Treating Male Suicide & Depression

In the past several years, the New York University Press has published a series of books on various aspects of psychiatry under the general heading of "Essential Papers." Their most recent-the 15th in this series-edited by John T. Maltsberger and Mark J. Goldblaft-is entitled Essential Papers on Suicide. An exact listing of the 40 items contained in that bushel basket of intellectual goodies is given in the table of contents. For Maltsberger and Goldblatt to put forward such a list of the 40 essential papers on this complicated, vexatious, and contentious topic is not only a feat of high scholarship, but also an act of considerable bravery. It takes courage for two suicidologists, no matter how impressive their own credentials, to tell their fellow suicidologists who is "in" and who is not; that this is the list; that, bibliographically speaking, here is what 20th-century suicidology is. They tell us in their introduction:

Our purpose in this collection is to offer an array of papers that are psychologically close to the suicide experience, or else throw light on that experience If these papers are essential, it is because they deepen our grasp of the texture and color of the inner lives and struggles of suicidal patients and the corollary challenges they pose for those who treat them.

In a general sense, Maltsberger and Goldblatt's book addresses the question, What clues to suicidal events-to their etiology and mollification-can we glean from the psychiatric and psychological literature published in the 20th century?

Here are some of my reactions to the contents of the book- eschewing the topics of obvious omissions and unnecessary inclusions-about groupings of papers, implications for therapy, views of the suicidal act, and what we are supposed to learn about suicidological theorizing.

After making obeisance to Freud's indispensable 1917 paper on "Mourning and Melancholy" in the preface-and saying that they did not reprint it because it is easily available elsewhere-Maltsberger and Goldblatt then reprint, with instructive comments, the 40 selections) chronologically, beginning with Ernest Jones's 1911 paper relating suicide to birth and death. Then follow important papers by Karl Menninger, Gregory Zilboorg, and two score of other worthies including Robert Litman, Aaron Beck, Marie Asberg, Herbert Hendin, and Jan Fawcett.

At first reading I felt overwhelmed by the plethora of intellectual richness, but then I saw that the papers might sensibly be divided among five categories: (a) papers about affective states; (b) papers relating to psychiatric diagnostic categories, physiological changes, or demographic indicia; (c) papers discussing the therapist or the family; (d) papers about the biology or possible genetics of suicide; and (e) papers concerning psychodynamic formulations. A few words about each:

1. Affective states. These included papers touching on such topics as hopelessness, loneliness, anxiety, depression, despair, fear, anguish, aggression, and anhedonia-11 such pieces.
2. Diagnostic categories, physiological measures, demographic indicia. There are around 20 papers in this category. They include papers centered on suicide and schizophrenia, depression, alcoholism, melancholia, borderline disorder, panic state, affective disorder, abnormal spinal fluid values, masochism, abandonment, somatic illness, family history of suicide, preoccupation with death, special vulnerabilities, lack of exterior resources, death fantasies, and poor reality testing. Many of these papers seemed to hover around the spirits of the two Emiles: Emile Kraepelin (alive today in the Diagnostic and Statistical Manual of Mental Disorders) and Emile Durkheim's Le Suicide, which explored the power of the nomothetic approach in suicide. It is not my opinion alone that these are 19th-century masterpieces, but it is my belief, perhaps idiosyncratic, that they are both outworn and are being systematically misapplied, almost a century later, in clinics, hospitals, and other health management organizations everywhere.
3. The therapist, the family. There are fewer than one handful of papers in this category; specifically, papers on the role of transference in psychotherapy, on countertransference hate, on the importance of consultation in treating suicidal patients, and on the role of death wishes within the family. The importance of significant others and of community resources is underrepresented in the technical literature on suicide.
4. Biology of suicide. in this category, two important papers are reproduced. They are Alec Roy's "Family History of Suicide" and "5-HIAA in the Cerebrospinal Fluid: A Biochemical Predictor?" by Marie Asberg and her Swedish colleagues.
5. Psychodynamic formulations. By far the largest number of papers-about 35 of them (remembering that some papers fell into more than one category)-were discussions of some psychodynamic constellation that, it is asserted, underlies the commission of suicide. It is alleged in serious venues, mostly psychoanalytic journals, that suicide can be seen as related to homicide, as associated with birth and death, as reflected in the wish to kill and the wish to be killed, as murderous aggression toward the selL as revenge, as spite, as reflected in fantasies of escape, as a discharge of aggression, as a ritual phenomenon, as related to the wish to sleep, as fusion with the other, as reunion with the dead, as a wish to be reborn, as narcissistic exhaustion, as abandonment, as an unconscious wish to be eaten) as confusion of self and others, and as atonement. In addition, suicide is discussed in terms of ambivalence, rescue fantasies, its dyadic nature, its erotic elements, and death instinct.

All of these formulations, a priori, might be true-or none might be true. It is certainly food for thought, and they have sometimes been the main course in banquets of psychotherapy, but I am not yet satisfied that the enduring proteins, carbohydrates, and vitamins of suicide prevention are contained in that menu.

It may well be that those 40 authors were not only examining very different parts of the beast-the trunk, the tail, a leg-but that it was not an elephant in the first place. It may have been a unicorn, in which case they certainly missed looking at its distinguishing horn that, in its pointed convolutions, may contain the magical elixir of knowledge.

Here is my summary of those 40 items contained in Essential Papers on Suicide: In the 20th century, suicidologists (mostly psychoanalytically oriented psychiatrists) seem to have written about four psychological aspects of suicide:

1. Fight. These are papers on suicide as murder, aggression, rage, anger, spite, rejection, revenge, the wish to kill. This thread has been overemphasized, in my opinion. Suicide can be other than homicide; the principal emotional state can be other than murderous rage.
2. Flight. These are papers on suicide as escape, rescue, sleep, rebirth, reunion, the wish to die, and as an effort to escape unbearable consciousness. This category represents the majority of my own voices on the principal meaning of suicide.
3. Fright. These are papers on suicide as painful loneliness, isolation) abandonment, hopelessness, anxiety, confusion, panic, psychic pain. In general, important opportunities for remedial action lie in this category.
4. Freight. These are papers on a family history of suicide, hatred in the family, scapegoating, history of abuse, mental illness in the family, genetic vulnerability. These are the onerous psychological burdens that one carries on one's shoulders, none conducive to running life's race in the happiest style.

The Maltsberger and Goldblatt book is important. The book itself is essential, but like many essential items in life, it nonetheless leaves us hungering for other templates, radically different approaches to suicidal phenomena. Some years ago, responding to some needs I felt-order? understanding?-and in an effort to be a more effective therapist with suicidal persons I was then treating at the University of California, Los Angeles, Neuropsychiatric Institute (where I was a professor for some 20 years), I prepared, on one sheet, a list of Henry A. Murray's psychological needs-taken from Chapter 3, "Aspects of Personality," of Murray's monumental Explorations in Personality. After a therapy session, I would rate the patient, distributing exactly ioo points among the 20 need categories.

I made these ratings after each session so that I could monitor the flow of the therapy. This simple form-admittedly a profanation of Murray's 100 pages of finely stenciled text-gave me a new format, a fresh conceptualization, another template for understanding my patient's dialogues with suicide-what Murray had called "the full Congress of the mind." I have always felt that the therapist's understanding of a concept is propaedeutic to any consistent psychotherapy. Psychotherapy is not just a hierarchical conversation; therapy goes much better if there is a clear conceptual template in the therapist's head. I thought then and believe today that I had found mine in Explorations in Personality.

In retrospect, in almost every case I have ever seen, it appears that suicide is pushed by pain; suicidal fantasies and acts are efforts to escape or put a stop to the pain that flows through the mind. It is a special kind of pain, psychological pain, the pain of the negative emotions-guilt, fear, shame, defeat, humiliation, disgrace, grief, dread, woe, loneliness, hopelessness, frustrated love, fractured needs, rage, hostility, and the perception that the pain is unbearable. For the suicidal person, that psychological pain, that pain in the mind, that psychache, has an intensity that pushes it into a special qualitative state; it is deemed unbearable, intolerable, unacceptable; it has crossed a certain critical line somewhere in the mind (see E. S. Shneidman, The Suicidal Mind. New York: Oxford University Press, 1996).

These are some of the reflections I could not have had if I had not been mesmerized and catalyzed by the cornucopia of thoughts contained in Essential Papers on Suicide. From my own experience with this endlessly stimulating volume, I cannot believe that any thoughtful reader can peruse these two-score papers (and read the editors' thoughtful comments) without significant inner growth.
- Shneidman, Edwin S., Comprehending Suicide: Landmarks in 20th~Century Suicidology, American Psychological Association: Washington DC, 2001.

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Personal Reflection Exercise #8
The preceding section contained information about essentials in treating suicide. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 22
According to Shneidman, suicide is "pushed by" what? Record the letter of the correct answer the CE Test.