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Section 21
Commonalities of Suicide

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Like food for a starving person or new clothes for a liberated concentration camp prisoner, new ideas create new hope. This is true for both the suicidal person and the therapist. For me, the new idea was that all suicidal patients - that is, all the committed suicidal people I have studied over the years, independent of their different psychological needs-exhibited a certain set of psychological characteristics. In the cauldron of thought, I boiled these down to 10 commonalities of suicide.'

By "commonality," I mean a feature that is present in at least 95 out of 100 committed suicides-an aspect of thought, feeling, or behavior that occurs in almost every case of suicide. I am not talking about suicide among males, or suicide among African Americans, or suicide among teenagers, or suicide among manic-depressives. I am talking about suicide-all suicide. I wish to focus not so much on age, sex, ethnic status, or psychiatric diagnosis, but more on specific cases of suicide so that we can understand the personality of the suicidal person-and, of course, why they are driven to such an extreme act.

Here are the 10 psychological commonalities of suicide that I have found in my studies. (See Table 3.)
1. The common purpose of suicide is to seek a solution. Suicide is not a random act. It is never done without purpose. It is a way out of a problem, a dilemma, a bind, a difficulty, a crisis, an unbearable situation. For Ariel, Beatrice, or Castro-and everyone else-the idea of suicide acquired an inexorable logic, taking on an impetus of its own. Suicide becomes the answer-seemingly the only available answer to a real puzzler: How can I get out of this? What am I to do? The purpose of suicide is to solve a problem, to seek a solution to a problem generating intense suffering. To understand what a suicide is about, we must know the psychological problem the suicidal person intends to address. As Ariel told us, she needed to do something so that she "would hurt no more." Castro reiterated this purpose: "I would obtain the peace that I had sought so long for."

2. The common goal of suicide is cessation of consciousness. Suicide is best understood as moving toward the complete stopping of one's consciousness and unendurable pain, especially when cessation is seen by the suffering person as the solution-indeed the perfect solution-of life's painful and pressing problems. The moment that the possibility of stopping consciousness occurs to the anguished mind as the answer or the way out, then the igniting spark has been added and the active suicidal scenario has begun. "I committed myself to the arms of death"-this was Castro's way of telling us that he wanted all things to stop, now, permanently.

Table 3 Ten Commonalities of Suicide
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o THE COMMON PURPOSE OF SUICIDE IS TO SEEK A SOLUTION.

o THE COMMON GOAL OF SUICIDE IS CESSATION OF CONSCIOUSNESS.

o THE COMMON STIMULUS OF SUICIDE IS UNBEARABLE PSYCHOLOGICAL PAIN.

o THE COMMON STRESSOR IN SUICIDE IS FRUSTRATED PSYCHOLOGICAL NEEDS.

o THE COMMON EMOTION IN SUICIDE IS HOPELESSNESS-HELPLESSNESS.

o THE COMMON COGNITIVE STATE IN SUICIDE IS AMBIVALENCE.

o THE COMMON PERCEPTUAL STATE IN SUICIDE IS CONSTRICTION.

o THE COMMON ACTION IN SUICIDE IS ESCAPE.

o THE COMMON INTERPERSONAL ACT IN SUICIDE IS COMMUNICATION OF INTENTION.

o THE COMMON PATTERN IN SUICIDE IS CONSISTENCY OF LIFELONG STYLES.
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3. The common stimulus in suicide is psychological pain. If cessation is what the suicidal person is moving toward, psychological pain (or psychache) is what the person is seeking to escape. In any close analysis, suicide is best understood as a combined movement toward cessation and a movement away from intolerable emotion, unbearable pain, unacceptable anguish. No one commits suicide out of joy. The enemy to life is pain. "I died inside." "I was hurting very badly inside." "Overflowing waves of pain washed though my body." Pain is the core of suicide. Suicide is an exclusively human response to extreme psychological pain, the pain of human suffering. I believe that if any one of us is able to capture the attention of a suicidal person, the key is to address the pain. If we are able to reduce the level of another person's suffering, even just a little bit, that individual may then see options other than suicide and can choose to live.

4. The common stressor in suicide is frustrated psychological needs. As we have seen in the cases of Ariel, Beatrice, and Castro, suicide stems from thwarted, blocked, or unfulfilled psychological needs. That is what causes the pain and pushes the suicidal act. To understand suicide in this context, we need to ask a much broader question: What is the psychological underpinning of most human acts? The best non-detailed answer is that, in general, human acts are intended to satisfy a variety of human needs. Of course, most suicides represent combinations of various needs. At a fundamental level, the suicidal person believes the act of suicide has a purpose. There are many pointless deaths, but every suicidal act reflects some specific unfulfilled psychological need.

5. The common emotion in suicide is hopelessness-helplessness. At the beginning of life, the infant experiences a number of emotions (rage, bliss) that quickly become differentiated. In the adolescent or adult suicidal state, the pervasive feeling is that of helplessness-hopelessness. "There is nothing I can do [except commit suicide], and there is no one who can help me [with the pain I am suffering.]" The early psychoanalytic formulation about suicide emphasized unconscious hostility, but today we suicidologists know that there are other deep basic emotions. The underlying one of these is that emotion active, impotent ennui, the despondent feelings that everything is hopeless and I am helpless. Castro put it this way: "the rays of hope are lost."

6. The common cognitive state in suicide is ambivalence. Freud brought to our unforgettable attention the psychological truth that transcends the surface appearance of neatness of logic by asserting that something can be both A and not-A at the same time. We can both love and hate the same person. "I can't really say if I hate you or love you." Ariel told us: "It all came out that I really did love my father. I thought I hated him." We are of two minds about many important things in our lives. I believe that people who are actually committing suicide are ambivalent about life and death at the very moment they are committing it. They wish to die and they simultaneously wish to be rescued. As the young woman said about her walking across the steel beam at the hospital, "[I was] hoping that someone would see me out of all those windows; the whole building is made of glass." The prototypical suicidal state is one in which an individual cuts his throat and cries for help at the same time, and is genuine on both sides of the act. Ambivalence is the common state in suicide: To feel that one has to do it, and, simultaneously, to yearn for intervention. I have never known anyone who was 100 percent for wanting to commit suicide without any fantasies of possible rescue. Individuals would be happy not to do it, if they didn't "have to." It is this omnipresent ambivalence that gives us the moral imperative for clinical intervention. In a life-and-death struggle, why would any civilized person not throw in on the side of life?

7. The common perceptual state in suicide is constriction. I am one who believes that suicide is not best understood as a psychosis, a neurosis, or a character disorder. I believe that suicide is more accurately seen as a more-or-less transient psychological constriction, involving our emotions and intellect. "There was nothing else to do." "The only way out was death." "The only thing I could do [was to kill myself,] and the only way to do it was to jump from something good and high." Those are examples of the constricted mind at work.

Synonyms for constriction are a tunneling or a focusing or narrowing of the range of options usually available to that individual's consciousness when the mind is not panicked into dichotomous (either-or) thinking. Either I achieve this specific (almost magical) happy solution or I cease to be. All or nothing.

The sad and dangerous fact is that in a state of constriction, the usual life-sustaining responsibilities toward loved ones are not merely disregarded; much worse, they are sometimes not even within the range of what is in the mind. A person who commits suicide turns off all ties to the past, declares a kind of mental bankruptcy, and his or her memories have no lien. Those memories can no longer save him; he is beyond their reach. Any attempt at rescue has to deal, from the first, with the suicidal person's psychological constriction. The challenge and the task are clear: Open up the possibilities; widen the perceptual blinders.

8. The common action in suicide is escape or egression. Egression is a person's intended departure from a region, often a region of distress. From the suicide notes: "So I'll get out by taking my life." "Now, at last, freedom from the mental torment." Suicide is the ultimate egression, besides which running away from home, quitting a job, deserting an army, or leaving a spouse-all egressions or escapes-pale in comparison. We speak of "unplugging" the world when we go on vacation or bury ourselves in a good book, but most of us distinguish between the wish to get away for a while and the desire to shut out life forever.

9. The common interpersonal act in suicide is communication of intention. One of the most interesting things we have found from the psychological autopsies of unequivocal suicidal deaths done at the Los Angeles Center was that there were clues to the impending lethal event in the vast majority of cases. "I am dying," said William Styron to a perfect stranger; Castro said, "I began to say goodbye to friends." Many individuals intent on committing suicide, albeit ambivalent about it, consciously or unconsciously, emit clues of intention, signals of distress, whimpers of helplessness, or pleas for intervention. It is a sad and paradoxical thing to note that the common interpersonal act of suicide is not hostility, not rage or destruction, not even withdrawal, not depression, but communication of intention. Of course, these verbal and behavioral communications are often indirect, but audible if one has the ears and wits to hear them.

10. The common pattern in suicide is consistent with lifelong styles of coping. People who are dying of a disease (say, cancer) over weeks or months are very much themselves, even exaggerations of their normal selves. In almost every such case, we can see, if we look, certain patterns: displays of emotion and uses of defense mechanisms consistent with that person's immediate and long-range reactions to pain, threat, failure, powerlessness, and duress that match earlier negative episodes in that life. People are enormously loyal to themselves, and they show this by the consistency of their reactions to certain aspects of life throughout its span. In suicide, however, we are initially thrown off the scent because suicide is an act which, by its definition, that individual has never done before, so there is no exact precedent. Yet there are some consistencies with how that individual has coped with previous setbacks. We must look to previous episodes of disturbance, dark times in that life, to assess the individual's capacity to endure psychological pain. We need to see whether or not there is a penchant for constriction and dichotomous thinking, a tendency to throw in the towel, for earlier paradigms of escape and egression. Information would lie in the details and nuances of how jobs were quit, how spouses were divorced, and how psychological pain was managed. This repetition of a tendency to capitulate, to flee, to blot it out, to escape is perhaps the most telling single clue to an ultimate suicide.
- Shneidman, Edwin, The Suicidal Mind, Oxford University Press: New York, 1996.

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Personal Reflection Exercise #7
preceding section contained information about commonalities of suicide. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 21
How can you assess your client's capacity to endure psychological pain which is more likely to result in suicide? Record the letter of the correct answer the Answer Booklet.