Understanding Suicide

Journal – Suicidology Online

Edwin S. Shneidman on Suicide

Click HERE for the original paper.

By Anton A. Leenaars

EXCERPTS FROM THE PAPER:

It is true that happenstance marked Shneidman’s career. While working at the LA Veterans Administration in 1949, he was asked to write condolence letters to widows of two victims by suicide. He researched the two cases at the LA County Coroner’s Office and there was led to a vault of suicide notes. He never looked back. Shneidman spent his life studying why people kill themselves, indeed, the intensive and creative study of people who died by suicide.

His life’s mission was to forestall death as long as possible. To accomplish this mission, he created a new discipline, named it, contributed to it, and most importantly, catalyzed other competent investigators to invest in it. He was a pioneer. He loved his work. His scholarly writings in suicidology reflect the efforts, and indeed, allow us to understand the suicidal mind better.

In his reflections, Edwin Shneidman does not know whether suicide was looking for him or he was looking for suicide.

Professor Shneidman stated that suicide is essentially psychological pain. It is not entirely so, and maybe not centrally so, but that is what, he stated, we can investigate and explicate.

Shneidman’s main contribution has been the explication of the pain.

He writes:

As I near the end of my career in suicidology, I think I can now say what has been on my mind in as few as five words:

Suicide is caused by psychache (sik-ak; two syllables).

Psychache refers to the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind.

It is intrinsically psychological – the pain of excessively felt shame, or guilt, or humiliation, or whatever. When it occurs, its reality is introspectively undeniable. Suicide occurs when the psychache is deemed by that person to be unbearable. This means that suicide also has to do with different individual thresholds for enduring psychological pain (Shneidman, 1985, 1992a). (Leenaars, 1999, p. 239).

From Shneidman’s perspective:

The view of the psychological factors in suicide, the key element in every case is psychological pain: psychache.

All affective states (such as rage, hostility, depression, shame, guilt, affectlessness, hopelessness, etc.) are relevant to suicide only as they related to unbearable psychological pain.

If, for example, feeling guilty or depressed or having a bad conscience or an overwhelming unconscious rage makes one suicidal, it does so only because it is painful.

No psychache, no suicide. (Leenaars, 1999, p. 243).

Shneidman’s (1992a) paper, “A Conspectus for Conceptualizing the Suicidal Scenario” was an outline on suicide. It is a survey of the suicidal mind. It was a place for Shneidman to state the ten commonalities that he has provided in his Definition of Suicide. The ten commonalities was Shneidman’s way of staking a claim for the psychological threads in suicide.

Here are Shneidman’s commonalities:

I. The common purpose of suicide is to seek a solution.

II. The common goal of suicide is cessation of consciousness.

III. The common stimulus in suicide is intolerable psychological pain.

IV. The common stressor in suicide is frustrated psychological needs.

V. The common emotion in suicide is hopelessness-helplessness.

VI. The common cognitive state in suicide is ambivalence.

VII. The common perceptual state in suicide is constriction.

VIII. The common action in suicide is egression.

IX. The common interpersonal act in suicide is communication of intention.

X. The common consistency in suicide is with lifelong coping patterns. (Leenaars, 1999, p. 225).

He believed that suicide could be prevented;

he writes:

The feasibility of preventing suicide – We might say that if we have learned anything from our decade of work on this topic, we have learned that, happily, most individuals who are acutely suicidal are so for only a relatively short period, and that, even during the time they are suicidal, they are extremely ambivalent about living and dying. If the techniques for identifying these individuals before rash acts are taken can be disseminated, and if there are agencies, like the Suicide Prevention Center, in the community that can throw resources in on the side of life and give the individual some temporary surcease or sanctuary, then after a short time most individuals can go on, voluntarily and willingly, to live useful lives. We know that it is feasible to prevent suicide. (Leenaars, 1999, p. 315).

Much of the current understanding and research in suicide, Shneidman believed, is at least half-paralyzed. It is, in fact, easy to criticize the education in the field, but it is more difficult to really teach the multitude, and perhaps, Shneidman has done so. Who in the field could forget Shneidman’s famous myths? On a clinical note, a key myth is that suicide happens without warning. The fact is at least 80% do, which obviously means that 20% do not. In the 1990’s, Shneidman (1994a) reconsidered his perspective on the clues to suicide. He asked, “how it is that some people who are on the verge of suicide…can hide or mask their secretly held intentions?” Shneidman suggests that many clues are veiled, clouded, and guarded, some even misleading. He argues that there are individuals who live secret lives, some suicidal. There are conscious and/or unconscious walls or barriers. To dissemble means to conceal one’s motives. It is to disguise or conceal one’s feelings, intention, or even suicide risk. These people wear “masks”. Shneidman (1994a, p. 395) stated: flux We suicidologists who deal with potentially suicidal people must…understand that in the ambivalent flow and of life, some desperately suicidal people…can dissemble and hide their true lethal feelings from the world.

How do you reach through the mask effectively? Shneidman’s main clinical work was psychotherapy, what he believed to be the major intervention. He espoused that treating suicidal people was different, not only the same, as people in general. Shneidman’s (1980) paper, “Psychotherapy with Suicidal Patients” provides certain rules for treatment of suicidal people that Shneidman thought should be stated. It contains prescriptive advice for the psychotherapist, suggesting a focus on the assessment of the patient’s lethality and on the therapist’s countertransference (and of the advisability of consultation if there are any difficulties in the countertransference). Implied in the paper is that all psychotherapy cures of suicidal people are transference cures.

The paper is also a brief comment at the whole topic of rational suicide. Shneidman does not think that we can usefully debate whether or not there is rational suicide.

Most suicides are sensible and logical to the person who commits them. The implication is: if suicide is a permanent solution to a transient problem, then you want to get that person through that time. You want to intervene. He writes: In human beings pain is ubiquitous, but suffering is optional, within the constraints of a person’s personality. Just as it is important to distinguish between the treatment of physical pain and the treatment of suffering (Cassell, 1991), so there are also important differences between the diagnosis of depression and the assessment of psychological pain. A focus on mental illness is often misleading. Physicians and other health professionals need the courage and the wisdom to work on a person’s suffering at the phenomenological level and to explore such questions as “How do you hurt?” and “How may I help you?” They should then do whatever is necessary, using a wide variety of legitimate tactics (Shneidman, 1984), including medication, to reduce that person’s self-destructive impulses. Diagnosis should be adjunctive to a larger understanding of the person’s pain-in-life. (Leenaars, 1999, p. 384).

At 90, Dr. Edwin S. Shneidman reflected one last time on suicide, in his book, A Commonsense Book of Death. He wrote:

My theory of suicide can be rather simply stated. There is a great deal of mental pain and suffering without suicide – millions to one – but there is almost no suicide without a great deal of mental pain. The basic formula for suicide is rather straightforward: introspective torture plus the idea of death as release. The key, the black heart of suicide, is an acute ache in the mind, in the psyche, it is called psychache . In this view, suicide is not a disease of the brain; but rather it is a perturbation in the mind, an introspective storm of dissatisfaction with the status quo , a dramatic (albeit self-destructive) effort to return to a status quo ante.

Thousands of observations can be distilled into as few as ten psychological commonalities of the suicidal states. One finds these attributes in almost every suicidal person. These attributes provide a fresh template for viewing the suicidal process (and the suicidal person) and they have direct implications for how an earnest therapist can act as an effective ombudsman. (Shneidman, 2008, pp. 139-140).