survived to tell about it: “One survivor stated, ‘I instantly realized that everything in my life that I’d thought was unfixable was totally fixable–except for having just jumped.’ Another said, ‘My first thought was What the hell did I just do? I don’t want to die.’ ”

According to Joiner, “Those who die by suicide have two simultaneous mental processes unfolding. One is mundane (and yet in a way incredible) and is happening in virtually everyone (including those whose deaths by suicide are impending): ‘Should I change jobs? What will I do this weekend? Should I get a new car?’ . . . The other is far from mundane, and is difficult for most people to even conceive of: ‘Why don’t I just die? It would be a relief. . . . Why don’t I just get it over with?’ ” (Myths About Suicide, Cambridge, MA: Harvard University Press, 2010, 64, 63, 69).

So now I understand a little better how it was possible to be in the same room with Mary hours before her death and not recognize in her behavior the devastation that lay in her thinking. After all, she filled water glasses before dinner, made a witty remark during dinner, and cleaned up the kitchen with her father after dinner. Maybe she was not merely trying to hide her thoughts; maybe she really was wavering between life and death.

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.

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.

When his father died by suicide in 1990, Thomas Joiner was studying for a doctorate in psychology. Thus surrounded by peers and professors adept at understanding the dynamics of the mind, Joiner was demoralized by their lack of empathy toward him in his bereavement.

“Peers and professors ignored my dad’s death altogether. One professor, a psychoanalytically oriented clinical supervisor of mine, was particularly inept and seemed unable to say anything at all in response to my dad’s suicide. He tried to hide his inability behind a psychoanalytic stance of neutral silence, but never was that charade more apparent and more pitiful.”

On the other hand, Joiner found himself moved by the kindness of his Uncle Jim upon meeting him at the airport a few days after the suicide. “[Uncle Jim, my dad’s older brother] must have been heartbroken and incredibly confused about how his very successful little brother could have suddenly died by suicide. He shouldered this shocking burden and put it aside . . . to pay attention to how I was feeling and, in the days following, to how my mom and sisters were feeling.”

What made the difference? Joiner theorizes that his psychology peers and professors needed to “intellectually grasp suicide before they could do anything else . . . and since they couldn’t grasp it intellectually–few can–their otherwise good hearts were hampered.”

Yet, it was exactly his Uncle Jim’s good heart that guided the airport reunion. “Some people don’t require understanding in order to act right,” Joiner states. “They just let compassion take over; that’s what my Uncle Jim did” (Why People Die By Suicide. Cambridge, Mass: Harvard University Press, 2005, 4-5, 3, 5, 3).

When my teenage daughter Mary died by suicide eighteen years ago, everyone who tried to console me seemed to be leading with their good hearts. At no time during the hundreds of emotional funeral home conversations did anyone say they understood what had happened to Mary or pretend that they understood. They knew how to act right by showing compassion, and being with them for even a few hours was one of the high points of my life.

A year or so into grieving for my daughter Mary after her suicide in 1995, my spiritual director, a Roman Catholic Benedictine sister, asked me if I was glad to have had her in my life.

“I’d have to think about that,” I said. At that moment, what I was experiencing was abandonment, rejection, sorrow, shock, horrible memories, and several wrenching emotions that lie too deep for words. Sister Mary Ellen remained neutral as I answered, neither approving nor disapproving. But my reply was a truthful expression of pain, and I was not sorry for providing it. My love for Mary, while never absent, had been eclipsed by the devastation of her suicide.

“Sometimes,” writes Thomas Attig, Past President of the Association for Death Education and Counseling, “there is something horrible associated with the deaths of those we love. Our minds fix on the horror to the virtual exclusion of all the good we hold in memory. We cannot help ourselves–we agonize over the dark emotions the horror arouses.”

To illustrate, Attig quotes from a father in a bereavement group whose son Juan had died by suicide: “At first, I hated what my son did. I hated him for doing it to himself and to me and his mother. . . . It will probably always hurt. . . . I couldn’t get my mind off what he did with that gun. But one day I saw that I hated what he did because he took a life I dearly loved. And I wished he had loved it more.”

In time the man eventually realized how sorry he felt for his son and how much he still wanted to love him. “Only then did it come to me–I could hate what Juan did to end his life but still love Juan. . . . I began to remember all that I loved about Juan, the fun, and how good it was to have him in my life. . . . I think that realization saved my sanity.”

Loosening the grip of horrible suicide memories is, as Attig acknowledges, a real struggle for many. Some find help by attending support groups for the suicide bereaved. However, those who have been traumatized by the “horror [of suicide] witnessed directly or imagined vividly” likely require professional help to “recover the full range of memories of [their] loved ones. Only then can [they] cherish them despite the horror . . .” (The Heart of Grief: Death and the Search for Lasting Love. New York: Oxford University Press, Inc., 2000, 123, 122-3, 124)

“I’m so glad to have had that girl in my life,” Beatle Paul McCartney said when his wife, Linda Eastman, died of cancer in 1998.

When my daughter Mary came into the conversation with Sister Mary Ellen again in 1998, my horrible feelings and memories had loosened to the point where I could honestly borrow from Paul McCartney: “I’m so glad to have had that girl in my life.”

One morning in 2001, six years after my daughter Mary died by intentional overdose, a friend and I were talking in a parking lot. “You need to let go of your kids,” she offered.

My kids at that time were my son, then 27 years old and living at home with a disabling psychiatric illness, and my daughter, then 17 and a high school senior. Of course, there was also Mary, who would have been 23 years old had she survived her overdose.

I was not about to let go of any of them that morning. To me, letting go of the living kids meant allowing them to make their own decisions and mistakes in the belief that somehow they would find their way in the world. But neither of my kids was in a position to find his or her way in the world that day, and so I dismissed my friend’s remark as ill-informed.

Letting go of Mary, for whom I was still yearning, was an equally dismissible idea. More than anything, I wanted to overcome the estrangement between us and have her in my life once again in a good way. Letting go of her? Unthinkable.

The desire not to let go is apparently universal among the bereaved. “I’ve never spoken to anyone who mourns for someone they love who does not want to continue loving them in some way,” writes Thomas Attig, Past President of the Association for Death Education and Counseling.

The question is, how does a bereaved person go about loving someone after he or she has died? According to Attig, the first step is overcoming the mistaken notion that grieving requires a complete letting go of those we love. “There is no reason to let go of the good with the bad [in the person who has died]. The great majority of our closest relationships with family and friends have good in them. Those we mourn lived lives filled with value and meaning” (The Heart of Grief: Death and the Search for Lasting Love. New York: Oxford University Press, 2000, xi, xvi).

When a loved one dies by suicide, it is deeply challenging to retrieve the good, the valuable, and the meaningful in their lives. Those left behind have to deal for years with the ugliness of suicide and its ultimate meaninglessness. But eventually, and not easily, it’s possible to let go of the pain and begin a new relationship with the person who died. It is possible; I think I have Mary back in my life in a good way.

Arnold Toynbee, a British historian of the twentieth century, argued that death is a “dyadic” (or two-person) event in which the survivor bears the heavier burden. “The sting of death is less sharp for the person who dies than it is for the bereaved survivor.” He adds, “There are two parties to the suffering that death inflicts; and, in the apportionment of this suffering, the survivor takes the brunt” (Man’s Concern with Death. New York: McGraw-Hill, 1968, as quoted in Stanley Lesse, M.D., Ed. What We Know About Suicidal Behavior and How to Treat It. Northvale, New Jersey: Jason Aronson Inc., 1988, 60).

While I appreciate Toynbee’s respect for suffering survivors, I can’t help asking, “How do you know? How can you speak with such assurance about the mystery of death?”

Psychologist Edwin Shneidman, who founded the American Association of Suicidology in 1968, also questions Toynbee’s assertion. “For all his wisdom, I believe that Toynbee is indulging unduly in what I would call the romanticization of death. In my view, the larger need is to deromanticize death and suicide.

“Individuals who are actively suicidal suffer–among their burdens (and especially the burden of unbearable anguish)–from a temporary loss of an unromanticized view of death-as-enemy. . . . they have lost sight of the foe: they openly sail with full lights in the hostile night; they smoke and show themselves on combat patrol. . . . They behave in strange, almost traitorous and defecting ways. Whose side are they on? They attempt to rationalize death’s supposed lofty qualities and, what is most difficult to deal with, to romanticize death as the noblest part of dyadic love. . . . Suicidal individuals have been brainwashed–and by their own thoughts” (“The Deromanticization of Death,” What We Know About Suicidal Behavior and How to Treat It. Northvale, New Jersey: Jason Aronson Inc., 1988, 66, 73-4).

My daughter Mary romanticized her suicide. The note she left describes suicide as “darkly mystical,” especially if the person is young and has suffered in silence, which she evidently thought she had done. Perhaps she considered her life a waste and her suicide a favor to family and friends; I’m not sure. But I do know she wasn’t on her own side at the end–hard as it is to conceive–and I imagine it was because of the unbearable anguish, the “psychache” that Edwin Shneidman deems to be the usual cause of suicide.

Over the months, I’ve noticed that some are led to this blog through an online search for words of comfort for those grieving a suicide. The sincerity of that search is beyond question. But when my teenage daughter Mary died by suicide some eighteen years ago, my response to well meant verbal comfort was usually silence accompanied by this thought: “Nothing you can say will make me feel better.”

I was wrong about that. There are words of comfort that would have helped. They just require know-how and practice. “For many of us,” writes Val Walker in The Art of Comforting, the most difficult way to offer comfort is face-to-face—just sitting quietly and talking with someone in distress. In these intimate moments, we can get so hung up on trying to use the ‘right’ words that we lose track of what it is we really want to say.”

Walker advises thinking ahead about the larger message of comfort we wish to convey. Here are examples of a larger message: “I’m here for you, I’m available, I care.” There’s also, “I’m listening, I’m following you, I’m with you” as well as, “I’m feeling some of what you’re feeling, I’m not going to judge you, I’d like to offer my support with something specific.”

We need to prepare our larger message, Walker says, so that we don’t default to the platitudes we’ve heard all our lives. “Our words can distance us from others, especially if they express that we think we know ‘what is best’ for them. Devastated people in the first weeks . . . of a loss or trauma can feel unheard, invalidated, or ‘preached at’ by well-intended teachings and words of wisdom.”

So what might a loving friend, family member, or acquaintance say to someone bereaved by suicide? First, among the “be strong” platitudes to be avoided is this: “God doesn’t give you any more than you can handle.” It can be replaced with, “It sounds like this is really hard.”

A “be positive” platitude such as “Something good will come out of this” can give way to, “It sounds as though it’s impossible to see what’s ahead.”

“Be faithful” platitudes such as, “Keep up the faith,” “This was part of God’s will,” and “God works in mysterious ways,” were, in my experience, particularly alienating. Someone who wants to comfort a grieving person should put them to rest and use life-giving statements instead. “I’m thinking of [and praying for] you every day,” “I hope things get easier for you,” and “I can offer my help,” are responses that soothe and draw a grieving person closer (The Art of Comforting: What to Say and Do for People in Distress. New York: Jeremy Tarcher, 2010, 107, 109, 110, 111, 112).

Knowing Mary

After my daughter Mary died by intentional overdose nearly eighteen years ago, I was jolted by the realization that I hadn’t known her at all. I hadn’t known the high school senior I’d eaten with and talked to every day, for if I had known Mary, I believed I would have recognized her fears, her sadness, and her suicidal thinking and acted to protect her.

Just the same, “People can only know the observable behavior of another person,” write clinical scholars John Jordan and John McIntosh on the topic of suicide bereavement. They add that unless a person verbally or nonverbally expresses what is really going on inside, no one else can know it.

“Human beings are capable of masking their inner thoughts and feelings,” they state, “while outwardly acting in ways that can be quite incongruent with their internal state. . . . This existential ‘separateness’ of the inner consciousness of each of us from others is the foundation for the psychological boundary between self and others. . . . It is also the condition that allows suicide to happen in a way that people who ‘know’ the deceased may be utterly stunned by the act” (Grief After Suicide: Understanding the Consequences and Caring for the Survivors. New York: Routledge, 2011, 253).

My daughter did not express what was going on inside her until it was too late. Only in her suicide note did she reveal sadness at not fitting in with her friends and a sense of personal weakness that she despised. She wrote that she’d not been silent about her suffering and doubted anyone would be surprised by her suicide. Those comments bewildered me. She had been silent, and we were all horribly surprised.

But I was also off-base about something else: I had known Mary, at least on a heart level. I had daily experienced a depth in her that was open to love and capable of love, and I’d seen life-giving values arising out of that depth.

While it’s taken years, I finally realize how inaccurately Mary’s final act reflects who she was and still is. She was not her mental illness and suicide. She is someone I know and someone I love knowing.

In a May, 2013, press release, the Centers for Disease Control and Prevention announced that in recent years, the number of annual suicide deaths in the United States has surpassed the number of people dying yearly in automobile accidents. In 2010, for example, 33,687 people died by automobile and 38,364 by suicide.

“Suicide is a tragedy that is far too common,” says CDC Director Tom Frieden, M.D. “[We] . . . need to expand our knowledge of risk factors so we can build on prevention programs. . .” (www.cdc.gov/media/releases/2013/p0502-suicide-rates.html)

Fortunately, Harvard psychologist Matthew Nock is attempting to do just that. In 2003, Nock and a colleague began developing a series of tests they consider potentially capable of detecting suicide risk. The tests are modeled on the Implicit Association Test originated in the late 1990s which uses word associations to reveal biases about race, sexuality, gender and age that people either don’t wish to acknowledge or cannot even recognize in themselves.

In short, Nock and his Harvard colleague have devised a series of tests to measure a person’s bias for and against being alive or dead. On a computer screen, “life” and “me” appear on one side and “death” and “not me” on the other. A person is asked to rapidly categorize a series of words such as “thrive,” “breathing,” and “funeral,” under one of those headings. Though complex in the execution, the tests basically detect how quickly a person identifies with either “life” or “death.” Hesitation in responding to the “life” heading, for example, might signal an association with dying that reveals a risk factor for suicide.

“Doctors of all kinds, including psychologists, do no better than pure chance at predicting who will attempt suicide and who won’t” writes Kim Tingley in a recent article in The New York Times. “Their patients often lie about their feelings to avoid hospitalization. Many also appear to mislead by accident, not realizing they are a risk to themselves or realizing but not knowing how so say so.” (www.nytimes.com/2013/06/30/magazine/the-suicide-detective.html)

Along with the hope Nock’s system brings to the worrisome field of suicide prevention, it brings deeper appreciation of my daughter Mary who died by suicide in 1995 at the age of 17. Several months before her death, Mary’s psychiatrist asked her whether she was thinking about suicide and heard, “No, I would never do that.” But maybe Mary wasn’t simply lying; maybe she didn’t recognize her risk or know how to talk about it.