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From Here Comes the Sun (Dealing With Depression)
by Gayle Rosellini & Mark Worden

Suicide:  The Romance and the Reality

Many have commented on the tendency to romanticize suicidal depression. In the wake of Goethe's eighteenth century novel, The Sorrows of Young Werther, Europe was swept with a wave of suicides by passionately melancholy young men, thwarted in love and, in the words of Keats, "half in love with easeful death."

More recently, writers like Sylvia Plath have glorified suicide. Her novel, The Bell Jar, featured a heroine whose own instability made suicide seem a romantic and courageous solution to spiritual distress. The Japanese, wrote Plath, "understood things of the spirit."

They disemboweled themselves when anything went wrong. I tried to imagine how they would go about it. They must have an extremely sharp knife. No, probably two sharp knives. Then they would sit down, cross-legged, a knife in either hand. Then they would cross their hands and point a knife at each side of the stomach. They would have to be naked or the knife would get stuck in their clothes.

Then in one quick flash, before they had time to think twice, they would jab the knives in, and zip them round, one on the upper crescent and one on the lower crescent, making a full circle. Then their stomach skin would come loose, like a plate, and their insides would fall out, and they would die.

It must take a lot of courage to die like that.

In a much-quoted poem ("Lady Lazarus"), Sylvia Plath continued her autobiographical flirtation with suicide:

     Is an art, like everything else.
     I do it exceptionally well.

 True to her art, Plath finally committed suicide successfully, after several previous attempts.

The Grisly Secret of Suicide

There has been much speculation about reasons for suicide--many theories, many explanations. Suicide can be viewed as a cry for help, as a romantic gesture of self-renunciation, or as a spiteful act of supreme vengeance -- in a sense, a willful triumph over real or imagined enemies, and a spit in the eye of God. But all too often the grisly reality of suicidal behavior remains a much-guarded secret.

The reality is this: Suicide is not a tidy solution. The suicide inevitably leaves an ugly mess behind -- in psychological and physical terms -- for someone else to clean up. In the words of sociologist Lionel Tiger, the aftermath of suicide is a "legacy of pain."

Tiger remarks that suicide is "vicious, distorted, unbear­ably painful to family and friends, and a gross violation of the tentative truce with mortality which all humans must make." Tiger goes on to say, "Suicides . . . make a major statement about the value of life and thus call into question the very source of optimistic gregariousness which sustains us all."

Writing on suicide in the CoEvolution Quarterly, Art Kleiner comments:

I suspect suicidal people are automatically rescued not for their own sakes, but for the rest of us. A suicide death, unless it is rationally prepared for, devastates. The message of a suicide attempt is often: Death is better than the pain you've caused me.

 Tiger, the author of Optimism: The Biology of Hope, had a close friend and colleague who killed himself. Tiger was the last person to see the man alive, and recalls, "I cannot begin to describe the profoundly demoralizing effect his suicide had on those of us around him." The impact was all the more demoralizing because the suicide victim was "an extraordinarily talented, charming, seductive and psychologically dramatic professor"

Years later the chairman of Tiger's department disclosed he had recommended that Tiger be given a year's leave of absence because the chairman believed Tiger was gravely depressed and needed to escape the blight of what had happened. "Was his diagnosis correct?" asks Tiger. "I think so, although I wasn't aware of the degree of my despondency then."

Such deep and soul-searching despondency is common in the people the suicide leaves behind. "When suicides occur;" Tiger reflects, "we all claim responsibility or feel we share in the failure of the social fabric to support the person in need."

Was there something we could have done or said to prevent the person from taking that last final step into oblivion? Did we ignore the obvious signs, did we bother to find out how depressed the person was? Did we fail to take the depression seriously and think it was "just a phase"? These questions and more run through the minds of the friends and loved ones left behind.

     But there's another aspect of suicide that undermines the foundations of our own lives. The suicide attempt devastates and fascinates us because it reminds us how fragile our hold on life really is. We struggle along with our problems, and the suicide just seems to put it all aside, saying, "It isn't worth the struggle. Good-bye, cruel world." It's a shocking repudiation of the high value most of us place on life. The suicide tosses life aside like so much trash. As Tiger puts it, "Suicide is a violent challenge to our general complacency about the extraordinary value of life. To be sure, suicide is not only violent against the community but also against the survivors”

This might be called the psychological legacy of pain. But there's another legacy of pain that most suicides never take into consideration -- the legacy of a broken, battered, blood-and excrement-soaked body drowning in vomit, clinging to life in spite of all the good intentions about a sanitized and uncomplicated self-deliverance.

Just as alcohol and other drug abuse have been glamorized in the past by showing the use of drugs without real-life consequences, so suicide has frequently been depicted as a swift, painless, and uncomplicated solution to life's problems. An extreme solution, to be sure, but an awesome and perhaps courageous step into the void.

What more people need to know is that suicide is most often the pathetic act of a confused and desperate person. If we look at the real-life consequences of suicide and suicide attempts, we find that the seemingly antiseptic solution turns out to be messy and unpredictable.

In the words of an advocate of rational self-deliverance, more people need to know "how not to commit suicide."

 Little Known Hazards of Suicide

The theme song from the movie M-A-S-H is titled "Suicide," and the lyrics go: "Suicide is painless, It brings on many changes. . . . ."

However, suicide does not always bring on swift, painless, sweet oblivion. The attempt sometimes gets all botched up and the would-be suicide suffers a good deal of pain and disfigurement.

Most suicides and suicide attempts take the form of drug overdoses. Art Kleiner describes what happens:

The danger in all drug overdoses is that the brain may not get enough oxygen. The airway to the lungs may get blocked off by the patient's vomit, or by the tongue falling back into the throat, or by drug-induced slow­down in the part of the deep brain that controls the rate and depth of breathing.

Permanent brain damage occurs when the brain is deprived of oxygen for three to five minutes. Higher brain functions are the first to go -- memory is destroyed, verbal skills are impaired -- and the longer the oxygen starvation goes on, the more severe the retardation.

Aspirin is one of the most common drugs used in botched suicide attempts, probably because of its wide availability  and our ignorance about the terminal effectiveness of    an overdose. One pharmacologist calls aspirin "one of the messiest, most complicated overdoses you ever hope to see." Aspirin can burn the gastrointestinal tract and can damage the kidneys, lungs, and liver.  Aspirin in sufficient quantity can produce a fever and seizures. People who survive aspirin overdoses can suffer permanent liver damage and sometimes suffer deafness or tinnitus (ringing in the ears).

Tylenol (or acetaminophen) poisoning also destroys the liver This can result in an especially painful death because patients often sleep off the initial sickness, recover enough to realize they didn't really want to die, then slowly slip off into a coma after five days because the liver has been destroyed.

Sedatives and alcohol are a common and dangerous combination in suicide attempts. When taken together, alcohol and Valium, Seconal, or other sedatives and mild tranquilizers produce nausea and vomiting. Instead of drifting off into death, the suicidal person sucks vomit into the lungs. If the person doesn't drown in vomit, they can become infected and develop pneumonia and irreversible lung damage.

The most painful form of a suicide attempt is swallowing lye, Drano, oven cleaner, or some other form of household caustic agent. Very few people die from swallowing lye or other caustics. "If they do die," says one physician, "it's days, weeks, or even months later; of infection." Caustics like lye burn the mouth, tongue, and may burn holes through the esophagus and into the chest cavity. The resulting scar tissue can obstruct the gastrointestinal tract, and patients may have to undergo years of painful corrective surgery.

"Violent death is so often portrayed as sudden and painless," Kleiner reports, "but the human body is harder to kill than it seems."  Slitting the wrists, for example, rarely results in death. More often, tendons and nerves are damaged, and the would-he suicide ends up with a weak or deformed hand.

Those who cut their throats rarely die. They cut the nerve that controls their voice box and larynx and end up voiceless. Gunshot wounds can kill outright, but, remarkably enough, people frequently miss the brain and blow out an eye or part of a jaw. People can live for hours with a hole in the head the size of a half-dollar. Says one physician, "One man I treated is completely paralyzed on his left side, and can't speak, walk, or feed himself. It's as if he had a major stroke. He hit the area of the brain which controls motor function."

While brain death comes fairly rapidly with oxygen deprivation, the brain can survive bizarre assaults. One man tried to kill himself by hammering eleven nails into the top of his head. Finding himself still alive, he walked to the hospital and presented himself to the emergency ward.

Hanging seems to offer a fairly rapid demise, but those who try to hang themselves may dangle and slowly choke. They don't always die but, like other failed suicides, end up with irreversible brain damage.

Jumping from a high place can cause a nonfatal, but painful and permanent injury. In 1986, a world-class runner dropped out of the middle of a race and jumped off a bridge. She did not kill herself, but her jump caused irreversible injuries --she became quadriplegic. According to those who have studied suicide attempts, people can fall over a hundred feet --and sometimes more -- without killing themselves. Jumpers who survive suffer multiple fractures -- crushed and shattered bones -- and ruptured internal organs. Because of the fragility of the spine and brain, jumpers may be left totally paralyzed.

     Botched suicides happen so frequently and have such unexpected and unseemly consequences that Dr George B. Mair, a British advocate of rational self-deliverance, wrote a book on suicidal etiquette called How to Die With Dignity. Dr Mair cautions:

·  It is exceptionally unwise to attempt to jump in front of trains, motor buses, or other vehicles. Results are unpredictable.

·  Jumping into the sea from the ferry or other deep sea vessel is highly inconvenient for the ship's crew and passengers.

· An attempt to crash a car even moving at a very high speed is extremely uncertain and should be avoided.

·  Jumping onto the live rail of an electric rail system is not in any way dignified and is a great offense to witnesses.

In her poem "Resume," Dorothy Parker made some wry observations about various drawbacks of suicide techniques:

Razors pain you;
     Rivers are damp;
     Acids stain you;
     And drugs cause cramp.
     Guns aren't lawful;
     Nooses give;
     Gas smells awful;
     You might as well live.

 Rational Suicide?

Many students of depression and suicidal behavior have commented on the "rational suicide." Given the fact that most suicides leave a legacy of pain, there is another aspect to be considered: Some suicides appear to be well thought-out solutions to intolerable problems. From an outsider's point of view, the solution of suicide may not necessarily seem to be the best solution, but it is perhaps better; in the suicide's eye, than the perceived alternatives. Many students of depression and suicidal behavior have remarked on the "rational suicide."

Aaron Beck, a psychologist who has written extensively on depression, observes that depression stems from the cognitive stance the depressed person takes toward the world. The depressed person's expectations are permeated with negativity, and he or she sees only continued unhappiness and hopelessness on into the future. Rather than fact such a future, the suicide opts to turn away from a painfully futile existence.

"He cannot visualize any way of improving things;' says Beck. "He does not believe it is possible to get better. Suicide under these conditions seems to the patient to be a rational solution."

The Thanatos Society and similar groups give individuals support for the choice of suicide under intolerable conditions such as terminal illness.

Of course, what one person considers to be intolerable, another person might readily tolerate. In E. A. Robinson's well-known poem, Richard Cory had it made:

He was a gentleman from sole to crown,
Clean favored and imperially slim.

He "fluttered pulses when he said, Good morning, and he glittered when he walked." (What a guy!)

He was rich and well-schooled in every grace.
In fine, we thought that he was everything
To make us wish we were in his place.

But Robinson's poem comes to an ironic conclusion:

So on we worked, and waited for the light,
And went without the meat, and cursed the bread,
And Richard Cory, one calm summer night
Went home and put a bullet in his head.

 When a Nebraska farmer committed suicide, a friend reflected, "That last day seemed like all the others. I never knew how bad it was for him Pete never let on. He was cheerful, he ate turkey sandwiches with me, and then he killed himself."

 Mary, Pete's wife, bad no idea he had been plotting his suicide for six months or more. "I lived with a man who was planning to kill himself and I didn't notice any signals. I look back now, and I still don't see any signs. I worried about heart attacks and car wrecks. I didn't think about interest rates, foreclosures or bankruptcy. But that's what killed Pete.'"

 Pete was not immobilized by depression. Quite the opposite. He left a set of instructions about how to organize the funeral (along with a detailed script for his own funeral, including friends to notify and pallbearers). He also left elaborate suggestions about how to deal with bankers, bill collectors and other creditors, as well as insurance agents. He entered his wife's name in the new telephone book as president of their corporate ranch. He prepaid her dues at the country club for the next two years -- again without her knowledge. He filled in chores to be done on the pages of the next year's calendar. And he bought Christmas gifts for his wife and kids, to be delivered by friends.

No doubt Pete thought his elaborate preparations would make his death less traumatic. But his death shocked and devastated those closest to him. Would prepaid dues at the country club compensate for the loss of a husband? Would Christmas presents delivered by a third party really be any consolation for the loss of a father? What made him think it would be easier for his wife to deal with creditors than it was for him?

For all of his apparent concern for the future of his family, Pete was capable of enormous deception and irrational self-justification -- a sure sign of the distorted logic of the suicide. His "solution" solved nothing; it only created unspeakable pain for his survivors.

 Another example of the twisted covert thinking of the suicide can be seen in a beleaguered Wyoming farmer who also killed himself without any warning. His wife said his decision must have been a long time in the making. "In all our years together I never had to pick up a sock. He was very orderly and methodical. That day, for the first time in weeks, he didn't seem worried. He was in control. As he left the house, he turned around in the yard and came back three times to kiss me.''

 His wife asked if he was okay, and he said, "I love you very much." That was the last time she saw him alive. She had a long time to reflect on the kind of love that leaves behind immeasurable grief and confusion.

Psychiatrist William Glasser reports on one seventeen-year-old boy who committed suicide:

In a typical case, the parents of a seventeen-year-old boy thought in retrospect, he spent more time by himself than seemed normal. In school, where his work was satisfactory, what was noticeable was that he was not noticed; he tended to blend into the background. He did have a few close friends, and he did not complain that anything major was wrong. Obviously, he must have been suffering from a huge and growing perceptual error; the life he wanted was not at all working out. Even though he appeared outwardly calm, we believe that disturbing ideas that had never been there before were racing through his mind. More and more the idea that life was overwhelmingly painful crowded out other thoughts. To relieve the pain, he threw a rope over the garage rafter; fixed it around his neck, and stepped off the chair

But the boy did not understand that suicide is forever; not just for the victim, but for those around the victim -- the friends, children, and parents. For they are the ones left with the suicide's legacy of pain.


Evaluating Suicidal Risk

 How can one tell whether a person is suicidal or not? There is no way to predict with absolute certainty that an individual is a suicide risk. But there are a number of indicators that show up fairly often in high-risk individuals. Consider these questions when trying to assess the risk for suicide:

  1. Have there been previous attempts?  

  2. Has the person been preoccupied with thoughts of death -- rather than just casual thoughts of suicide?

  3. Have there been any recent deaths or losses?  

  4. Has the individual spoken of a plan to commit suicide, or talked about a specific method of suicide?  

  5. Has the person recently and unexpectedly finalized business, or written or revised a will?  

  6.   Does the person live alone - - with few friends, contacts?  

  7. Is there a family history of suicide?

  8.   Does the person have a history of alcohol problems or other forms of chemical dependency?

  9. Has the person ever had psychiatric treatment or hospitalization for pronounced mood changes?

  10. Has the person expressed feelings of unreality?

  11.  Does the person on suffer from severe illness with unremitting pain            accompanied by strong feelings of depression.? 

  12.   Were previous attempts serious with little likelihood of rescue or survival?  

A "yes" answer to two or more of the above questions indicates a high risk of suicide.


Suicide Prevention

How about suicide prevention? Most suicide prevention workers feel that suicidal people haven't examined all the alternatives to suicide. Those who work on telephone crisis hot lines try to get the caller to consider alternatives.

One worker speaks about the "tunnel vision" of suicidal callers. "Usually it hasn't dawned on them who it will affect or what the long-range effects of their act will be. Once they realize it, they often don't want the suicide to happen. They don't want to die; they want the pain to stop."

 When dealing with the depressed person, most of us tend to tippy-toe around the topic of suicide. There's a hidden agenda that goes, "Let's don't talk about it." Or: "I won't bring it up if you won't." We are often afraid to ask depressed people if they are considering suicide, because we think that somehow it might give them ideas, it might trigger a suicidal gesture. We are trapped by the myths about suicide.

 Myths About Suicide

Myth: People who talk about suicide do not commit suicide.

Fact: Talkers are often doers. Threats should be taken seriously.

Myth: Suicide happens without warning.

Fact: Suicides talk about hopelessness and the suicidal solution. They make threats - some veiled, some overt. They may talk about death fantasies or express the feeling, "They'll be sorry when I die." In general, the more specific the threat (as to method of suicide, time, place, etc.) the greater the probability of a real, serious attempt.

Myth: Suicidal people are fully intent on dying.

Fact: The man who jumped into the cactus patch said, "It seemed like a good idea at the time." So it is with suicides. Suicide may seem like a good idea at the time, but many suicidal people appreciate the opportunity to reconsider.  A man who survived a suicidal jump from the Golden Gate Bridge says he realized he was making a horrible mistake when his hands slipped from the railing and he plunged 249 feet into the Bay. A year later, he told a reporter be was "thrilled to be alive," and he urged others thinking about suicide to give life another chance.

Myth: Once a person is suicidal, he or she is suicidal forever

Fact: People who feel suicidal or who actually attempt suicide may find ways to strengthen their resolve to live and may put all thoughts of suicide entirely behind them, going on to live happy and productive lives.

Myth: Improvement following a suicidal crisis means the suicidal risk is over.

Fact: The mood change from suicidal depression to apparent tranquility may in fact reflect that a person has reached a decision to commit suicide. Having reached a decision, the burden of living is lifted, leaving room for a serenity that may mislead others into thinking the crisis has passed.

Myth: Suicide strikes more often among the rich, or almost exclusively among the poor.

Fact: The will to live appears to be distributed equally among all economic levels of the population.

  Most experts who have studied suicide agree that it's essential to dispel the myths and lift the taboos around talking about suicide. People who are suicidally depressed should be confronted about their suicidal ideas and they should be encouraged to look at alternatives. "Don't argue with them about why life is worth living because you can't win that one," says Kleiner.  Tell them something more concrete, more personal. "Tell them how you and other people will feel when they're gone. If there are mental health services you trust in your neighborhood, you may want to suggest them."

When free-lance journalist Karen Lindsey became suicidal, friends rallied to bolster her flagging motivation to continue living.

No one tried to deny or judge my suicidal feelings, but Byrna was especially good at talking about suicide as a practical decision. How much physical pain could I endure? How was I going to carry it out? Was I sure I could do it without botching it and ending up alive and para­lyzed or brain damaged? Could I do it in such a way that my body wasn't discovered by someone who loved me and would be traumatized for life?

Karen Lindsey appreciated this straightforward, reality-based focus on suicide. Her friend Byrna spoke about the unspeakable, bringing up all the unpleasant details, grisly secrets, and uncontemplated hazards of suicide. It may sound heartless, but Karen found the discussion to be helpful.

It demystified suicide, taking it out of the realm of guilt and sentiment and making it what it was: a totally serious and irrevocable decision which I had the right to make, but was responsible -- both to myself and my friends -- for making clearheadedly.

 What about suicide prevention services? Do they help?

The data is sketchy. Studies show that these services in the United States have failed to produce the hoped for reduction in suicide rates in the locales where they have been developed. The harsh fact remains: "People who are sure about killing themselves rarely call the suicide hot line." These are what some researchers have called "the true suicide constituency."

In the book Suicide: Theory and Clinical Aspects, L. D. Hankoff and Bernice Einsidler report:

Mass information approaches which emphasize telephone hot lines may be profitable for alcoholism and acute emotional upsets, but some other means is needed for dealing with chronically and more malignantly suicidal individuals who account for the greater proportion of suicide fatalities and are probably the least responsive to hot line services.

 In the end, we must candidly admit that suicide prevention is in its infancy. We can list endless reasonable arguments against suicide, but as writer Cesare Pavese, a member of the "true suicide constituency" (he committed suicide) once observed: "No one ever lacks a good reason for suicide."

But if given the opportunity, depressed people who think they have found a way to relieve their misery through suicide, might find that there are better means of relieving the misery. . . by changing their lives instead of abandoning them.