Leaving Psychiatry Chapter 10; Thanatology

On Suicide and Private Property.

Le suicide. Edouard Manet. 1877.

"They tell us that Suicide is the greatest piece of Cowardice… That Suicide is wrong; when it is quite obvious that there is nothing in this world to which every man has a more unassailable title than to his own life and person."

Arthur Schopenhauer

"When suicide is out of fashion we conclude that none but madmen destroy themselves; and all the efforts of courage appear chimerical to dastardly minds ... Nevertheless, how many instances are there, well attested, of men, in every other respect perfectly discreet, who, without remorse, rage, or despair, have quitted life for no other reason than because it was a burden to them, and have died with more composure than they lived?"

David Hume

Preface April 2023

A warning. The current chapter deals with a distressing theme. My approach might superficially seem callous or commit the greatest of liberal sins, i.e. be perceived as “judgmental”. That said it issues from both a place of great care and great experience. Though this be madness, there is method in it.

Thanatology, written sometime mid 2019

Camus is credited with having thought suicide to be the “only one really serious philosophical problem” Well he would say that. So convinced he was that existence was absurd, that the question was whether to take flight into superstition and myth or let go of existence altogether. I’m not sure I agree it is the philosophical problem. Perhaps as an atheist he wanted the world to be absurd. Then he could cast off the shackles of religion, his superego and all attendant moral injunctions. Then he could conduct his affairs with moral impunity, his own sin projected out into the world as its “mood of absurdity”. But if his bleak diagnosis is transcendent with all in all, how can it be defeated by death? Or how can he transcend it by death? Even a revolt against absurdity must surely be infused with absurdity itself. Annihilation is not a victory. In the very act of escape one ceases to be. The whole puzzle is full of contradictions, but worse still contains a certain arrogance. For the one who might suicide (I will use the word “suist” and justify the choice later), there is often a pessimism almost optimistic in its certitude of what suicide will deliver as the better of all possible futures. Claiming to understand the world as transcendently meaningless or claiming to know the future will be worse than today is a very bold claim. How can they claim such grand knowledge? A far bleaker picture is to deny myself suicide precisely because I cannot know the answers. Might humility and hope be the twin curses holding us back from suicide? Pessimism is optimism and hope is a curse. Or might there be better reasons for living? Perhaps we are cursed with curiosity.

Nonetheless I’ll pause from criticizing Camus. In fairness there is much to the man and his thought that is commendable. When one looks at psychiatry’s conception of suicide, it evidences a kind of absurdity that may lead one to even despair and a want to exit if not from the existence, at least then to exit from psychiatry. Why? Well, for all the critique we may level at Camus, credit is his due. For it ought not be lost on us that he placed suicide in the correct categories, i.e. a philosophical problem.  Not biological, not medical, not social even, but existential and individual. To the extent the state and law becomes involved it is also legal and political. To the extent to which it is a moral act, it is also subsumed back into philosophy at least, if not a/theology also. But medical? Don’t be absurd.

A younger version of myself should have not made the naïve assumption psychiatry would see suicide for what it is, or at least for what it isn’t. Or at least I should have known psychiatry would not care to ask deeply the questions Camus raised. Back many moons ago, before entering the church of psychiatry and when fishing around for a PhD project, I happened upon a conversation with someone who was working on, as they phrased it, the “genetic basis of suicide”. “How strange” I thought. I politely did not voice my scepticism aloud as they fervently described their project with the enthusiasm of one who had just begun a PhD, as opposed to labouring to write the doctoral thesis at the end. I had a background in formally studying genetics and none at the time in psychology and the humanities. Like many a science major, a younger version of myself erroneously heaped scorn on philosophy and all its “isms”. But even then it seemed immediately obvious, a priori obvious, that a suicide is a behaviour of one living in a web of psychological relationships with self and the world, a choice made by a free agent, however hastily and ill considered, and however for or against the grain of surrounding opinion. It had never crossed my mind that had Sophocles lived in the genetic age he might have figured into the plot the Oedipus family (so to speak) having a faulty gene predisposing it to suicide. It would have seemed mad to suggest a counterfactual history might have seen the samurai or religious martyrs recruit based on genetic testing as to their proclivity towards their own death (by proxy). Or perhaps Sophocles would have ceded to scientism, with humanity all the worse for it. I’m not a genetic denialist. Sure, what might possibly be found is a genetic proclivity towards alcoholism as a very common contextual factor in suicide, though this is a far cry from determinism. Or what might be found is a genetic proclivity to impulsively or other features of personality that may be correlated with an increased risk of suicide. Even these variables seemed many degrees of diluted separation from the act itself. They are thoroughly divorced from the context of say, the suicide from unrequited love, the act made poignantly sweet from sad songs before the blood runs warm and the body and the bathwater goes cold. All this is to say, the old nature and nurture ledger within scientism simply won’t do. I have seen countless attempts after working on the front line in emergency department psychiatry for longer than almost any other psychiatric doctor I know. It is not correct to say genes are the first determinative step on a chain of causation. They are the smallest of drops in a larger ocean of multiple co-determinants. I might as well have asked this scientistic geneticist what gene (or second order epigenetic mechanism, for genes aren’t the whole story), as a meaningful explanatory datum, determined their choice of career as a geneticist? And not just a geneticist, but which gene determined her gross reductive medicalization of suicide, the interest in this specific project? Or what gene determined the band she listened to on the radio in the lab today or the postcard of that tropical island she placed above the PCR machine? All this too would have been absurd, were it not also horrifying. For at the ends of every attempt at genetic over-determinism is eugenics. And if not eugenics, at least a drive towards social engineering, a want to “save” people from their genes, the genes of others, and from any notion of free will and personal responsibility. Such appeals to compassion and saving people drive the funding for the gene hunt in the first place, for the love of money and career directs the thoughts that attract it, and thought creates money in turn. This kind of reductionist ground is also revealed in psychiatric practice. There is the belief lithium salts and clozapine have, in addition to manifold other effects, a specific and independent biological anti-suicidal effect. How? Do these medications act upon the suicide receptor or suicide brain circuit? What nonsense! However much orthodox psychiatry might speak of the so called biopsychosocial model or person centred care, make no mistake it is driven to consider suicide a medical illness, the act being an epiphenomena of events occurring in the brain informed by events in the environment. The whole language game is geared in that direction with “triggers” to suicide, “what made you take the overdose” etc. Such reductive nonsense is lubricated by metaphor also, for the cells that comprise the body can commit “cell suicide”, otherwise known as apoptosis (for those of the academic lineage of Sir John Kerr the second “p” is silent, apoptosis being, etymologically a metaphor for the falling leaves of Autumn). Here’s a few examples. At certain stages of development cells may involute and die, the resultant being that we can have separated fingers as opposed to a webbed paddle of a hand. Or a cancerous cell may “commit suicide” after damage from radiotherapy, providing the cell has retained the “program” and capacity to “decide” on suicide as an act of cellular civic consciousness, much like the heroic character in the zombie film who kills themselves while they still can and before they turn into the walking dead. The reader will see in one cellular phenomena I’ve made appeal to multiple metaphors, of conscious deliberation and decision, of computation in the cell having the program, of telos in the ends to development, of sacrifice for the common good in cancer, of changes in the weather in the word “apoptosis”, and so on. I once made a joke, unfortunately seriously taken, about writing a paper arguing that suicide of the person was just an evolutionarily upscaling of cellular suicide. Yet cells do not commit suicide. This is a metaphor. People do.

If we bookend my career from that conversation to the present day, we now have a “Camusian” despair at the absurdity of the zero-suicide movement sweeping the psychiatric world. Very much framed in corporate newspeak, if one peruses the website of the likes of zerosuicide.org as the largest of several international organizations, you will see it populated psychiatric doctors and psychologists rebranding themselves as “thought leaders”, “re-designers” (pray tell of what?), “educators”, “movers”, “top influencers” and (my favourite) “full scalers”. Whilst it’s organization and language are nauseatingly corporate (without the tax burden of course, why not add “monetizers” to the list?), it’s goal is totalitarian, hence the aspirational name to drop the suicide body count to zero. The only way to even countenance such an aspiration is either

-to be open to bio-political totalitarian control and abolition of individual autonomy,

-and/or a drive to change the very substance of the human condition on a crypto-Orwellian scale (full scaling?),

-and/or to have an absolute wanton ignorance of the history of suicide to have embarked on the project in the first place.

The zero suicide movement also seeks to craft the way in which the mental health clinician and populace speaks of suicide, in turn to craft the way they think about suicide. It aspires to abolish language such as “killing yourself”, “successful suicide”, “committing suicide” or “taking your life” for fear that this makes a statement about personal agency, or moral judgment or value or goal directedness. Suicide is like a seizure, something that happens to someone unless saved by the hero psychiatrist.

Its 2015 International declaration opens with the statement that, on average, there is a death from suicide every 40 seconds. This is reminiscent of a distant past when I could recall the preacher standing aside the pulpit clicking his fingers at the rate at which souls enter hell. He wanted to save souls also, and what horrors he could have done with a slick website and the powers of the state at his side to deprive liberty of Faust of deciding his own fate. Yet another example that the powers are not separated. The state replaced the church with psychiatry and forced the church to the margins.

It continues, this being current at the time of writing of this chapter and representative of the zeitgeist of 2019

“Suicide is a complex, multifaceted biological, sociological, psychological, and societal problem with few resources for prevention. As a major global health problem, it is estimated that it will contribute more than 2% to the global burden of disease by 2020. Suicide imposes a huge unrecognized and unmeasured economic global hardship in terms of potential years of life lost (YPLL), medical costs incurred, and work time lost by mourners.”

They had to mention the money didn’t they, as economic concerns drive the funding for burgeoning industry. There is no model offered to integrate and give meaning to the four contributors to complexity, two of which (sociological and societal) sound so similar as to be arguably synonymous. Perhaps we could say sociological, societal and social just to increase the word count and appear more erudite? We then ought to add the word “socialist” also? Reading a book is also all these four things in being biological (requiring vision and the biomechanics of page turning), psychological (motivation to read etc), social (the economics, supply, and marketing of the book within the social milieu) and so much more. These words are empty of explanation of what it is for you to read this particular book and this particular time. Reading a book can be simple or complex depending on one’s point of view, as can everything else for that matter. And so complexity can be everything and nothing. Appeals to “complexity” is code for an elite intelligentsia claiming they are the only ones to understand the phenomena to which the word “complexity” is attached. Putting that aside for now, the zero-suicide movement (and yes in places it explicitly invokes the word “movement”) also explicitly makes suicide a disease, hence I imagine the need in turn for the social “redesigners” of this suicide industry to counter those naysayers who might seek to dissolve it back to the individual with liberty making their own choices in the world.

I ask the reader to keep in mind those three things, i.e. a) zero aspiration, b) the power of psychiatry underwritten by the state to deprive suicidal persons of their liberty and c) viewing suicide as a complex “disease” the likes that only the psychiatric intelligentsia can understand (or if not a disease all its own, the manifestation of a psychopathology or mental illness all the same). Contra this apogee of the new psychiatry, let’s look at some typical cases from history and my own experience. Let’s look at what psychiatry might have done, or did indeed do. Of each historical/mythological case of suicide, if any psychiatrist is even aware of them, this was most certainly not the result of psychiatric training. To each case I challenge you to formulate the goodness of fit between the zero suicide ideology and the reality of the human condition. Hopefully I can start to dislodge you from what might be the conviction that suicide is a dreadful epidemic that must be stopped at all costs, as opposed to a tragedy to be grieved. We shall see.

Suicidality in the mythology of antiquity was not a representation of historical events in time. Nevertheless, mythology reflects human concerns, the way they are managed and the way the author might have suggested they are best managed. Though we be neither Gods nor kings, mythology is, in its way, stories about us in a time before it was contaminated by psychiatry. One can look back at the works attributed to Hypocrites and find mention of mania and melancholia not as descriptors of so called psychiatric mood disorders a la DSM so much as instead descriptors of noisy and quiet delirium in severe physical illness. That small piece of trivia is a digression, but an important one corrosive to the notion that psychiatry looks back and discovers diseases misdiagnosed or unknown at the time. Similarly, if one looks at, for example, the latinized Fabularum Liber (Book of Fables), by Hyginus one will find suicides aplenty in the literature of ancient Greece. Yet within these plots will not be placed anything equating with alleged major depressive disorder, bipolar disorder, schizophrenia or any other so called mental illness for that matter. Some few dozen in number, the protagonists of ancient tales took their lives for reasons of great pathos, not psycho-pathology. From Antigone to Themisto and everyone in between (including in Sophocles renditions most of the house of Laius), they killed themselves out of pride, shame, lost or unrequited love, vanity, social disconnectedness, all the well-worn themes of human drama in literature as in life.

The list is hardly restricted to the fictional. Here is but a tiny elaboration on our already tiny sample. Cato suicided as a political protest, as have countless others up to the current age (I’m thinking for example of self- immolating monks of southeast Asia). Antony and Cleopatra suicided in a drama that presages and partially resembles the tale of Romeo and Juliet. Kalanos suicided rather than live as an elderly invalid, as has countless others for the same reason down to the present day. I have lost count of the number of times I have been called to the bedside of an old person who wishes to die for no other reason but age and infirmary or on account of intractable pain. “But they are suicidal…”, says the physician as if this one terrifying word dissolves all humanity and good sense into the inhuman void of psychiatry. The savy physician might wish to deny what the patient says and invent hidden reasons. They appeal to a gnostic argument, that they might have “masked depression” driving their want to die. The use of the word “masked” is to say they are depressed even whilst not claiming to be depressed, merely claiming they want to die. To the physician who insists a mask is being worn, no pulling at the face will convince them it is not there. Or another example. When a patient states “but for the fact I’m in pain I would not be suicidal..” this is a call first, second and third for the psychiatrist. When I politely suggest to the physician they may wish look at the pain, I’m met with a dumb look of perplexity. “But what about their mental illness” is the attitude. They will acknowledge their place in treating the pain yet demand I treat the suicide. The patient and what they say has vanished now. All that remains are two doctors battling over a fiction. 

Returning to the history lesson, Judas suicided after a radical confrontation with his sin. How many Samurai suicided out of honour, indeed even as a natural expression of their commitment to Zen and an ever readiness for death that could only ever be fully actualized by meeting death at the hand of their own blade, if not also the blade of a comrade. Even the enemy is their comrade in bringing them into a confrontation with their meaning in death. And so, no one is really an enemy. We have all heard of Socrates, who accepted the hemlock for no other reason than to be true to himself to the end. Insomuch as he might have been allowed to escape Athens and his death sentence yet chose not to, his was a case that places martyrdom within a conceptual spectrum where homicide and suicide become blurred (though in my opinion this would be an error). Then there are group suicides, as in Masada and a couple millennia later in Russian/Ukrainian villages as the Reich closed in, and some German villages suiciding later as a red army sought vengeance for some twenty million of their own dead. Then there are terrorist murder suicides, perhaps with Samson being the first. The list is so long as to paint psychiatry thick with embarrassment, were they not either ignorant of history or hell bent to interpret all these cases as undiagnosed mental illness… if only they could? Dilettante or philistine. That is the differential diagnosis we might write in the margins to the patient is “name; psychiatry”. Ancient sources also put paid to the notion that limiting access to means can limit the behaviour of suicide. Ajax had his sword and so fell on it. Females usually didn’t have a sword handy. So they find a cliff, a river or a rope instead. Making loved ones the custodians of the medication and putting the kitchen knives up high might limit the access to means for those who impulsively reach for an aid to self-killing. This is common sense and good advice. But for those determined to do it, antiquity proved that where the spirit is willing, the flesh shall follow. People committed to the goal of self-murder will find a way. This is a truism that the suicidologists will say is a myth.

An emblematic case from my own experience

There I was sitting amongst colleagues discussing the suicide of the patient from another treating team. If pressed, all would admit that suicide is nigh on impossible to predict and the tenor of the meeting was the usual political babble of a working “culture of no blame”. Despite our inability to predict, the incoherent purpose of the meeting was to transport ourselves back in time and try anyway. As such it was from the beginning an illogical exercise in vanity. Anyway, we were there to discuss what we might have done differently to see the suicide coming and prevent it. The case was of a man who killed himself. His tale of woe began after moving from a war torn almost lawless place where gun attacks were common, to a place where they were exceedingly rare. And here he moved, in part to the furtherance of his safety. Against all the odds, here in a safe country he suffered severe injury at the hands of an idiot with a gun. It was a reckless act, though not an intentional attack. Following the shooting he would have many painful surgeries. The shooter evaded justice on a technicality, and so the patient took to drinking and arming himself, not with a plan of revenge as opposed to simply feeling safe. Unfortunately, his gun was not legally owned and so he was the one facing charges, along with multiple surgeries. Now one way to formulate the case is in terms of “major depressive disorder”, “medication” required to treat it, the suggestion of “house calls to review his mental state” and “psychiatric admissions” to “contain the risk” of suicide. This was the talk of psychiatry. This was all they could, and did, say. What was obvious however was that here was a man made a victim of fate and the blackly ironic humour of the world. Moved from a place of war. Shot in a place of safety. Prosecuted when the real criminal walks free. His body was injured and injured badly. Where could he perceive a quantum of good in the world? And what made life more painful? Was it the injury, the injustice or perhaps even the medicalisation further victimizing him? In any case he ended it. Where is the place of medicine here, or the state except as a further source of taking the man’s freedom away and saying there was something wrong with him? Would psychiatry have the gall to prevent him to choose his end as he did? They would if they could.

Or take the case of the young woman brought into hospital by police (plural) after threatening to throw herself on the railroad tracks. That’s three police policing suicide. That’s three less police policing crime, and not her crime either, for such patients are mentally ill don’t you know, and so no charges are laid for public nuisance etcetera (laying charges incurs paperwork and ought to be avoided as a strained judiciary will do nothing anyway). Her behaviour was very dramatic and potentially lethal, only a fool would deny. Yet she had been assessed only hours before in the same emergency department for the same behaviour and discharged. Now with me and within ear shot of one of the police officers she clearly stated, inter alia, that she made the threats with the express intent of worrying her mother and not to end her life (her intent to worry succeeding in spades). Not wanting to reward bad behaviour, I discharged her also, and kindly requested of the police that they not return her thrice. “But she’s suicidal” came the reply, as they spoke as if the word evokes in them an animalistic reflex to act, completely divesting themselves of their common sense. We agreed to disagree on what constitutes common sense. We did reach an understanding of what they would do as pure vehicles of “following orders”. If she repeated her threats they would return her for assessment every six hours for the term of her natural life, and every 6 hours I would discharge her. There are countless other patients besides in similar situations. Patient number one is brought into the emergency department with threat to suicide, and engages in argument with another already there for the same reason. The first threatens to kill the second. I ask the police if they will prosecute the threat that their own ears have born witness to. The police answer being they cannot as no crime is committed. A threat to kill another incurs no penalty. A threat to kill oneself involves a deprivation of liberty and takes at least two to four police officers off the beat.

How did suicide become medicalized? I would not be so bold as to suggest that 17th and 18th century England was the first place and time, yet it certainly was an early place and time, and one of the nuclei around which the anlage of Anglo psychiatry could collect and construct itself. If one reads, for example, Blackstones “Commentaries on the Laws of England”, suicide was correctly seen as a crime against the self, a felo de se. In the case of completed suicide, the indictment hardly can be met with any defence against the charge. The accused is there hanging by the noose and can say nothing in their own defence. And so the dead are declared guilty and needs some kind of punishment. In England of Blackstone’s time a suicide, qua a crime was met often by harsh fines and asset seizures that the estate of the departed were forced to pay. The dead being dead, the poor family was left to foot the bill. This is to say the poor family were effectively the ones punished by the crime of the suist, and with no recourse to escape from the fine. And the penalty was not just with coin and assets. The loved one also faced an ignoble burial and the family face social shame. How does one escape all this miscarriage of justice where the family is punished for the crime of the departed? The escape was the construction of the insanity defence, defended by family with the accused dead and in absentia. If the departed could be posthumously proven to be insane, certain forgiveness may be possible, both in terms of financial penalty and social stigma. It made no sense of course, for the family cannot of necessity be guilty for another’s crime against themselves (and God). Much harm to truth could have been averted had the government not been as greedy. The argument and reforms were more about financial exploitation by the state than in good faith concern over the morality of suicide. Nothing much has changed.

But enough of mythology, history and personal experience of what might be called rational suicidality. More on rationality later. After all, what lessons from a few thousand years of humanity have to bestow upon us of today? Anyway, you might assume emergency psychiatric departments are nowadays filled with persons who have taken leave of reason and their senses, the ostensive insanity being from no fault of their own of course, and which may carry them into the arms of death, in extensio, as part of the “mental illness”. This, or you may think the emergency department is filled with suicidal persons who are involuntarily driven to wanting death on account of some gravely melancholic depressive “disease” that takes over their person and renders them completely unable to see any good in the world. To encounter such a rare melancholic patient is to encounter a psycho-physiological abyss. Such cases are far from being the norm however, proof being in how psychiatry reacts to them. I have long witnessed in colleagues the paradoxically pleasant surprise they experience when encountering a truly depressed person to whom their heart reaches out spontaneously, a person for whom they need not make a deliberate attempt to quell the “negative counter-transference”, [where counter-transference is now nothing more than a euphemism for disliking the patient and failing to sympathize with their plight. We must not take too harsh a view of what is often (self) ascribed to be negative counter-transference, as it is often an aide to diagnosis. Moreover, when one points the finger at others, as the saying goes, one points a few fingers back at oneself. This is to say that the one who passes judgment on the negative counter-transference of the mental health practitioner are themselves exercising a negative countertransference of a kind, this time against the practitioner, and guilty of the same judgmental sin they see in the other. The splinter in my brothers eye, the forest growing out of my own....]

Returning to the point, the assumption most suists in emergency departments are deeply melancholic is incorrect. Apart from the procession of psychotic and dysphoric methamphetamine and cannabis users, emergency psychiatric departments fill on a daily basis with individuals who profess to be suicidal on account of the passions and problems of daily living. Often these problems are only opaquely acknowledged or disavowed as the cause, as even patients want to be diagnosed and treated. Often an infantilism in personality within the context of stressors also heavily contributes to the cause (personality vulnerabilities about which they are often determined to be unaware). Their plight is often the likes of which a friend of mine once remarked “we in Africa have real problems whereas you in your world need invent problems for entertainment”.

Take for example the adolescent girl who passionately hated her stepfather. He had been banished for a time by the mother though soon to return as mother and stepfather were involved in talks to reconcile. If you are a psychoanalyst, you might speculate correctly the hate was held with a tinge of love and a want not to be abandoned again. On the other hand, the love for mother was with a measure of hate, for she drove him away the first time. For the reader who would be latter day witch hunters the answer is no, there was not an inkling of a suggestion that he had sexually abused the girl as an attribution for her suicidality. To a hammer everything is a nail. But in the real world not everything is a nail. Nor is everything sexual abuse. In any case, her mother wanted the father figure restored front and centre in the family circle. The mother demanded the daughter bend her knee so to speak, and respect the man who would be king. This was a demand to which the daughter responded, almost literally, that such an acquiescence would be over her dead body. And so she threatened suicide. And so she was brought for psychiatric assessment and treatment.  She had of course the set criterion for diagnosis of a major depressive disorder, for such criteria are exceedingly easy to meet. She was “depressed”, sullen and not engaged with her usual hobbies, as frivolity and leisure are seldom befitting the occasion in times of domestic warfare. She was excessively sleeping, a behaviour for which even she had excellent insight was an act of escape. She was not interested so much in eating with the family either. Why would she? Then there were the suicidal threats, another criterion in the checklist towards the diagnosis a la DSM 5 of a major depressive episode. She doubted that she would win her war and doubted her future to be a happy one (hopelessness, another tick box criterion of major depression). To me it was clear. The whole pseudo-depressive symptomatic set cried “protest” and she fought with a very powerful weapon. Perhaps her only weapon, she would instil fear in her mother, making her suicidality a sado-masochistic act. Yet to those around me, from the mother aghast at my formulation to the emergency staff and the psychiatric machine, this was illness that demanded treatment. None would heed my simple anti-prescription that there is not a pill in the world that will change the situation. Apart from a) the stepfather exiting the stage, the only remedy was for b) the mothers stubborn will to break and give in to the daughter, or c) the daughters will bend to the mother. And my strategically feigned perplexity that anyone expect otherwise fell on deaf ears. Certainly, an SSRI was prescribed by the psychiatrist who came after. It dulled the girls emotions a tad, and changed nothing else.

Or take the almost endless march of young men, often burley, muscled, with tattoos often up to (and sometimes now sometimes unfortunately within) their eye balls. These are the kind that you’d feel intimidated if you pass them in the street and some are professional thugs. But when their sweetheart ends the affair these alpha males are reduced to a blubbering suicidal mess. On occasion the now ex sweetheart attends the scene with him, delivering a mixed message in the very fact of her presence. The diagnosis is break up of relationship. And yet both will then look doe eyed awaiting the magic of the psychiatrist, as she will tell the blubbering mess that he is here to “get the help” he “needs” to stop him being “made to kill himself”. Once again all and sundry assume a medication will be involved, including hospital staff. They assume I will, nay I should, have an answer in the form of a diagnosis and so on. Once again I am the secular priest who sanctifies them as diseased. But why? And what is this “help” she says he will receive? What is the diagnosis? She has left him, for the moment anyway. In her oscillation between love object and mother object, now she is playing mum. Either she a) changes her mind and takes him back, or b) he reconciles with the reality of her choice and moves on. It really is that simple. I could dull the anxieties in his mind with drugs probably more safely than the illicit drug dealer or bartender down the street. This is easy and I did prescribe something. I could give him some words from Epictetus, with psychiatry not to thank for the stoic wisdom they have only partially plagiarized (and not the better part at that). But psychiatry doesn’t have anything special to offer outside of ritual, authority and a rebranding of much that has come before. The pangs of lost or unrequited love are not the pain of a disease. The real sickness is in the want to medicalise. The real sickness is in those who think its appropriate the person (re-branded patient) is even in the emergency department.

Suicidality often also mirrors the case of the misuse of domestic violence or restraining orders, a sadomasochistic weapon in the battles between (and within) the sexes, between parent and child or between neighbour and neighbour. If you report me to the police for assault, I’ll report you to the police. After all, false allegations like many sins and indeed many crimes, attract no consequences. If you proclaim your emotional pain and seek to distress me by crying suicide then I will do the same. Psychiatry serves to sanctify both claims. Each competing to be the victim, they each want me to pronounce judgment on their enemy as “making them suicidal”.  The problem is that in the race to the bottom of responsibility, who will win the prize? 

We in psychiatry can make of the boy who cried wolf a boy facing a real wolf with real teeth. That is our authority in the village. We can easily be accomplices to bad behaviour en route to breeding personality disorders using suicidality as a semiotic weapon. Thankfully I never started counting what would become innumerable cases of revenge suicidality in threat or gesture. And then there are the variant consequents of other bad behaviour. For example, there’s the case of the suicidal older adolescent girl who sent risqué photos to a male she barely knew, only to have him circulate the files amongst the peer group. The following evening that same male was in the emergency department, suicidal out of fear that the girl’s older brothers would teach him a lesson out of school. What is to be my diagnosis? “Adjustment disorder” or “poetic justice”? The whole kindergarten circus keeps playing on. The best way to start an epidemic of suicidal threats in a school is to parachute in a charismatic little wuthering heights dying swan espousing the virtue of suicide as she cuts herself. Then stir the social pot. Others will start cutting in turn, all catching “mental illness” and leading teachers to fetishize the same. Make no mistake, suicidality is semiotic. It’s a social idiom and a contagious one at that. Yet not every contagion is a disease, and no social idiom is the stuff of medicine unless the doctor steps across the social and political divide and makes it so.

Or take the alcohol abusers. This cohort probably dwarfs all others. They are brought into the emergency department drunk and suicidal. They probably won’t remember anything of the previous evening when they reach sobriety in the cold light of the next morning, amnesia to suicidal ideation inclusive. Yet still the spectre of suicide hangs in the air. They made the threat or performed the gesture. Once again, the expectation is often placed on the psychiatrist that he/she then continue look for the occult suicidality hiding deep within our previously intoxicated patient. We are expected cure them and follow them up for days with laborious safety plans. This is especially the case if the presentations are recurrent or the suicide attempts are near misses. Yet the answer to pseudo-complexity is once again simple. When beer is in, brains are out. To drink is to court a suicidal drive again, and to depress the mood over the longer term. To drink or not to drink. That is the question when applied to suicidality in this case. The patient knows it. The psychiatrist knows it. Everyone knows it. It has always been thus. Why is this the stuff of medicine?

Or take the borderline personality cohort. These women (and very often hysterical young men, over diagnosis in women being a form of soft chauvinism) often have had incredibly unpleasant upbringings. They often suffer not so pleasant current life circumstances also. I spoke something of these patients in the second chapter, in asserting the non-existence of type II bipolar disorder except as a model within which the psychiatrist may work to medicalize especially dramatic personality disorders, and from which to justify the prescription of domesticating medications. In the embodied mind of the borderline patient is an emptiness, a parent or other who is missing and a void that never enduringly filled, and usually is never temporarily filled but by distress. For these patients their lives are in perpetual chaos and the suicidal ideation is often never far from their mind. It is not unusual they come to see the hospital as a kind of giant mother object, each nurse another muscle or sinew who holds them in a warm embrace for as long as the admission lasts. Of course the problem is that no admission lasts forever. And there is no evidence, not in my experience nor in that of the literature, that hospital admission does more good than harm. It fails to put the slightest dent in the psychopathology whilst indeed infantilising the patient even further. And so at the stroke of midnight they appear, in crisis and in undeniable psychological pain, with an addiction to admission made stronger from each admission they receive. Usually a well-intentioned psychologist or family member has told them they simply must present to the hospital, that they need admission and it will surely be granted. Promises made can always be made by those who have no part in the delivery. The vehicle by which the patient gets what they want, undeniably a drive often sincerely felt, is nonetheless amplified by what they know will be others response to it. That vehicle is largely culturally specific. In some non-western countries the embodied distress and emptiness may be expressed as body aches and pains with barely a mention of the want to die. In my world, and probably the readers also, the vehicle by which the distress is communicated is suicidality. With the “S” word comes the inevitable battle of wills. In one corner an emotionally dysregulated and psychologically damaged child trapped in an adult’s body. In the other, the mental health clinician who wishes either to preserve the resource of the hospital against the interests of the patient or admit them as quick as possible so as to bring the interaction to a prompt close. One protagonist is playing the game to be admitted and the other (the psychiatrist) to avoid granting the same. The first might even deny the desire to be admitted whilst advertising the suicidality that will ensure it happens. Consequently they lie to themselves and to others “I hate hospital and don’t want to come in but if you don’t admit me I’ll kill myself, and no other option will suffice so you must admit me. You must!”. The situation is like the proverbial child who, in wishing a piece of candy and the parent denying them the wish, the child may threaten the hold their breath. A most rare and resolute child may even make good with the threat, hold their breath and pass out (or so I’m told as I’ve never observed this myself). Now no child is Palemon and neither parent nor child is Ondine. Before long the physiological drives inevitably overcome to restore breathing and no child dies from breath holding. Just as well. For the futility of the threat enables the strong parent to stand their ground, refuse the child the candy and win the day. More than a battle of wills and more to the point, the wellbeing of the child is won because the parent demonstrates resoluteness to principle. This paves the way to crafting the child into a better adult from forcing them develop delayed gratification.

Scale up the risks and the stakes and we have a similar situation in the emergency department. “If you do not admit me, I will kill myself and the blood is on your hands” is often the explicit statement, and often the subtext. Only this time the patient is liable to mean business. The game is now in play, and with it the move to externalize blame and responsibility. Now I know what you are thinking. They are simply communicating their awareness of vulnerability and a fear of what might follow. No different to the patient with chest pain and possible heart attack is afraid of discharge until appropriate investigation and treatment runs its course, they genuinely are afraid of that part of themselves they cannot control. Such an analogy would be misplaced. On one hand, heart attacks are, more or less, completely beyond the control of personal choice. How we approach the suicidal patient either acknowledges choice or undermines it at every turn. It is these high stakes therapeutic encounters that can make or break forever the possibility we ever take their own choices to be choices. On the other hand, after hundreds (or thousands) of encounters one develops the intuitions of when words are used to communicate feared facts as the patient sees them, and words used as stratagems on the other. From the changing dynamic one may ask where narcissism and anti-sociality ends and borderline personality (or the child in an adult body) begins. The candy prohibited child is playing on its parent’s fears. The patient is playing on the psychiatrist’s fears and a shared knowledge there can be severe repercussions if a suicide is not prevented. Unfortunately, psychiatrists for the most part practice in a state of perpetual castration. They fail to take the risks required, treating their own fears at the expense of what they secretly know to be true.  

Don’t misunderstand me. Once again, the psychological turmoil of these poor souls is not to be denied. However just as any parent must aspire not to be simply the friend of their child, and certainly not an extension of the child’s hand, any parent or physician qua parent object needs remember their role is to do what is best. What is best is not always what the patient thinks or feels is best. And it is certainly not to do what one is coerced to do by another. By the same token, not every soul who says it is tortured is tortured in fact. Sometimes the most raging of waves sit above the shallowest of reefs. I have had the patients who, when incidentally asked, will say that they had a good time on leave from the ward for a morning excursion. When asked to describe the events of the morning, their thoughts and feelings, what is reported back is overwhelmingly positive. “So then…”, I say with a sense of the opening to a shared celebration, “…..it seems you have reached a readiness to leave us”. The reply then is, if they wish it to be, that such is not possible. I’m told that if discharged, they will surely kill themselves. They realise the previous move in the game was a bad one. The narrative then changes to all the awfulness that was the morning, this to legitimize what they want me to believe unto the ends they desire. Yet there is, in all of these exchanges, the unspoken conversation. Both of us give the small slight smiles at just the right times to acknowledge the second move is well played, that she/he is playing the move on what s/he perceives is my fear of suicide. And stay on in the ward they usually do until they grow bored with the world inside and curious about the world outside. They are cured only by their caprice, this being part of what ails them. Sometimes fate delivers me a strong card to play. Many a time I have encountered a very suicidal patient who has decided not to be suicidal when I show them the ward list (identities of patient’s names covered). Here I prove all beds are occupied. I am not being selfish you see. I really cannot grant them their wish. The best I can do is allow them to languish in an emergency department for a few days. When they see I am caring, honest and not rejecting them so much as us both being a victim of finite resources, i.e. when they see that Mummy and Daddy have their hands full and really cannot drop tools for the metaphorical hug that is the hospital admission, then many of these adult children change the narrative from “I will surely kill myself if let go” to “well I’ll just have to go home and live on until a bed is available”. But if one can survive a day without being in hospital, then why not a second, and a third, and so on? Contrast this with the patient who has had a bone broken or a heart attack. The consequences from lack of action lay outside the choices of the patient involved.

Now if reading this, many a psychiatrist reader will have the heckles raised. They will recall those unusual times they did discharge a patient who vowed to kill themselves if politely shown the door. My question to them would be why is this an unusual memory? Contra propaganda, the fact is that suicide is a rare event. Far more than any casino the odds are on the side of the house (i.e. psychiatry). Most patients will not attempt to end their life, much less succeed, no matter how great their threats. Granted there have been many hanging attempts which have come my way, only saved by the branch breaking or the loved one who unexpectedly came home early. Yet there are also many more patients about whom it is said they have had several hanging attempts. Each one was made only when the suist could see the paramedics coming through the door. That or each time the most breakable branch was deliberately chosen. And I have seen countless patients for whom it is said they tried to jump off the cliff or building several times, miraculously pulled back every time. Apparently they don’t make tall places like they used to. And though certain diagnoses are said to inflate the risks of suicide (e.g. bipolar disorder a 20-40 fold risk vs the population norm), when viewed through the lens of the actuary this is a very low risk indeed in the here and now (e.g. if the baseline suicide rate is 10/100,000 persons per year, then a 20-40 fold figure of 200-400/100,000 persons per year equates to a greater than 99% chance of survival within the given year). Ergo, psychiatrists can afford to bet on what courage they have, and ought to place the bet far more often than they do. I’ve seen allegedly courageous psychiatrists also. But they don’t exercise courage typically. And never ever have I seen them hold their ground to the bitter end when the would be suist digs in and ups the ante. I have seen teams of psychiatrists sign documents on the eternal futility of hospital admissions for a given patient, even its counter-productivity. They all sign on the line that this patient is not to be admitted. But when the newspaper writes the damaging article or the patient climbs a high place and demands their time inside, the clinicians all lose their nerve and fold their hand. Never is there the attempt to withhold admission out of any principle of granting the patient a radical responsibility and radical freedom come what may.

If a suicide does come to crash into the orbit of a psychiatrist’s career, whatever small courageous creature that did reside within is evicted. They then return to being agents of the therapeutic state, very unlikely to say no to a patient who would insist they say yes. Even patients presenting with marginal risks who do not wish to come in are involuntarily admitted. Who can blame the frightened psychiatrist, accustomed to placing pragmatism over principal? Most are biological determinists who never believed in personal responsibility anyway. Neither did their superiors (we all have superiors) or the whole psychiatric machine. They likely were only able to occasionally argue the case of forced discharge after observing “no pervasive mood disorder” or “no psychotic disorder”, a direct appeal to the DSM to legitimise action in informing risks, this being the book they otherwise state is “just a guideline”. Most only comfortably practice when they perceive themselves to be part of a collective opinion, the mentality of the herd. When a suicide does occur the fingers of responsibility are not pointed at the one who exercised autonomy to end their own life, often accidentally after a threat or gesture gone too far too fast or when too intoxicated. No the fingers are pointed at the practitioner who let them loose to do it. Finger pointing has consequences despite always buried in the politically correct newspeak of smiling assassins, a culture of “no blame”, of “incident analysis”, of “quality improvement” and so on. Despite a career of taking the risks almost all others shied away from, I never had the suicide. Consequently, I never faced the inquisition of having my practice interrogated. Good intuition or good management? Or perhaps just good luck? I have had colleagues not so fortunate. When the inquisitors say this isn’t about you, then you know you’re on trial.
 

You may say “yes but these are selectively chosen cases dramatic people, added to cases from history and mythology with little relevance to the here and now”. Am I perhaps implying we ignore all suicidal threats and gestures, even judging them all as bad behaviour”? What about the “real” mental illness such as major depressive illness or psychosis as earlier alluded to? Are there not any who are melancholic with the “disease” of depression, this in turn feeding their thoughts with irresistible temptation to suicide, driving in turn their behaviour to shuffle off the mortal coil as the only way to escape the pain? Are there not also those whose voices tell them to kill themselves, with suicide being behavioural manifestation of the schizophrenic disease? Besides, ought not even those persons with infantile or dramatic personalities be given the protections of the state, perchance that they avoid the misadventures that stand between who they are in the present and who they might become in the future? Am I not being terribly cruel, sadistically cruel, in suggesting we deliver these victims into the clutches of a mental illnesses that will kill them by their own hand? Am I not even projecting out my own sense of therapeutic nihilism after too many times hearing the same old threats?

To this I have several retorts, all the while informed by the cases I have seen, along with a plea to ethical clarity and the bigger picture.

Let us first consider the turn towards the zero-suicide ideology as a replacement for what came before, which was risk assessment with a view to prediction of risk and treatment accordingly (coercive treatment included). Current practice in psychiatry is finally coming to the grudging realization that its crystal ball was useless, along with hierarchies of low, medium and high risk of suicide as similarly useless (years after I and many others realized the same). No matter how severe the mental illness and how loud are the threats, it is impossible to predict whether the attempt will even be made until it is made, if it is made. In absolute terms it remains a rare event. Yet they try resurrecting the faith in prediction by a subtle reframing from prediction to prevention. We cannot know the future they say, but we can manipulate the circumstances creating the future. The question is, if a variable is unhelpful in prediction, how can its manipulation be helpful in prevention? There is a certain common-sense appeal that the smoker who quits has a reduced chance of developing lung cancer. Similarly, there is common sense appeal that the alcoholic who goes sober has a decreased risk of suicide. Yet the game we are playing is not an actuarial one of large numbers. The smoker who ceases might develop lung cancer anyway, though on first principles we are confident cessation reduces their chances. Why? Because non smoking never causes the cancer and their lungs are an isolated system of risk. On the other hand, the alcoholic who becomes sober might suicide because they are sober. The patient who threatens suicide might have their meagre resilience weakened in the act of being admitted and their risk increased. Admitting one suicidal patient sends out social signals informing and changing whole society wide risks. In any case, the game is not an actuarial one. It is moral, legal and social. If I cannot predict if you will suicide, I cannot claim to know changing something about you will prevent it. I cannot then lay claim to justify depriving you of liberty save you from yourself. The turn from prediction to prevention is a cynical rebranding of the prediction calculus whilst looking to the same variables as if enlivened with new potential to see into the future.

Next, it is not piggish pedantry to note that the zero-suicide ideology has made of suicide per se a disease, a public health problem, and an event in the world to which we must aspire to have eradicated (i.e., not the behaviour of a rational agent). They effectively equate a suicidal person with a malarial mosquito or an aquifer poisoned with cholera. If its goal was zero irrational suicide this might be acceptable, though I would then ask how the zero-suicide movement can discern the rational from the irrational. They fail before they begin in denying there to be these two basic categories and lumping all suicides together as a health problem. Such colossal ignorance cannot be excused and may even be deliberate. Perhaps they pretend the question does not exist, hoping we will all be similarly ignorant. To some, there is forever and always sound reason not to suicide, from which may be concluded all suicide is a priori and always irrational and/or immoral, depending on how the argument is formulated. For example, most, but not all, readings of Kant would have us arrive at this conclusion. Kant might say that our bodies, as Gods property, are not our own property. Consequently, we categorically do not have the right to abuse another’s property, most especially when its owner is the author of the rulebook. Insomuch as the physical body is the vehicle within which moral life and duty is made possible, only under extraordinary circumstances where the grave corruption of the moral life is certain and imminent might we be permitted to end the life of the physical body. This is represented in film. The hero is bitten by a zombie. He suicides to avoid turning into the same. Our moral sensibilities resonate with the justness of the act. At least we can take a bow to Kant for having approached the question and to have formulated an answer as a moral one. Can we say his answer is correct? Maybe yes and maybe no. Who is to judge. It is an entirely different question if another individual or state ought to assume to know the answer and intervene.

Kants argument was mostly theoretical. There are those who believe suicide is a sequelae of a disease rendering the diseased body or psyche so tortured as to leave them no other choice. Take the archetypal example; the cancer ridden patient with intractable pain who shan’t survive long anyway. If so, the Epicurian or Utilitarian avoidance of pain is exceedingly rational. Should we presume to know the moral answer to the problem and intervene to prevent them killing themselves? But this is physical illness. What of those in various kinds of psychological pain? What if they are of the belief psychiatry has nothing to offer and they decline offers made. Whether a) the utilitarian basis of the belief upon which one acts is correct or not, b) whether it be morally sound and c) whether the state ought to intervene to prevent (or facilitate it) suicide are d) entirely different questions. It is rational to avoid emotional pain and maximize collective utility. And suicide is, rationally speaking, a way of avoiding pain for the individual and a way of reducing collective burden on the other. Personally, I’m disposed to the belief utilitarianism is monstrous on one hand and on the other that Kant is too austere and autistic. No matter though, and utilitarianism can argue for or against anything. These as questions psychiatry is ill equipped to answer so as to claim it can intervene.  

Then there are those radical materialists who believe suicide is the direct outcome of a psychological disease, only the psychological self shares identity with the brain. If true, then to speak of some behaviour being irrational is a category error projected upon the suist from another (meta) irrational agent. There cannot be rationality in purely physical systems, only two brains pumping salts and other chemicals around and doing what brains do, one brain interacting with the other via stimulus and response. Only minds and mental phenomena can potentially be rational. Minds can have rational understandings of diseases, of brains and of moral speculations. Yet diseases and brains themselves cannot be rational. And if everything is material then nothing is truly rational. It is simply what it is. As it so happens most of psychiatry is wedded to either the notion of mind brain identity (leaving rationality without sense, and what is lacking sense is non-sense). That or it deals with the functional sequelae of what is assumed to be brain disease, the suicidal act or attempt itself. Avoiding problematic assumptions does not make them go away.  

You see it is not so easy to locate, define and argue the rational vs the irrational suicide. Such a notion is entangled with deep philosophical assumptions and problems. The praxis of use of these words has little to do with rationality anyway even when they are used. We ought to look at the use of the term “rational suicide”, as perhaps emerging from a) an empathy or emotional understandability with the decision to suicide, and/or b) a word that is proxy for arguing, or being on the road to arguing, the political permissibility of suicide in the given case, i.e., when not prevent or condemn people who want to kill themselves. But what is empathic or politically expedient or informed by ideology is not necessarily an exercise in reason. Rational or irrational? The words are not rationally used. Consequently, the problem here is a want for clarity and honesty. Words ought to best reflect what is the case.

Once again, the onus is on the practitioner, zero suicide ideologues included, to defend both their formulations of suicide and their motivation to prevent it. Just being a robot to process or dogma given them is not good enough. This is but a taste of the depth to which the question might reach, and ought to reach, before anyone can even begin a claim to knowledge and before anyone can judge another’s formulation of what suicidality is or is not in moral terms. Certainly this is a question that ought to be asked and dialectically defended before anyone can have the audacity to intervene in what is the relationship between an individual and their own bodies (or the body God has conditionally loaned them). It is not callousness to recognize that what is yours is not mine. Nor do I have the licence to be Kant’s God over the bodies of his creation. Those who wish to ride roughshod over the person to prevent their suicide have simply decided as a fait accompli that the suist is always a victim needing saving. I disagree.

Rationality and irrationality aside, if the goal were a tighter fit for psychiatry, e.g. “zero depression” (business of psychiatry) and not zero suicide (not the business of psychiatry), this might be arguably the ground for practice. On the road to zero depression, we may or may not see the prevalence of suicide fall. But then the zero-suicide movement would cease to be, replaced instead by the zero-depression movement. The question then to ask is what the depression is as a medical matter, as opposed to a time of low mood (unpleasant though not the stuff of medicine). Where do we draw the line? Is it even rationally possible? Why ought we try to eradicate low mood?  Does low mood never serve any salutary purpose? Are low moods, even very low mood, reason enough to deprive persons of liberty? These are very difficult questions. I would argue “clinical depression” to be almost entirely a social construct, the boundary between it and garden variety low mood being necessarily arbitrary. What would the “zero depression” movement do? They would first medicalize low mood. Second they would justify depriving a person of their freedom on account of symptoms of depression, chiefly suicide risk. In so doing they would smuggle in the zero suicide ideology and place suicide centre stage once again. Depression is not a disease with suicidal ideas and the suicide attempt as its respective symptoms and signs. This is scientistic nonsense. Suicide is a choice that someone freely makes within many contexts, mood state included. It makes little difference to say that person X or person Y later enjoyed an improvement in mood thanked us for intervening to prevent them doing what they threatened in the past. Changing one’s mind logically does not prove the existence of a disease. Nor does it justify our coercion? If we prevented someone from voting for a party they later decided was the worst option, would we be justified in depriving them of democracy? If so, we can always prevent them voting until they provide us with the correct answer of where they intend cast their ballot. Change of mind be an explained on many axes to be sure, least of which would be the remission of a disease.

As for voices, delusions, and such, these are addressed in the previous chapter on psychosis. Suffice to say, voices and other so called psychotic phenomena are not the alien happenings they are commonly thought to be. Hearing voices commanding us to kill ourselves too sits upon a spectrum within which distinguishing the normal from the “pathological” is incredibly problematic, not the least given that such distinctions are again necessarily (and empirically) arbitrary. Voices of course cannot always be ignored or escaped. Auditory hallucinations sometimes follow the sufferer around like an annoying shadow. To the extent to which a patient exercises choice to take neuroleptic medication, these can often curb the voices if s/he wishes. If they decline the offer, they choose the voice. They can also entertain the hypothesis that the voices may be a product of their own mind as part of an inner dialogue. To the extent they cannot be curbed, voices need never be obeyed. Those of us who only hear the voices of flesh and blood people (i.e. persons who actually exist and stand before us) know this choice to be self-evidently true. To the extent to which a voice cannot be curbed and a person’s decision is to end their life rather than listen to it, this too is a choice, however tragic it may be. If suicide is not disease or even a symptom, then it ought not be a variable that over-informs what we do as clinicians. Suicide is not some way in which depression or schizophrenia is expressed through, as it were, the person with the person dissolving away as if they never had agency. To say it is a symptom, sign, public health issue etc are misplays of metaphor. Suicide is a choice a person makes, informed of course by their mood and many factors besides, yet not determined by it.

Next in the defence of the charge of cruelty and indifference that might be arraigned against me, we must examine the potential for unintended consequences. The rule of unintended consequences makes fools of us all, cruel as well as kind. Only the wise might have a hope of avoiding them. Elsewhere in this chapter I have alluded to the fact that suicidality varies cross culturally according to the emphasis placed upon it. It is a social idiom of distress as much as personal choice. And there is simply no denying that social idioms are necessarily contagions and gather strength by the response they engender in others. Taking bona fide objective medicine as the metaphor, were there to be an outbreak of severe influenza the likes of which occurred a century ago this would objectively be very contagious. Physicians would mount immediate responses. Hospitals would have detailed protocols. Histories would be taken from patients with the ear tuned to certain significant aspects of history, symptoms reported, and signs observed. The amplified responses of the physician reflect the amplified nature of the threat, both becoming known to the community. We would have, so to speak, influenza consciousness.

Now when we have

a) psychological or physical distress and insecurity, e.g. the lonely old person, the wounded child within, the homeless person looking for shelter, the patient in chronic pain for whom inadequate analgesia is being provided etcetera all looking for recognition and

b) the physician is looking for something and happens to focus a la mode’ upon a particular social idiom or representation of distress such as suicidality and

c) the psychiatrist is crytpo-egoistically looking to be the saviour of the person as an object afflicted with a serious disease beyond the persons power to heal themselves, i.e. to be a real doctor,

then we have the ingredients of

d) the emergence of an economy of transactions including expressions of distress such as suicide at far greater levels than would naturally be the case. These expressions are not just found to be expressed as in the physician discovering something already within nature and heretofore underdiagnosed. No, such excursions of psychiatry into the world of suicidality leads to suicidality entering into the mind of the patient more than it otherwise would in the first place and with a greater intensity and frequency. The psychiatrist literally acts in this metaphor as some mad scientist inventing a more virulent strain of flu then becoming the vector of transmission. Psychiatry breeds the suicidality it then seeks to cure.

In the above paragraph I refer to suicidal thoughts sincerely held. Insomuch as the mental world is not an objectively observable thing in the sense of which psychopathology is of a different category to physical pathology, we also must admit to the politically incorrect truism of the human condition. What is this truism? People can and do lie! Indeed they lie with such a great prevalence that pathological lying (i.e. pseudologia fantastica) is to date not part of the DSM, though factitious disorder is and is underdiagnosed. Why lie about suicidal thoughts and lie about history of past attempts? The answer has already been provided. Expressions from which more intense care responses follow are naturally more likely to be used by the malingerer and amplified by those who do have some degree of suicidal ideation. Remember the example of psychosis and Rosenhan’s experiment in the previous chapter “Sanity”. Outside of having made an unambiguously near fatal attempt, how can the psychiatrist know when suicidal ideation expressed is suicidal ideation sincerely held and when it is not? How can psychiatrists know what the potential suist wants to get out of the disclosure? Psychiatrists and all manner of false mentalists want to believe they can know. They want you to believe they know also. But wanting, believing and knowing are three entirely different things. For the psychiatrist who a) remains a true believer in the sincerity of most if not all suicidal threats and b) believes in their own power and necessity to treat the underlying “mental illness” I propose c) a thought experiment. Here it is. Imagine the patient who has an established history of multiple threats and/or attempts. Their mental illness made the do it and might immanently make them do it again. They get to choose either psychiatric care as currently provided them or a 7 day stay at a luxury resort every couple months when they feel suicidal, this without possibility of extension, accumulation or transfer (this will be less expensive than standard psychiatric care). I predict such an option may be taken up in droves, the participants reliably become suicidal so as to avail themselves of the resort and more likely to survive so as to use it in future. A tiny fraction of these whom the psychiatrist would be utterly unable to identity in advance will end their lives, just as there will be those who take their lives and never announce an intent to anyone.

Next, we must consider the subtle dynamics in the exchange between the psychiatrist and the patient. These are the dynamics I have witnessed again and again with mental health practitioners of all stripes, along with police and emergency services, mental health phone lines etcetera. Our superficial selves may believe we are the pure vehicle of compassion when we focus on suicide. They would take great umbrage if I were to suggest they are cruller than me in my apparent callousness. Allow me to cut through this apparent contradiction and explain. With such a great focus on suicidality as we have, and such great consequences in terms of responsibility placed upon the practitioner to save the patient from acts of their own hand, what inevitably follows is that suicidality itself becomes the object of therapy. The patient as person recedes distantly into the background. There is a world of difference between approaching a person in crisis where the beneficial outcome might be that they decide not to kill themselves, vs the approach that we treat the suicidality (as primary therapeutic object) through talking to the person about their problems. The person becomes nothing more than a vehicle through which the objective is achieved. Once again mine is the voice of experience. I know what clinicians care about by their behaviour and the dominant themes in their speech. This is quite different to what they claim to care about and why they claim to care. Suicidality is a monster that has been elevated to such a great height by psychiatry and the whole social milieu that all else is just political lip service and moral posturing. Moreover, the matter is deeper than a direly needed turn towards a direct engagement with the person. Such a revolutionary act is impossible unless and until we heroically place suicide in the background. No. The sub-textual layers become deeper still, for the psychiatrist and other mental health clinicians (and services) are driven not simply by suicidality itself as the primary therapeutic object. I have earlier stated that the goal of psychiatry is also self-preservation and defence of guild interests. They are also driven by the preservation of themselves as the practitioner who does not have a suicide on their hands, the avoidance of questioning of their capability as a practitioner, and even the preservation of their career. The focus on preventing suicide appearance of being salvific to the patient, when its purpose is the prevention of a homicide to the practitioners narcissism and career. Placing suicide back into the hands of the person themselves is one of the greatest acts of respect and love we can give another. It recognizes qualities we have or ought to have within ourselves, i.e. free will and personal responsibility without which we are not really adult humans. These are not discovered but declared.

In a final irony, to defend against the charge of cruelty, I need to become crueller still. After the suicide of a loved one may ask “why”? Significant others usually ask this question, and well they should. But what they don’t realise is that they are not simply asking why their loved one decided on death. No, they are also asking the necessary complement to this question, i.e. why did he/she let go of life? What they are therefore asking is the significance of life in general. Even as they live on in their mourning, the event brings them within the orbit of enquiring about the significance of their own lives. This is existentially confronting stuff. A life affirming answer can only be found and expressed affectively and ceremonially in the lamentations at the passing of the one who would let go of life, and the regrets and guilt at not having saved them. Whom are they really trying to explain? Who are they really wishing could have been saved? Is it the life of the now departed loved one? Surely this is true in a sense. After seeing years of tears shed by those left behind, their grief is beyond words. It cannot be denied. It’s enough to convince me thoroughly the most loved ones never ever “get over it”, they never ever “move on” and rarely are “better off”. This is partly the reason why I use the word “suist” when describing the one who takes their own life. The word means placing one’s interests above another, in this case another who will suffer terribly. The surviving significant other is not only placed on the path looking for answers as to the meaning of the act and the value of life of the departed. We risk the act provoking other questions as well. If the dearly departed can throw away life, then perhaps it is not so great a gift after all, not so great as to trump the option of returning the gift to its sender. What is this life, a thin sliver of time sitting within transcendent eternity, a time of pain now perhaps only remedied by me joining them. Suicide can take many casualties even amongst the living.

What of religion? We have some crude scenarios. If the loved one laments at the notion of the suist passing into hell this surely is a matter for religion, not psychiatry. Maybe there is no hell. Or maybe if God is so irresistible in love and forgiveness the suist will be carried up into whatever heaven is, perhaps after a chastisement from the divine. This is a nicer ending to be sure, yet once again none of psychiatry’s business what breaches of contract mankind has with his or her maker. Similar is the case with reincarnation. What is a momentary karmic regression of a dozen generations or so against getting back on track towards the inevitability of a nirvana which is, ironically, the final blowing out of the candle of being, the greatest death of all. Finally, we have the bleakest metaphysical variant, that of the biological machine decomposing into the Earth from which it came, that being the end of the matter of being in one form, and the beginnings of being matter in another (perhaps a worm, perhaps a rosebush). From oblivion to meaningless absurdity to oblivion, in such a scenario the question of who cares ought not to be conflated with a metaphysical justification to cosmic tragedy, i.e. that there is anything to care about outside the act of caring itself which surely ought to be informed by the (in)significance of the whole cosmic circus. I don’t subscribe to this latter view myself, though simply point out it’s possibility. Its place also lay outside of psychiatry. And so does suicide.

So what is suicide?

As previously described, currently the tide has taken us to a place where suicide or threatened suicide is rendered as a disease suffered by a person, this or at least a symptom of another disease.  On the macro level it’s a public health problem. Whether one is a traditional theist, a stalwart atheist humanist or of whatever other metaphysical stripe, I hope to have convinced that this is ridiculous, a category error, a metaphor gone malignant. It depends on the construction of psychiatric disorders to prop it up. And it is a ghastly confused position, for the disease is seen as morally neutral, displacing the morality to the attitude of all and sundry apart from the mind and choices of the suist themselves. This is where the laity misunderstands psychiatry. The orthopaedist might care about the hip more than the patient as person. Psychiatry annihilates the person.    

So, what is suicide? Suicide is, like many behaviours, simply the outcome of a choice made by an individual. The gravitas of an act does not make suicide any less the outcome of a choice than that of homicide, armed robbery of walking away you’re your work and family, joining a commune or the life of a sadhu. All these behaviours at one time or another in one individual or another might have been described as acts of desperate necessity. True, we may imagine that the vast majority of persons would rather not be placed in whatever situation besets them such as to be making drastic choices. People would often prefer the final chapter of our lives be written differently. They would rather have claimed victory in war, or to have avoided a collapse in stock prices, or to have been born into a better body, or better family, or any family at all, or to see a world sunnier than they perceive it to be. And obviously they are often deeply ambivalent and pained, even terrified, at the decision and approach it with weakened knees, as if hoping that something or someone would deliver them from their own private Gethsemane. Only a fool would trivialise suicide and ignore the obvious. And what of it? Does not the woman who might give up the child for adoption, or the one who might walk away from years of a commitment to a failed marriage, or a thankless job often arrive at a decision reluctantly. Rightly or wrongly they arrive at a decision nonetheless. Even Socrates might have wished the tide to have turned otherwise, and rather not to have raised the hemlock to his lips. The lists of “would rather” and “if only” defies typology. None of these regrets ultimately take an agent out of the world of choice and the liberty to decline what passes for alternate choices, to disbelieve in their existence or relative value. Even the one who might, as one of my patients did, believe that the shape shifting lizard creatures will kill their family if they don’t kill themselves, even they must make the choice of how to nobly act in a world of their own beliefs. Whether or not a behaviour driven by a choice is driven in turn by a false belief cannot possibly squeeze the place of choice out of the picture.

The literature on suicide from time to time attempts to make an issue of the temporality of thought to action, as if to imply this means something substantial. Some say it is a myth that suicide is impulsive, stating that the suist lays out ample clues as to their covert or simply poorly detected ideation for perhaps months before the apparently impulsive event. The idea is that they want to be caught. Others will say that most suicide attempts are almost preconscious impulsive acts within the heat of the moment. Whatever ideation that they may have had before, the attempt/act comes all of a sudden without apparent “triggers” any different from the day before or the day before that. The answer is, of course, suicide is neither and both. As with any choice/behaviour dyad, some make the decision hastily (i.e. impulsively) and some deliberate and plan for quite some time, years perhaps. There is no valid objectification of suicide such as to say that it is or need be either impulsive or planned. The want to delineate the impulsive from the planned attempt exists more within the pragmatism of the psychiatrist than a recognition of what suicide is, or as having informed the risk calculus. Just as any choice may be long considered or hasty, suicide can also be a choice made from deep consideration of the reasons to live or die, or the decision made by one whose capricious mind only fleetingly skims the surface of all that might be considered. Once again, the temporality of the decision does not take suicide out of the orbit of the category of choice made by a person with personality. If the decision to suicide is long considered we may argue there is the evidence of a deeply entrenched chronic mental illness. Or we may conclude in the deliberation that it is hyper-rational and well considered, a choice to be respected. If it is impulsive, we may claim that the person need be saved from an action they did not give due consideration, and we ought to attempt to capture and contain the wind almost before it blows. Or we may instead conclude that in its impulsively that there is no enduring or foreseeable risk, and so nothing that ought to be done at all. Impulsive or planned? Once again, the argument is pragmatic and the words can be used to argue any case. The goal is first defined, and the argument comes after.

So what might we do about suicide?

As with many a moral or political or legal question, the issue is the is/ought fallacy; what right does one have to X (claim to freedom from impediment) vs the question if X is right in itself (freedom from moral judgment).

The legal right to suicide is, prima facie, easily addressed, though not nearly as easy as might be imagined. The answer in positivist law is whatever the state wishes it to be and writes into legislation. To answer this question is simply glance at the calendar, note the year, orientate oneself to the location where one lives, and look at the local jurisdictions criminal and mental health legislation. The matter becomes tricky when addressing specific context and how we frame relationships (e.g. the displacement of physician’s personal responsibility as in the physician accomplice to self-homicide or “physician assisted suicide”) along with the question of the degree of vigour in application of law. We live in a time and place where, by and large, completed suicide is decriminalized, and fair enough. No corpse ought to be thrown in jail. Yet insomuch as any mention or attempt towards the act of suicide might result in home invasion (forced entry into premises without need for judicial warrant), arrest (detention for assessment), trial (involuntary mental health assessment at the nearest authorized hospital) and corrective incarceration (further forced hospitalization and forced treatment), suicidality most certainly remains quasi criminalized. Why? Because the response of the state involves a deprivation of liberty, and so comfortably finds it’s analogue in the penal system which in recent times has been formulated to be more rehabilitative than retributive in its justice. Jails claiming to be benevolent centres of social engineering are jails all the same. Lest we be intoxicated by euphemisms, none can argue against this basic fact and we would do well to have words that bark as hard as they bite in practice.

Moreover, I have also worked within legislative frameworks where arrest for a criminal charge justly requires evidence and a warrant, whereas one can be involuntarily detained, drugged, dragged out of one’s house and transported for suicide risk assessment on nothing more than hearsay and accusation, without the police necessarily having heard or seen the would be suist say or do anything at all. Police and paramedics then document hearsay as if this was heard by their own ears and witnessed with their own eyes. Even when credible witnesses are present contradicting the charge of thought crime and conspiracy to suicide and the person themselves denies having made the threat, this usually will not deter the police and paramedics from prejudicially insisting on a mental health assessment. They do this daily and with absolute impunity. Or alternatively the individual may confirm having made the threat, be thankful to receive help, and involuntarily detained and transported anyway without any hope of legal recourse of their own were they to pursue a complaint for being treated like a criminal. Why involuntarily detain a person who is willing to seek help? The police officer can only answer that the individual is ostensibly mentally ill, for that is taken to be reason enough. They may be erratic in behaviour. They may alight from the vehicle. They may change their mind and attempt suicide on route to the hospital, and so on and so forth. Or in quieter conversation the police and emergency services admit to their true motivations, i.e. that they will do anything and everything necessary not to be hauled up and have their career threatened for failure to prevent a suicide. Once again, the suist is assumed to be void of personal responsibility. All too often their senior leadership instructs the paramedic or police foot solider to detain and transport no matter what. The rank and file fall into step and deprive persons of their liberty using excuses that disguise reasons that vary from unprincipled personal interest to the Eichmann defence of following orders. Why are the police not as terrified and authoritative over the potential criminal who might have had merely an ideation towards real crime? The answer is that to do so would be to immediately reveal we live in a police state, the police patrolling against thought crime. Where other liberties find themselves perched upon the precipice of remaining unmolested for the time being, patrolling against thought crime is already permitted under the rubric of psychiatry and mental health legislation. This is but part of the reason why the machine of psychiatry is best dismantled altogether, for the problem becomes more pernicious still. Mental health services might acknowledge the short comings of police and paramedics. Their solution? To create task forces of mobile mental health outreach teams, with ominous job titles such as “behavioural health technicians” and “mental health technicians”. I am not kidding. Naturally this is the police by extension masquerading as substitution. These services have it written into legislation that they may conscript police and paramedics to aid them in involuntarily detaining and transporting the person who wishes to end their life.

Can anyone not see in this the whole odious Orwellian infrastructure falling into place? In extremis, the technocratic worldview is there in plain sight, for the use of words such as “technician” is to engineer. Such an ethos would not change were the name to change tomorrow. You are form upon which the engineer places his stencil to craft a unit of the utopia of the therapeutic state, the happy and well adjusted citizen who does not distress yourself or others.

Even if the law were rendered perfectly transparent and a more robust due process put in place for alleged suists, the question arises what the individual morally ought to have the right to do with themselves, irrespective of the laws of the state. To this I would personally be inclined to the Kantian conclusion. Albeit I approach it from an overlapping though not identical line of reasoning, along with an article of faith. That is to say, I personally view suicide as an almost universally immoral act, with the few exceptions proving the deontological rule. Stated briefly, the religious regardless of stripe have the answer to suicide already at hand, and ought to be true to their faith. Yet even in a secular world, one can take a Burkean outlook. I suggest at least the possibility that any individual has a duty to the preceding generations for the life they have been given and to future generations for the legacy that they may leave behind. Granted the suist may have had abysmal parents. They may wish to punish them by punishing the parent’s creation and out of hatred and loathing of the creation itself (i.e. themselves). Their suffering is not denied. That having been said, there are plenty of innocently disenfranchised and lonely parental and grandparental figures about. Their hearts and souls cry out to mean something to someone. In their own indirect and small ways they might have contributed something of good to the world of the potential suist. Why not be that needed person for them? Similarly, almost every would be suist has the wherewithal to be a meaningful source of kindness to some child somewhere, enough to make both lives worth living and pass onto the child a baton of the good, the beautiful and the true that the child in turn can carry on into future generations. Dare I suggest then that even a secular suist can find themselves by losing themselves. Come the end of the long day, perhaps this is the closest thing to mental health any of us can hope to achieve. It is difficult to ignore such a call to duty without rejecting the world being radically narcissistic or radically nihilistic. Maybe they just have not thought it through.

That short paragraph aside, if you have been gracious enough to have ventured so far, this book is not a sermon. The question is not what I ought to do with the preservation of my life or you ought to do with the preservation of yours. The question is what I ought to do with yours and you ought to do with mine.

So what ought I morally have the right to do with the would be suist? Surely there is no greater exemplar of personal property than ownership over one’s body and one’s life. From Locke and Mill to Hayek and Mises or Szasz, a reading of the literature of the so called classical liberal and libertarian movement won’t give a defence of why this is the case, for such a right over the body is assumed and part of the foundation of further argument on private property rights and civil liberties. How can I even begin to approach the question of how my liberty might be exercised in the world and if the fruits of my labour be mine, or the question of land ownership via aboriginal propriety or free contract of exchange, if I am not absolutely a free and separate actor to you, and you to me. The starting point must be the body as a private property. My body is mine. Your body is yours. My labours are an extension of myself, as is potentially the soil I till that you do not. Only the almighty might be said to have a greater claim, this irrelevant in the secular state. This sort of thinking in part undergirded the abolitionist movement. Only with basic axioms in place can conflict over who purports to own me can be averted, by the complete negation of the possibility of slavery. To imagine otherwise can mean that I am partly yours, or fully, for a moment or for a time. What I am saying is that the possibility of slavery is won or lost at the margins. It is at the margins that we must hold the line. Don’t misunderstand me, the moral rightness of community and shared duty is not challenged here. Socialism of a kind might be the better way, and I am not the champion of a vulgar libertarianism. Rather it is just to warn that if you give an inch to the state will try and take a mile. The right to suicide bizarrely saves us all even while the act itself diminishes us.  

Only in the most extreme of cases; the unconscious, the demented, the delirious, the temporarily panic stricken “hysterical” patient and so on can we even countenance taking someone’s choice of what is to be done with their body away from them. It is, after all, their personal property. Moreover, it is only under the justified presumption of what we reasonably predict they wished us to do to them when compos mentis that we can manipulate the body without permission. Just as it is immoral and even logically incoherent for someone to make of themselves a slave (slavery being by definition involuntary servitude), the individual can never give away their responsibility over their own body except by voluntary contract, which is to say it remains subsumed within the fact of having made a choice and ongoing freedom to change their mind. Giving over oneself can only ever be done in contingent and indirect ways. I can choose for the welfare of my body to be placed into the hands of the pilot or bus driver. I can relax the body for the physical therapist or dentist to move it as s/he thinks best or the anaesthetist to insert the line. Yet when my unforced hand moves it is I who move it. If the act of the unforced hand is either to grab the gun to shoot another or to turn it on myself, this is never, and can never, be seen as the responsibility of any but myself. I can form a voluntary contract with another to assist me in times of crisis, so that I might attain a mental state less inclined to kill myself. This courting of death versus life is like a courting in the romantic life, also a matter of choice and contract. But at the end of the day, which might be the end of all days, in suicide as in marriage I have no one to blame but myself in saying “I do” or “I don’t”.

If I am aggressive with another, that other (or those acting on their behalf) ought to have recourse to damage my own body if necessary. Why? It is obvious. My aggressive act is impacting upon their liberty, and by extension their ability to act as moral agents to the furtherance of their own duties and potentials, with their choices towards their consequences. I cannot make them a slave towards my own chosen ends, even if the aims are ostensibly benevolent. Many a psychiatrist would prefer a Huxley’ian world of universal happiness. The pyramids were grander. Though I would not destroy them, their grandeur doesn’t ex post justify slavery. Same with grand visions of social engineering.

In my own practice, I see this war against this liberty and responsibility all the time. Often patients are asked “do you feel safe?” or speak of themselves in the same manner “I don’t feel safe”. Patients who have become well versed in this kind of exchange become quite perplexed when I first feign perplexity at hearing them say “I don’t feel safe” or various permutations of the same. In response I ask them about their risk of being burgled, of domestic violence, of natural disasters, accidents and injuries in the home etc, the harm they fear from others. When we together conclude the risk from all of these is low, or burglary not the business of psychiatry in any case, then I ask them how then they might possibly “not feel safe”, i.e., in what sense might this turn of phrase have meaning? It is only then we can begin to deconstruct the perverse lessons psychiatrists and psychologists have taught them, as well as their own want to be a slave to a disintegrated self, or habit in being one. Only then can we have the discussion about free will and personal agency. For, as I challenge them, “how can you feel unsafe from yourself, when it is you who controls the actions of your own hand, when your body is your personal property”? And how can I, another person existing in a different phenomenological space apropos personal agency, control your hand for you. It is your hand. You are in possession of your rational faculties, or at least have the capacity to be in possession of them? Moreover, if you feel unsafe that implies a hostile force of nature or an aggressor. As we have concluded the aggressor is not outside of yourself or nature in any substantive way, then that aggressor is you. How can I prosecute and incarcerate the aggressor without also incarcerating the would-be victim? Why I should I, a doctor, prosecute and incarcerate anyone at all, split internal objects inclusive? Would it not be better for the internal victim to decide within themselves whether to banish the internal aggressor or identify with them. Both are nothing more than different sides of a dialectic within the same person. And the person should be a single identity to themselves. Just as importantly, they should be a single identity to the community around them. How can I conjecture on the diffusion of identity and ego as part of the psychopathology of a borderline personality whilst employing the language that someone is unsafe lest I take charge of their body? In so doing I would be endorsing a diffusion of identity and self control? But unitary identity must be affirmed as much in the battle within for/against suicide as it should be with alleged multiple personality disorder.

With this conversational exchange I attempt divest the patient from the nonsense notion of saving someone from themselves. If I were I to try, it would undercut the validity of their own agency and identity as the one who chooses which side within the self will win and integrates the choice within the greater self. For me to do otherwise is to breed psychopathology, indeed even to share in it. When I suggest it is not possible for someone to be unsafe with themselves as aggressor and victim both, most of the time what I am then met with is not fear but a certain kind of frustration and confusion. The confusion in turn is borne from the dawning realisation that their idiom of divesting themselves of personal responsibility is neither convincing to me. More importantly, is not terribly convincing to them either. Only in the denial of the logical possibilities of their powerlessness can they hope to find the strength to identify with their better half within. Disturbingly it is the patients more educated in psychobabble that present the greater challenge in this process. The more one is naive to psychiatry and the contemporary western infantilizing climate, the more they seem to comprehend free will and personal responsibility as a given.

But people are a complicated mix of competing drives? What about those patients whose life preserving part of themselves is the weaker of the two? Ought we not tip the balance in our favour by imposing ourselves upon them and being a substitute for the greater self, to be an integrating principle that they can later hopefully introject and identify with (that is take control as an ally with their more sensible selves until the balance of power shifts)? To this I would say that a kingdom cannot war against itself. We should not lose our nerve, and our nerve should be true to principle. Slopes have a way, believe it or not, of fast becoming slippery. And a defence of personal agency and responsibility ought to be fought in the ever present now, never better than here in the space where we sit across from one another at 2am in the emergency department. No one ever crafted a legitimate adult by returning the adult to childhood, let alone the womb. In ordinary life, only children lack responsibility. It is no accident that this freedom from responsibility is complemented by an absence of liberty. Children are children until they are not. As stated above, except in cases of dire illness with gross unequivocal loss of cognitive function such as dementia, or temporary states such as delirium and extreme panic, adults ideally must never ever have the liberty and responsibility of their adulthood taken from them. Spontaneous excursions from these hard lines are forgivable if rare, this the stuff of later chapters.