Relating to Self-Harm and Suicide

Psychoanalytic Perspectives on Practice, Theory and Prevention

Stephen Briggs, Alessandra Lemma, William Crouch, Stephen Briggs, Alessandra Lemma, William Crouch

• Publisher: Routledge
• Year: 2009
• eBook ISBN: 9781135250126
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Alessandra Lemma - Winner of the Levy-Goldfarb Award for Child Psychoanalysis!

Relating to Self-Harm and Suicide presents original studies and research from contemporary psychoanalysts, therapists and academics focusing on the psychoanalytic understanding of suicide and self-harm, and how this can be applied to clinical work and policy.

This powerful critique of current thinking suggests that suicide and self-harm must be understood as having meaning within interpersonal and intrapsychic relationships, offering a new and more hopeful dimension for prevention and recovery. Divided into three sections, the book includes:

• a theoretical overview
• examples of psychoanalytic practice with self-harming and suicidal patients
• applications of psychoanalytic thinking to suicide and self-harm prevention.

Relating to Self-Harm and Suicide will be helpful to psychoanalytic therapists, analysts and mental health professionals wanting to integrate psychoanalytic ideas into their work with self-harmers and the suicidal. This text will also be of use to academics and professionals involved in suicidal prevention.

Part 1
Developments in theory

Chapter 1
Psychoanalysis and suicide: process and typology

Robert Hale

This chapter presents what I consider to be some of the basic dynamics of suicide. Much of it is taken from a paper written with Donald Campbell in 1991 (Campbell and Hale 1991), but it also borrows from authors in Essential Papers on Suicide by Maltsberger and Goldblatt (1996). It is, then, a mixture of my own and other people’s ideas. The work on which it is based took place over twenty-five years ago when I was working at St Mary’s Hospital. For five years I saw only people who had attempted suicide. I had an office on the Acute Medical Admissions ward and saw well over 500 people who had been admitted following a suicide attempt. Some of these people went on to psychotherapy with me or a colleague, and a very small number entered psychoanalysis. Some twenty-two years later, two colleagues (Jenkins et al. 2002) followed up a cohort of 240 consecutive admissions following a suicide attempt. Not surprisingly, given previous studies, a much higher proportion of them ended up killing themselves than would be expected by chance, but surprisingly the rate of death by suicide did not fall significantly over the years. The conclusion, then, is that suicide remains a lifelong option which can be employed at times of crisis.

It is worth recording a note of caution in relation to much psychiatric research on suicide. A recent review on American figures by Luoma and colleagues (2002) revealed that of those people who killed themselves, only 33 per cent had been in contact with secondary psychiatric services in the previous year, but 75 per cent had been in contact with their GP. In the month prior to death 20 per cent had been in contact with mental health services, whereas 50 per cent had consulted their GP. It is impossible to say whether this indicates that the majority of those killing themselves are not mentally ill or do not recognise it, or, alternatively, do not see any purpose in consulting psychiatric services. However, figures would suggest that we might be looking in the wrong place since most psychiatric research concentrates on those in contact with secondary psychiatric services and ignores the vast majority who are not. Therefore prevention strategies might be better focused on education and support of general practitioners and counsellors in general practice settings.

Psychoanalytic interest in suicide dates from the 1910 symposium On Suicide in which Wilhelm Stekel wrote the most basic and crucial statement on suicide: ‘I am inclined to feel that the principle of talion plays the decisive role here. No one kills himself who has never wanted to kill, or at least wished the death of another’ (Friedman 1967:87). He went on to explore the nature of the relationship between the suicidal young person and his or her parent:

The child wants to rob his parents of their greatest and most precious possession: his own life. The child knows that thereby he will inflict the greatest pain. Thus the punishment the child imposes upon himself is simultaneously a punishment he imposes on the instigators of his suffering.

(Friedman 1967:87)

On the other side of Europe, in England, the poet A.E.Housman (1939/ 1995) wrote the following lines in the same year:

Good creatures, do you love your lives
And have you ears for sense?

Here is a knife like other knives,
That cost me eighteen pence.

I need but stick it in my heart
And down will come the sky,

And earth’s foundations will depart
And all you folk will die.

From these authors we learn immediately that suicide is an act with meaning and has a purpose, both manifest and unconscious. It takes place in the context of a dyadic relationship, or rather its failure, and the suffering is experienced by the survivors, or rather, part survivors, of the suicide attempt.

It will already be seen that I do not draw a distinction between suicide and attempted suicide as do many descriptive psychiatrists. This is because I understand suicidal acts along a spectrum: fundamentally the wish to kill the body is present in all suicidal acts, as is the wish to survive. The fantasies which drive the suicidal act are multiple, complex and overdetermined. They frequently contain internal contradictions, the most obvious being the wish to live and the wish to die. A patient who was himself a statistician took 199 aspirins. When asked why he did not take the two-hundredth, he replied, ‘It fell on the floor—I thought it would have germs on it.’ My working definition of the suicidal act is the conscious or unconscious intention at the time of the act to kill the self’s body. This should be contrasted with acts of self-mutilation in which the intention is not to kill but to torture the body.

Suicide is a form of acting out. Freud (1914) originally used the term to describe the phenomenon of a patient, whilst in psychoanalytic treatment, carrying out an action that in symbolic form represents an unconscious wish or fantasy, which cannot be experienced or expressed in any other way within the treatment. Over the years the term has been broadened to describe a general character trait in which a person is given to relieving any intrapsychic tension by physical action.

Acting out is the substitute for remembering a traumatic childhood experience, and unconsciously aims to reverse that early trauma. The patient is spared the painful memory of the trauma, and via his action masters in the present the early experience he originally suffered passively. The actors in the current situation are seen for what they are now rather than for what they represent from the past. Furthermore, the internal drama passes directly from unconscious impulse to action, shortcutting both conscious thought and feeling. The crucial element is that the conflict is resolved, albeit temporarily, by the use of the patient’s body, often in a destructive or erotised way.

The person will implicate and involve others in this enactment. The others may be innocent bystanders, or have their own unconscious reasons for entering and playing a continuing role in the patient’s scenario. The patient thus creates the characters and conflicts of his past in the people of his present, forcing them (by the use of projection and projective identification) to experience feelings which his consciousness cannot contain. He gains temporary relief, but as the players in the patient’s play disentangle themselves from their appointed roles, projections break down, and what has been projected returns to the patient. Because he knows no other solution by which he can escape his inner conflicts, the patient is forced to create anew the same scenario in a different setting. This is the essence of what Freud (1920) referred to as ‘the repetition compulsion’. In suicide, the unconscious fantasy often revolves around settling old scores from unfinished and unacknowledged battles of childhood. These are memories that reside in that part of the patient’s mind of which he is unaware, and of which he has no understanding. Freud described these memories as ‘ghosts’ which compulsively haunt the patient: ‘That which cannot be understood inevitably reappears; like an unlaid ghost that cannot rest until the mystery has been solved and the spell broken’ (1901:122).

Our way into this mystery is by viewing acting out as equivalent to a symptom. In a symptom a fantasy finds symbolic expression in psychological phenomena (or in the case of a psychosomatic symptom, in physical illness); in acting out it is the action which is the symbol of the unconscious conflict. As with the symptom, the exact form of the action is precisely and specifically fashioned by the unconscious fantasies and conflicts. A close examination of the external facts of a suicidal act and the analysis of their symbolic meaning are the clearest pathways to the fantasies which have driven it.

I want now to consider the three sets of personality constellations that underlie a propensity towards suicidal behaviour, and then to describe the final common pathway of the descent into suicide with the fantasies which drive this movement. A recent paper by Apter (2004) confirms the limitations of sole reliance upon assessment of psychiatric disorder in determining suicidal risks. Apter cites the frequent association between suicidal states and mental disorder, commenting, ‘However, these diagnostic indicators have low specificity, do not aid greatly the prediction of suicidal behaviour within diagnostic categories such as depression and do not shed light on the aetiology of suicidal behaviour’ (2004:24). Apter hypothesises that there are three sets of personality constellations that may underlie a propensity towards suicidal behaviour:

1 Narcissism, perfectionism and the inability to tolerate failure and imperfection, combined with an underlying schizoid personality structure that does not allow the individual to ask for help and denies him the comforts of intimacy. In most cases these seem to be lifelong personality patterns not related to stress or periods of depression. Apter describes these people as using achievement as a kind of pseudo-mastery substitute for a lack of real interpersonal closeness in the form of a suicidal act. Shame and humiliation are triggers for suicidal acts in this group of people.

2 Impulsive and aggressive characteristics combined with an over-sensitivity to minor life events. This sensitivity often leads to angry and anxious reactions with secondary depression. These people tend to use defences such as regression, splitting, dissociation and displacement. They have often suffered childhood physical and sexual abuse and there is often a history of alcohol or substance abuse in adult life. Apter (2004) links these characteristics to an underlying disturbance of serotonin metabolism, which he suggests is genetic in origin. However, given the high incidence of childhood traumatic events in this group of patients, and with the increasing knowledge of the biological consequences of child abuse, it seems possible that the biochemical abnormalities are at least to an extent determined by childhood trauma. In adult life these people are seen as impulsive, at times aggressive, with a low tolerance of frustration. They are often categorised as having borderline personality disorder.

3 In those persons whose suicidal behaviour is driven by hopelessness often related to an underlying depressive state, Apter suggests that this hopelessness results from mental illness, such as affective disorder, schizophrenia or anxiety disorder, using the paradigm underlying mental illness to account for the suicidal behaviour. Clearly this is the case when one encounters an individual who has longstanding bipolar disorder (recurrent manic depression or recurrent depression) or a recurring schizophrenic illness. However, in my experience, in the majority of cases, the depressive state is a reaction to life circumstances and represents unconscious anger turned towards the self.

Core complex relationship

The starting point for suicide is the core complex relationship, as described by Glasser (1979), which refers to a way of relating to the ‘significant other’. For the person who engages in this sort of relationship there are two equal and opposite terrors: first, that of closeness, because with it comes the fear of being engulfed by the other person, and thus of losing one’s own identity; and second, that of being left and thus abandoned to starve by the other. Whilst this is an almost ubiquitous phenomenon, what identifies the core complex individual is first the intensity of the feelings, and second the means by which they control their partner. In ‘normal’ individuals, the signals for an appropriate degree of togetherness or separation are affectionate or collaborative; in the core complex individual the distance is maintained by communications or acts of cruelty and coercion.

Betrayal and the pre-suicidal state

Inevitably something will happen which is perceived by the suicidal individual as a betrayal of trust, usually an act of abandonment, and the individual enters the pre-suicidal state described by Ringel (1976). This is the ‘accident about to happen’ state in which the suicidal fantasies are becoming conscious, and preparations for the suicidal act are made. The pre-suicidal state may last hours or days, but eventually there will be a final trigger which will destroy all ego controls, and the individual’s mind fragments into a state of confusion.

The trigger

A trigger to violence may take any of three forms, and precipitate the final breakdown into a destructive attack, either suicidal or violent:

1 An actual physical attack, however small, which crosses the body boundary. In the process of an extended argument, one workmate pushed his fingers into the ribs of Mr A to make his point more forcefully. In response, Mr A broke his mate’s jaw.

2 A physical gesture may be experienced as an attack or as rejection. The commonest gesture must be a V-sign, but it can be a denigrating look, or a turning away, or a rejection, like shutting the door in someone’s face.

3 Words which have an intrusive, dismissing and sexualised character, which are felt as a physical assault or dismissal.

All three things have in common, first, that they are experienced as an assault or as a rejection, and, second, that the recipient/‘victim’ cannot assess them objectively so that they are felt to be overwhelming. It is thus the internal meaning of the trigger that matters. What is explosive to one person may be innocuous to another. What is catastrophic at one time may be irrelevant at another.

Confusion

Two observations substantiate the importance of confusion as an element in violent suicidal acts. First, in general hospitals the commonest cause of violence is a toxic confusional state in which an innocuous stimulus is perce...

Table of contents

• Contents
• List of contributors
• Foreword
• Preface
• Acknowledgements
• Introduction
• Part 1 Developments in theory
• Part 2 Practice
• Part 3 Applications in practice, prevention and postvention
• Name index
• Subject index