Editor's note: If you or anyone you know is having suicidal thoughts, you are not alone. For support and resources please call a helpline within your region.
Aunt Martha was my mother’s older sister by just a few years. Her husband had an extraordinarily successful career in the post-war home building boom. Their suburban home was idyllic; a brick Cape Cod set beside a quiet creek that separated their house from the others. They would certainly have been considered “upper middle class” in suburban Pittsburgh terms and it was always a special treat when my parents made the 45-minute drive to their house for a Sunday dinner. They were the parents of three daughters, the youngest of whom was five years older than me, and my cousins and I enjoyed pleasant but infrequent contact while growing up. My uncle was the king of his castle, reclining in his chair in the corner of the living room. In the early 1960s, they had one of the first color televisions with remote control, another indicator of his success. My father and I sat in rapture as he clicked through the channels with this technology we could never afford.
My aunt was a dutiful post-war suburban housewife, supporting her husband as he won the bread, keeping the home in order, ceaselessly parenting the kids and preparing meals. She had a gentle kindness about her. Rare to ask for help with anything, she might ask me to help carry a bag of groceries or bring her some tissue. She would always begin, “Artie, would you be so kind as to bring Aunt Martha…?”
Then, one day in 1977, my mother called and tearfully explained that Martha had driven their car into the garage, left it running, closed the doors and windows, and died by asphyxiation from carbon monoxide poisoning. She left no note. A few years ago, my cousin told me over lunch that a day before her death her mother had wearily remarked, “I don’t think I can fix one more meal.” They were the last words she heard her mother speak. My cousin remembers hearing it as something one might have said out of fatigue or frustration with everyday life and nothing more. There had been no overt signs of emotional or psychological distress. How could she have known?
I have been an individual and family psychotherapist for nearly 40 years. Over the course of that time, three of my clients have died by suicide in a variety of ways, from drug overdose to more “violent” means. The most recent of these occurred nearly 25 years ago, and I learned of it on a typical day when I was routinely seeing clients. The young man in his 20s was found hanging in a rented room near my office, normally occupied by college students.
Therapists are typically informed of such occurrences when there is a record of their participation in a therapy program. In better programs, a form of “psychological autopsy” is convened to provide the therapist with an opportunity to present their impressions of the person’s life and clinical course and to consider potential warning signs or blind spots that the therapist may have missed. But most importantly, the autopsy offers the therapist the support of colleagues who recognize the daily challenge of working with individuals with chronic mental illness. There is a general tone in these discussions that, as a therapist, it is only a matter of when, not if, you will experience this tragedy in your clinical work.
Perhaps a word should be said about that term “chronic.” In the behavioral health field, “chronic” is generally understood to be the converse of “acute”; that is, it will likely be a condition with which an individual will struggle throughout their lifetime, with symptoms experienced in peaks and troughs, magnified or mitigated by any number of internal and external variables, such as comorbid medical conditions, financial hardship, family conflict, and unending nuances of psychological and emotional stressors.
Therapists who work with people experiencing this constellation of concerns become accustomed to hearing expressions of consideration or intent to commit self-harm (referred to as “suicidal ideation”) as the individual wends his or her way through the various life challenges that may culminate in such thoughts. If you work with a person in a therapeutic relationship long enough, you begin to get a sense of when such thoughts are transient or fleeting (as they often are) and when they should be explored more fully. Or you think you do. In my experience, while “anxiety” in its general and more specific forms may manifest intimations of self-harm, individuals with severe chronic clinical depression are generally more prone to feeling and declaring a sense of worthlessness, hopelessness, and despair to a degree that thoughts of suicide, however tentative, are more likely.
While suicides by noted individuals in recent years—such as Robin Williams, Naomi Judd, Anthony Bourdain, Kate Spade (the latter two explored in Frank Bruni’s recent book, The Beauty of Dusk) and, most recently, Stephen “tWitch” Boss—are widely reported, the “phenomenon” of suicide has been known and studied for at least 3,000 years: “studied” in the sense that the act of “self-killing” has been examined from social, economic, and psychological perspectives and attributed to a variety of motivations.
Prior to an evolution of conceptions about suicide in the late 17th and early 18th centuries, suicide was viewed as a religious and moral offense. Following a death, internment could consist of a corpse being buried at a crossroads with a stake through the heart and the denial of any formal religious burial rites. Then, in 1897, French sociologist Émile Durkheim’s classic and still highly regarded and oft-quoted text Suicide was the first attempt at a scholarly understanding from the perspective of “social physics,” the discipline later to be known as Sociology. It was an attempt to develop categories of suicidal behavior. Individuals who die by suicide, according to Durkheim, may be ascribed to one of four categories along a continuum, but are generally suffering from an imbalance in “social integration” and “moral regulation.”
“Egoistic suicide” occurs when individuals fail to establish a sense of belonging to or integration with a larger community, resulting in the potential for developing symptoms of what today is known as clinical depression. Durkheim found that such suicides occurred more often in unmarried people and especially in unmarried men, a statistic that holds true even today.
“Altruistic suicide” may be seen as the opposite end of the continuum and occurs when an individual feels “overwhelmed” by a community’s shared goals and beliefs. In such cases, suicide becomes the ultimate expression of fidelity to societal goals. Japanese kamikaze pilots during World War II may be seen as examples.
“Anomic suicide” suggests that individuals may be more prone to suicide when they experience some form of social or moral upheaval; there may have been significant changes in a person’s personal or social environment leading to an inability to recalibrate one’s expectations and capacity for change. Individuals may lose a sense of where they “fit” in the larger social order.
“Fatalistic suicide” occurs under conditions of extreme repression and regulation and individuals see little possibility of “escape,” such as in prisoners who may choose death over a life of incarceration. This category is acknowledged to be Durkheim’s most speculative.
Historians’ interest in suicide waned until the 1980s, when many began to look anew at culture-centric phenomena related to suicide. Statistical data related to demographics continues to be collected and non-profit organizations for “prevention of suicide” abound, with frequent public service announcements devoted to suicide helplines and other resources. Nevertheless, suicide rates among certain demographic groups continue to increase.
None of those resources helped Darla. Darla was the administrative assistant for my staff and me when I was director of a behavioral health unit at a large commercial health plan, beginning in 2005. The start-up of the program required hiring multiple staff positions and, as the position reported directly to me, I made the hiring decision. Darla and other candidates were interviewed but she stood out from the others given her competence in past positions, creativity, and enthusiasm. She remained in that position for eight years until she was transferred to another department during a company reorganization.
I spent many hours with Darla, assigning and supervising her direct work, which she always completed promptly and efficiently. During those discussions, Darla would occasionally, and tearfully, share her aspirations for another career, perhaps in occupational therapy, and her sense that she “would never be more than just a secretary.” I sensed that her aspirations were driven by a desire to be more directly helpful to those in need, whatever the need may be. As the mother of two teenage sons, Darla watched them struggle academically and continually looked for additional resources to see them both graduate from high school. Despite her struggles, she always saw each day as an opportunity for a “new start,” as she would say, and continued to explore opportunities for advancement along the way.
I tried to provide as much support for her search for a new career as I could within the limitations of our roles. I encouraged her to take steps to build a foundation for her aspirations and to seek additional help with what had by then become a fragile sense of self. Darla subsequently enrolled in some community college basic biology courses prerequisite to an occupational training program, but eventually dropped the coursework when the science seemed too daunting. It was then that Darla’s overall attitude seemed to become one of resignation to her “fate” as she perceived it—that she would always be “just a secretary.”
Darla’s transfer to another department resulted in infrequent contact for the next couple of years, except for occasional stops at her cube to say hello and exchange office chat. By then, both her sons had graduated from high school. Looking back, one might infer that a final blow came when Darla’s position was eliminated due to another reorganization. Several weeks passed before news of Darla’s suicide began to circulate. She was found unresponsive by a family member in a gardening shed in the backyard.
I, and those who knew Darla, searched for clues as to what we may have missed in our relationships and innumerable discussions with her. Like Aunt Martha, did she say something that we may have disregarded as a casual comment but suggested something much deeper? Was her apparent sense of resignation at being “just a secretary” something to which I should have been more attentive? I revisit her obituary occasionally and look for any hints of something that should have been obvious to me; her picture looks back with a kind of terse expression that belies her usually kind and easy smile. There are no clues to be found there. From the obituary: “Darla enjoyed hosting parties for any occasion (when asked what to bring she would answer just yourself.)” I can only infer that she must have felt something immovable, irreconcilable, and above all, intolerable within herself that made her life—her very existence—intolerable.
Learning of a suicide is fundamentally different to learning of a death following a prolonged illness or even from an unexpected event such as a fatal accident or natural disaster. If a loved one provides any clues about their potential for self-destruction, these are often expressed as some sense that, “The world (or my family, my wife) would be better off without me.” They can see only their desire to be free from pain they perceive as unbearable and are unable to recognize the pain of those who will be left behind. The confused range of emotions experienced following any loss may therefore be magnified in the wake of suicide. Sadness and loss will accompany anger (“How could he/she do this to me?”) and guilt (“What more could I have done?”) and are likely to rise to the surface and feel especially unmanageable.
These emotions can feel unmanageable and like being caught in an inescapable cycle: “Why am I feeling guilty about being angry?” Sorting through all of this can be emotionally daunting and finding the support of good listeners is critical; those who can allow friends and relatives coping with loss to express whatever they may be feeling at any given time. Therapy can help but “good listening” is not a skill possessed by therapists alone. A sense of patience can be cultivated by the practice of allowing feelings to be experienced as they come and not trying to fight them off due to misplaced feelings of “disloyalty” to the departed. The tendency to fill up time with activity for its own sake seldom helps in the long term, as moving quickly from one thing to the next can become an avoidance of “settling in” to feelings that can be painful to experience.
John Donne wrote, “No man is an island entire of itself … any man’s death diminishes me…” This is never truer than when a loss by suicide enters our lives and becomes part of us forever. The experience of support and patience will, in time, ease the pain of grief and help navigate the turbulent waters of sudden and painful bereavement.