Suicide has never been dealt with except as a social phenomenon. On the contrary, we are concerned here, at the outset, with the relationship between individual thought and suicide. An act like this is prepared within the silence of the heart, as is a great work of art.

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Living, naturally, is never easy. You continue making the gestures commanded by existence, for many reasons, the first of which is habit. Dying voluntarily implies that you have recognized, even instinctively, the ridiculous character of that habit, the absence of any profound reason for living, the insane character of that daily agitation, and the uselessness of suffering.

Albert Camus, “The Myth of Sisyphus” (1942)

The following is an excerpt of a broadcast aired August 9, 2018 on BBC Radio 4:

In January a young Dutch woman drank poison supplied by a doctor and lay down to die. Euthanasia and doctor-assisted suicide are legal in Holland, so hers was a death sanctioned by the state. But Aurelia Brouwers was not terminally ill – she was allowed to end her life on account of her psychiatric illness.

“I’m 29 years old and I’ve chosen to be voluntarily euthanised.  I’ve chosen this because I have a lot of mental health issues. I suffer unbearably and hopelessly. Every breath I take is torture…”

In many ways her story is uniquely Dutch. Euthanasia is against the law in most countries, but in the Netherlands it is allowed if a doctor is satisfied a patient’s suffering is “unbearable with no prospect of improvement” and if there is “no reasonable alternative in the patient’s situation”. 

These criteria may be more straightforward to apply in the case of someone with a terminal diagnosis from untreatable cancer, who is in great pain. And the vast majority of the 6,585 deaths from euthanasia in Holland in 2017 were cases of people with a physical disease. But 83 people were euthanised on the grounds of psychiatric suffering. So these were people – like Aurelia – whose conditions were not necessarily terminal.

Should the Dutch government have aided Aurelia Brouwers in committing suicide for what it deemed “psychiatric” reasons?  Our answer to this question is, of course, of real consequence.  However, the purpose of this essay is not to attempt to resolve what is a narrow question of public policy, as important as it may be.  Rather, here I want to advance the idea that we must first consider how the phenomenon of suicide may be engaged and comprehended in the context of the meanings that make it compelling in the first place.  It is my belief that until these meanings – and by implication the structure of meaning as such – are first understood authentically, that our conclusions about Brouwers’ suicide, whatever they are, will be unmoored from the mystery and challenge of the question of human existence itself.  With Camus, I believe that the inquiry into the essential reasonableness of “going on” living – the “why” and “wherefore” of the desire to continue with life – addresses the most primordial philosophical category with which we as living beings can be concerned; hence, the one to which Brouwers’ death is first and most centrally related.

Not surprisingly, it is also therefore invariably the last one that we summon to awareness, if it is ever considered at all.  The usefulness of thinking about suicide is that it is a phenomenon that does not easily admit of analysis by any lesser standard than that of what we think is the worth of existing itself.  Still, the typical responses to the suicide of someone familiar to us can be as much an occasion for evasion as anything else.  It is just that in this instance the range of available routes for dodging the question becomes quite limited.  This is due to suicide’s utter foreclosure of the future – that is, the loss of possibility itself, which throws into the sharpest possible relief our usually mutely uncomprehending position before existence as such.

I define “authentic” understanding as one whose approach to this matter embraces the fact that we exist and are therefore confronted with the task of contemplating the essential significance and desirability of continuing to do so.  Of course, this most vital of all decisions is only rarely made deliberately.  It is almost never arrived at in moments of quiet, reasoned reflection, perhaps in some darkened garrote with a dog-eared copy of a Buddhist sutra or the Talmud open on a table.  This is to say that a resolve to live is almost never settled upon as the result of a conscious process, then to be set forth as guiding credo for life.  Rather, the overwhelming majority of us say “yes” to life and its vicissitudes at every passing moment, but do so completely unconsciously; yet each instant that we “go on” expresses and serves as the latest affirmation of this decision, whether we are aware of this or not.  Put starkly, and in the style of Camus, the fact that we clean the kitchen sink rather than drive to the local gunsmith, purchase a shotgun, and blow our brains out with it quietly declares our determination to proceed.

Modernity and the Outermost Limits of Personal Choice

I cannot say with certainty if Aurelia Brouwers should have killed herself or not.  Although, as noted, my purpose here is to foreground the importance of attending first to what I see as the neglected existential import of her dilemma, I am not without an opinion about her decision; one that I support, albeit reluctantly.  My position is partly an expression of living in the historical time and place that I do; like hundreds of millions of others, I am a child of modernism and its morally relativizing, democratic sensibilities.  To a point I am consoled and inspired by modernity, which I see as having created unprecedented possibilities for individual and social freedom.  I have a near absolute regard for human life, which, in the context of modernity, means honoring the  meaning that others may ascribe to their lives.  Ironically, it is modernity’s high regard for individual existence that yields the possibility that one may will the annihilation of their own being, arguably an act that may serve as an inverse affirmation of its meaningfulness, as well as one counter-intuitively expressing a certain, perhaps perverse kind of self-care.  So my perspective can be described as a qualified modernism, one that is hopefully intellectually and emotionally “open”.

My acceptance of the worldview of this socio-historical situation (one that I would like to think is fundamentally freely chosen, rather than expressing the naiveté of youth or frightened withdrawal into “common sense”) has implications for how I and those around me approach life.  Modernity does not frame the question of the morality of state-sanctioned suicide as answerable in any absolute sense, apart from within the strictures of its own definitions of reverence for individual choice and self-expression.  Of course, affirming the contextual, relative nature of our decisions is itself a type of absolutism, since no value system can be enforced when its basic premises can be ignored on a personal whim.  In this sense it is perhaps more precise to say that modernity harbors a constrained relativism toward existence, one that is “absolutely relative”; or, alternately, one that is “relatively absolute”, which means the same thing.

So the Dutch authorities did not simply allow Brouwers to end her life apart from any ethical standards.  Rather, it followed the logic underlying the modernist support for self-determination to its outermost, perhaps most radical conclusion.  The aspect of the modernist credo applied to analyzing Brouwers’ appeal was based upon something more or less definable as “quality of life”.  This is a purely contemporary idea loosely related to what the authors of the U.S. Declaration of Independence deemed our inalienable right to what they imprecisely designated “the pursuit of happiness”.  In Brouwers’ case these descriptors are logically accurate, though they obviously vastly understate the gravity of

Francis Bacon, c. 1945+ (2)
Francis Bacon, circa 1945

her act.  However, the point here is that at its core it was the individual’s private assessment of her life’s worth and its ultimate direction, assessed by what is arguably the aesthetic standard of quality, upon which the Dutch arrived at their decision.  As Camus relates in the first of this essay’s two epigrams, it is perhaps that they implicitly evaluated her decision as one would a work of art.

The Dubious Role of Medical Science in Euthanasia 

This said, the Dutch authorities were not uncompromising in their adherence to the axiom of self-determination.  Rather, they split the ideological difference by seeking validation of Brouwers’ wish in the most esteemed step-child of modernist rationalism, science.  I propose that this is likely why written into Dutch euthanasia law is the provision that a physician provide support for a death by euthanasia to proceed.  Therefore, Brouwers’ doctor was key to her wish to die, by citing the irreversible and “unbearable” nature of her condition and the absence of what the legal code defines as a “reasonable” availability of other ameliorative measures.  In the present sociocultural context, a physician’s opinion matters in such cases because it provides the appearance of a soberly objective presence in these deliberations.  But assigning this responsibility to a medical professional is indefensible, intellectually and morally.  In fact, I think it is flat out wrong in nearly every way, most fundamentally because it equates expertise in matters of physical life and death with facility in comprehending and responding meaningfully to the question of their existential meaning.  Doctors are skilled at certain things, but with a few notable exceptions they are absurdly incompetent when acting as de facto philosophers and theologians.  In the West, medical training is an almost exclusively technical affair, one unconcerned with issues of ultimate meaning.  Hence, it should come as no surprise to find that doctors share the same resistance to incorporating an understanding of the phenomenon of meaning as such into their personal and working identities that is probably innate to human beings generally.  In short, physicians are by and large incapable of meaningfully considering the existential issues at stake in suicide, and should not be in the position of doing so.

Yet, in most industrialized societies medical professionals are regularly thrust into this heady role.  That this occurs is another expression of modernist liberal and “progressive” social policy, specifically of its adoption of scientific rationalism and materialism as the venue of choice for transmitting what is assumed to be value-neutral, clear-sighted renderings of human nature and the world generally.  So-called “hard” science is a formidable tool for assessing physical phenomena, as well as limited dimensions of the non-physical world.  However, so deeply enamored are we of the power of this worldview that it is now accepted that its explanatory power extends well beyond these boundaries.  Specifically, it is regularly called upon to elucidate the structure of all dimensions of being, including the essential nature of mind, emotion, social bonding, and, as illustrated in the case of Aurelia Brouwers, the significance and merit of life itself.  This is like using a glass jar as a pair of glasses.  While the two objects bear some crude superficial similarities, each is appropriate only for circumscribed and quite different tasks.  In philosophy such confusion is called a “category error”, and leads to inaccurate, sometimes harebrained conclusions about the object of investigation.

This categorical confusion is endemic.  For example, it is seen in the language of the BBC report describing Brouwers’ mental state, an excerpt of which begins this essay, stating that Brouwer suffered a “psychiatric illness”.  And, unsurprisingly, the transcript also quotes Brouwer herself as assessing her condition as due to a “mental illness”.  That said, the transcript may reveal a certain ill-defined uncertainty about ascribing emotional suffering to biological causes: at a later point it subtly delineates Brouwers’ condition from that of a medical condition, classifying her state as one of “psychiatric suffering”, which it implicitly differentiates from one attributable to physical disease.  However, overall, the thrust of the transcript shows the same unquestioning acceptance of a medicalized approach to psychic conflict that is now a nearly universal norm in the West, and one whose claims are only rarely critically examined.

So Brouwers’ doctor signaled approval of her suicide by appealing to some version of a medical construction of human nature, forwarding the idea that their patient had a “disorder” that was likely “incurable”, thus invoking the prestige of empirical science to advocate for her choice.  Here the doctor acted in the socially-assigned role of someone presumed to have knowledge of a verifiable “brain disease” as the cause of Brouwers’ misery.  But while the medical model enjoys iconic popularity in the industrialized West, there is and I predict will never be credible evidence that people who kill themselves do so because of a neuro-biological, genetic, or other physical disorder.  Such a perspective only approaches believability if one is to attribute our encounter with life’s endmost value – including our basic intuition that there are such “things” as values in the first place and that these matter to us – to the operations of neurons, neuro-chemical phenomena, certain strands of DNA, and the like.  Dopamine does not envision meaning, and it is the most childishly concrete kind of thinking that reduces our impulse to cherish, say, hope, beauty, or transcendence to a brain-based electrochemical reaction.

That said, I suspect that many physicians authorizing a patient’s suicide actually doubt the foregoing “medicalized” rationale for such a conclusion.  Some may even admit privately that they consider it bunk.  Such equanimity of judgement assumes that a physician who is charged with this grim task has led a reasonably human life: has fallen in love, been filled with awe at the night sky, pondered why there is something rather than nothing, laughed with friends, perhaps has had children, and has suffered at least some measure of loss and disillusionment.  Perhaps many such physicians see their warrant to answer the question of life’s quintessential value as simply a matter of rendering unto Caesar what is his, using the “thing-a-fying” language of the currently dominant scientific vision of reality; not because they actually think that physical science is capable of analyzing this facet of existence, but simply so as move on efficiently with a painful and vexing process.

All this to say that the procedural steps in this and other, similar cases completely miss a larger point about the nature of meaning itself, I believe.  Rather, they are diversions from this point, a comprehension that cannot be achieved through the diagnosis of a physical condition, but only in a dialogical engagement with the very meaning of human existence itself, one aspect of which elicits the question of its quintessential value.  Issues of government policy about a person’s wish to end their life are rendered morally and culturally vacuous if conducted without prior contemplation of the more basic question of why we think it is desirable to “go on” at all.  Accurately comprehending the import of such a thought is outside the purview of a science that discounts the relevance and often the very existence of immaterial realities.  As an aside, I wonder if the Dutch government sought the counsel of one or more philosophers, theologians, and/or historians of culture when deciding their policy on euthanasia.  We must presume that they did not.  But a panel of such intellectuals would have been in order to clarify and interpret the religio-philosophical underpinnings of their mission.  These foundational premises and their implications cry out for comprehension, and they must not be handed over to physical science to define or explore.

So, within limits and perhaps with a certain amount of ambivalence, the Dutch government’s legal ruling that Ms. Brouwers may end her own life affirmed the modernist stance that in nearly all important existential matters we are free to decide for ourselves.  Of course, open societies restrict such freedom in situations that cause serious harm to others.  In this regard, it is a significant indication of the purity of the Dutch regard for self-determination, and the direction of the evolution of Western moral sensibilities, that here the grief to be inflicted on Brouwers’ family and friends by her death failed to rise to any standard for refusing her request.

Being free in this way is the endgame and dearest desire of secular humanism.  We love this liberated state of being, which has emancipated us, like much of humanity, from the bondage of aristocracies.  But here it is necessary to enclose “free” in quotes: for all its beauty such freedom simultaneously imposes terrific, what we typically feel to be consciously unmanageable demands on each of us to assess questions of fundamental meaning and purpose, a task that was formerly solely the domain of an authority, benevolent or often otherwise.  Such authority was usually religious, and imperiously handed down edicts as to how reality should be – indeed, was allowed to be – construed.  In quickly progressing acts of individual and collective affirmation of social liberty, all that was swept away.  But then the genuinely hard work began, as we only had ourselves to look to for interpretations of life’s cruelties.  Now, more self-determining or “freer” than ever before, we nonetheless feel a deep, objectless, and unquenchable anxiety.  Among other things, this angst tells us that that which keeps us from realizing complete self-expression is not and never was outside of us, but within us.  Hence, when confronted by the question of the meaning of our death, which is intertwined with our comprehension of the meaning of our lives up until the moment of death, most of us become psychologically paralyzed to some degree, and stand mute before the abyss of Being.

And so we look away from the whole question, sinking into the forgetfulness afforded us by the bounty of our now considerable social freedoms: consumer capitalism, so-called “family life” and its mundane commitments, self-medication with drugs, and/or our work or careers.  In his poem “Thirteen Ways of Looking at a Blackbird” twentieth-century American poet Wallace Stevens (1923/2015) conveys how modernity’s loss of religious faith makes even more pressing and unavoidable the question of, as he wrote there, “how to live, what to do”.  As this line by Stevens implies, it is a question that did not dissolve into the ether when we disempowered the priests and sequestered them behind church walls.  On the contrary, doing so caused this question to grow in urgency, uncontained as in former times by creed, ritual, and blind faith, so that it swiftly became central to human life in ways inconceivable in previous, unfree social orders.

To return to the specific case of Aurelia Brouwers, let us reframe Stevens’ question in a way appropriate to her situation: her query was not how to live and what to do, but the more primordial “Should I live?” and “Should I care to do anything ever again?”.  I believe that these are the fundamental questions that her dilemma and final decision puts before us.  It is typically our reaction to click our tongues and express regret at such a choice to, as is commonly said, “throw one’s life away”.  But we generate such a judgement from the false belief that such a person’s untimely death is their own business; a sad and confusing act, granted, but one that in no way involves or reflects anything about us.  We instinctively find suicide uncanny, meaning something vaguely familiar that is rendered as an eerie “other”, or what American psychoanalyst Harry Stack Sullivan (1947) called the “not me”.  This is to say that a person’s death by suicide brings in its wake the return to our consciousness of something disavowed, a phenomenon that we typically treat dismissively as, say, a pointless “morbid thought” or the bothersome expression of some dark but passing mood.

Doubt as to the worthwhileness of one’s existence is not merely a personal problem.  Rather, it is one that foregrounds our private entanglements within the selfsame quandary that for some becomes an excruciating, obsessive, and finally fatal fascination.  Brouwers’ act is an interrogation of the essential merit and desirability of one’s existence itself.  That is, it is a question addressing the very primordial bedrock of what twentieth-century German phenomenologist Martin Heidegger (1927/1962) called our “Being-in-the-world”.  In voicing and dramatically enacting this gravest of wishes publicly, Ms. Brouwers forcefully shoved beneath our noses the only meaningful philosophical question there is, according to French intellectual and novelist Albert Camus.  In his famous 1942 essay “The Myth of Sisyphus” he wrote, “(There) is but one truly serious philosophical problem, and that is suicide.  Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy”.  (Camus, 1942/1991)

Bringing to Light our Collective Identity with Aurelia Brouwer

Predictably, Brouwers’ resounding “no” to what Camus called the only relevant philosophical question provoked extreme responses from those with their own, understandably prized outlooks on life’s value and meaning.  Both camps have rushed to substitute doctrinaire insistence on their worldviews for reasoned dialogue about the meaning(s) of Aurelia’s suicide.  The battle-lines are utterly predictable, to the point of being boring.  Some angrily decried her death as expressing an abandonment of our responsibility for someone who is mentally “ill”, the implication being that this person was psychologically incapable of deliberating sanely about the worth of her life.  Dr. Frank Koerselman, a Dutch psychiatrist and vocal critic of euthanasia law, stated, “How could I know – how could anybody know – that her death wish was not a sign of her psychiatric disease?  The fact that one can rationalize about it, does not mean it’s not a sign of the disease”.  While I am confident that Koerselman’s resistance to the law stems at least partially from his concern for suffering persons, his choice of words to define and defend his position are telling.  I take them as another version of the hackneyed disease model, with what I have argued is its unsubstantiated and dogmatically biological notion of causality.  (One wonders if Dr. Koerselman would concede that any choice to end one’s own life is “sane”, even if it were possible to prove that such a decision was arrived at uninfluenced by a hypothetical brain disorder.)  Others stalwartly defended the state’s willingness to allow her to have her way.  Their arguments are also likely motivated by the same concern for suffering and the ultimate direction of a human life that I infer is present in Koerselman’s position.  However, these defenses of the Dutch law are nearly unanimous in dodging what I have defined as the only truly relevant consideration: whether or not any of us should deem life valuable enough to “go on” with it.  Hence, ironically, both the opponents and supporters of Brouwers’ actions set out their positions by in different ways repudiating identity with her struggle, one that after all is a common feature of our humanity.

To approach this differently, we may consider that the adamant quality of the ideological postures just noted reveal the deeply personally meaningful reality that Brouwers’ suicide carries for all of us.  In such defensive resolve we always find a deeper, unarticulated, and often fierce personal investment in the interpretation of the event being debated.  Buried within such investment is the fact of our identification with Brouwer.  That is, in a way perhaps poorly elaborated in our conscious understandings of ourselves, we sense that we are like her, with the same burning question as to the ultimate desirability of having been born.  Like most polarizing public figures, Brouwers is controversial because she embodies something both in the cultural air and, more fundamentally, latent and unarticulated within the depths of our human nature.  Considering her death elicits a confrontation with this most essential, horrific, and hence avoided of all questions.

We turn those like Brouwers into frightening “others” by framing them as “ungodly”, laboring under “cognitive distortions” (such as a globally negative valuation of various events in ways that common sense deems unrealistic), or, the penultimate damnation, “mentally ill”.  Such individuals are feared and even loathed because they represent, in uncomfortably pure form, a tendency latent within all of us.  Hence, we should first be thoughtful about this feature of our shared humanity, rather than dwell myopically on whether or not someone should be granted the lawful privilege of ending their life.  Here I am arguing that the most profound and pivotal of all questions – “why should I go on?” – cannot be comprehended, much less met with a truly human response, by relying on what is arguably the lowest criteria possible; this being whether or not the answer affirms the continuation of physical existence, regardless of how monotonous and empty it may be.

Let us step back from the anxious desire to issue a fast and definitive verdict on her decision: whether one agrees with her choice and the Dutch government’s support for this or not, Brouwers has done us a huge favor by momentarily tearing away the veil of repression that we customarily cast over this most central of all human concerns.  Someone who has dismissed the existential demand of genuinely and deeply considering, however briefly, if their life is worth maintaining, has either never been born psychologically (and most of us go through life about half-born, psychically, I think), or has committed a metaphoric form of suicide by killing off their capacity to sensitively engage reality.  This kind of violence against one’s consciousness is entirely common and acceptable, socially.  Arguably, it is essential to the very creation and maintenance of culture itself, as psychoanalytic-existential social theorist Ernst Becker (1973) wrote in his important book “The Denial of Death”.  Said Becker, culture consists in an initial, unconscious act of extinguishing one’s capacity to consciously contemplate what Heidegger (1927/1962) called the “Being-toward-death” that he saw as constitutive of human existence, and then proceeding to distractedly direct our energies toward the manic busy-work of self and world mastery.

All this to say that the question of whether or not this woman should have been allowed, in a legal sense, to kill herself seems entirely beside the point.  I do not deny that debate about this issue in the cause of establishing public policy is politically and morally necessary.  But whatever answer we arrive at is incoherent apart from our having first considered the more essential question posed to us by Camus.  That is, if we feel that life is a phenomenon of utmost value, then why should this be so?  We who remain among the living (for now, at least) want to remain that way, though at the edge of the – using another of Heidegger’s terms – “average everydayness” of our lives we know that this cannot be.  Of course, our inevitable deaths are probably the very last thing any of us think about, much less discuss.  Arguably, the nearly impenetrable density of our denial of death constitutes as much a hypothetical psychiatric illness as we presume exists in the wish to kill oneself.  To our contemplation of the meaning of suicide, then, must be added the possibility that it was Brouwers who at the end evidenced some genuine psychic clarity about life.  This would also mean that in dying she left behind a human herd mired in irrational participation in a mass delusion of life without death, an anemic reverie whose potency and intransigence equals that of the tribal spiritualities over which it imagines it has triumphed.  In this view, Brouwers escaped from the madhouse, so to speak, through the one exit that is always left unguarded.  This is a door watched over by an ineffable spirit, one unknown to the now-banished God of the West.  This “unknown god” stands outside the portal, silent and defiant, granting entry to all who seek it, without judgement.

Contributions of the Psychoanalytic Theory of Self-Destructiveness

My general worldview – professionally and personally – is heavily influenced by psychoanalysis, and I think its perspectives greatly enhance our reflections upon the nature of suicide.  This worldview both deepens and further complicates our understanding of this subject by proposing that we are not as resolutely devoted to our well-being as we think.  In this view all of us, at all times, compulsively live out certain dimensions of our desires motivated by what Sigmund Freud (1926) called the death instinct.  Here Freud characteristically offends by undermining yet another of our dear presumptions, in this case by suggesting that we are only ambivalently oriented toward life and love: within the darker, opaque dimensions of our souls we nurse an innate desire for non-being, he thought.  Freud initially posited the drive toward death as a biological predisposition to seek the dissolution of consciousness in unreflective matter.  Rather than mull the accuracy of such a claim, it seems more convincing to point to our common human experience of finding ourselves repetitively seeking out the very experiences and situations that deplete – and, in extreme case, eviscerate – our capacity to care about ourselves, invest in the world about us, or to even want to think about the future meaningfully.  These are symptomatic, symbolic expressions of self-destructiveness, not the kind expressed in the fully self-murderous act of suicide, usually; though, that said, they can and do culminate in this very ending for some people.

Take that certain “type” of love interest that many of us are continually drawn to, for example.  This is that person whose allure we start to realize, perhaps well into the affair, that we somehow knew consisted largely in their status as the latest edition of a perverse romantic fascination, one that we again enacted with “eyes wide shut”, in defiance of our conscious agendas.  Prior rationalizations begin to crumble, as the understanding forms that the consciously life-affirming intentions with which we began the relationship were actually fragile, possibly familiar illusions.  Reiterating such an inexplicably self-defeating attraction gradually undermines our capacity to find pleasure in life; that is, it metaphorically “kills” us, which is why Freud located the key symptomatic expression of the death instinct in what he called “the compulsion to repeat”.  Usually we don’t physically die as a result of this, though we may complain of wishing we were dead.  In such a conundrum we may simply go through the motions of living, entombed mentally in a zombie-like state, physically alive but inwardly facing an ominous nothingness.  That is, we feel metaphorically “dead”.  This inner vacuity is an encounter with non-being, or what Heidegger (1927/1962) called the “nullity” that constitutes our existence, and which he saw as a structural pillar of human nature.  In individuals who have suffered developmentally early, profound disillusionments, the emergence in the ego of this existential vacuum may easily become the trigger for all manner of self-destructive behavior, up to and including suicide.  But from this perspective physically ending one’s own life is simply a radical, often literal reading of a script that is innately inscribed on every heart.

Freudian thought often provokes considerable contempt due to its disillusioning features.  And this response is most forcefully evoked by its concept of an instinct toward non-being.  However, there is a dimension of this general thrust of Freud’s theorizing that is also uniquely capable of revitalizing our awareness of identity with someone like Brouwers.  Part of its capacity to do so lies in its subtle departure from the ontological assumptions and methodologies of so-called “hard” science.  From its inception psychoanalysis has been situated within a Western sociocultural milieu that idealizes objectivist, empirical visions of reality.  In matters relating to human nature, the modern West’s preferred vision of existence yields a habit of dividing certain mental states and behaviors into opposing categories of “normality” and “abnormality”.  But while appropriating this scientific language, Freud and his heirs also implicitly reject its dichotomizing spirit.  This is found in their theorem that every mental state, desire, and behavior is the common property of all human beings, and is only comprehensible as such.  All that every person thinks, hopes for, and acts so as to attain reflects a bio-psycho-social inheritance whose core dispositions reside within all of us, in some form constitutive of the “givenness” of the mind’s structure itself.  This challenges the legitimacy of modernist scientific rhetoric claiming to be capable of “diagnosing” some expressions of human nature as “healthy” and still others as “unhealthy” or “disordered”.

Here we find Freud’s theoretical relevance to our earlier discussion of our identity with Aurelia Brouwers.  In his instinct theory Freud posited a fundamental commonality to all human desire and motivation.  Viewed thus, it becomes impossible for any of us to dissociate ourselves from the set of dark impulses that possessed Brouwers, by assigning them to the categories of the non-human, unrecognizable, and/or uncanny.  The sixth chapter of the Hindu Chandogya Upanishad (c. 600 BCE), composed in Sanskrit, puts it thus: Tat tvam asi, roughly translated into English as “you are that”, indicating the relationship of existential unity between individual life and the absolute dimensions of Being.  Given our collective human proneness to viciously turn on ourselves in a vast array of ways, including those that are metaphoric though quite real in their effects, it seems that we should examine our temptation to define someone who deliberately ends their life as an alien outlier.

Toward Existential Resoluteness in the Encounter with Death

Philosophically and spiritually, I am convinced that where there’s life there’s hope.  Now that I’m pushing sixty years of age, I have more or less made my peace with reality, which, to borrow analyst C.G. Jung’s (1961/1989) musing on the course of his own life, I find simultaneously “meaningful and meaningless”.  More precisely put, I find that the meaninglessness of life is itself strangely evocative, compelling, and hence paradoxically meaningful.  But in engaging with others who may not share this sense of optimism about reality, I strive – usually successfully, I’d like to think – to maintain what I see as my existential obligation to both myself and them to approach the question of life’s ultimate value in a spiritually authentic manner.  Here “authenticity” means with a minimum of denial, rationalization, and/or that selfish and self-protective fretfulness that insists upon coercing others to embrace life simply to bolster one’s own state of willful ignorance about the fact that it must end.  This means keeping my profound anxiety about my personal, inevitable demise in check.  I can do this only to the extent that I am authentically alive enough to tolerate and perhaps even integrate into my conscious identity the knowledge that one day I will cease to be.

Obviously, this is a daunting task for even the most resolute person, and so it is almost never done with consistency.  But I am convinced it can be carried out in almost every circumstance, to some important extent anyway: we are all able lurch, however ungraciously, toward the truth, trying all the while to be reconciled to the fact that we will constantly recoil and retreat from this goal, and so will fairly regularly be forced to

Paul Cezanne, Still Life With Skull (1898)
Paul Cezanne, 1898

regroup and reconsider our stance.  Forthrightly acknowledging the fact of death involves a certain self-discipline, one that maintains cognizance of the fact that death discloses both the terrors and promise of our human condition more starkly than any other experience of our being-in-the world.  That is, as Heidegger (1927/1962) noted, it is singularly, as he stated, “disclosive” of Being itself in a way unmatched by any other mental state.  This attitude reveals itself in specific ways in my relationships with certain patients who have come to trust me enough to openly speak of such a “taboo” solution to their hopelessness as self-murder.  Specifically, it is a kind of self-comportment that supports a dialogue whose purpose is to honestly and forthrightly assess what could be the elements and meaning(s) of a life that someone genuinely wants to live; and, conversely, those that constitute a life that someone may flatly refuse to live.  This stance can only be maintained with existential integrity when the question of death itself is approached without the usual evasions; which, to be clear, is not the same as to say “without anxiety”, but with anxiety temporarily mentally “bracketed” and put to the periphery of consciousness.  That is to say, one experiences the cold chill of nullity and proceeds forward anyway.

A Model for Responding Therapeutically to Patients’ Suicidal Wishes

Human communities’ deep emotional investment in deciding the meaning of suicide and the nature of their corporate response to this, is expressed in the legal code of every nation in which psychotherapy is recognized as a profession and regulated.  In the United States we require psychologists, social workers, counselors, and psychiatrists to intervene decisively when a patient reveals an imminent and serious intention to harm or kill themselves.  Written into all state licensing codes is the mandate to report such an individual to someone who can reliably avert such an outcome, be this the police, family member, or some other person or institutional entity.  The psychotherapist is exempted from maintaining confidentiality in such situations, and so may reveal any information about their patient sufficient to ensure that they remain physically safe, without their consent, if necessary.  In terms of the actively suicidal patient, this requirement poses real emotional challenges for the psychotherapist, in addition to the already heavy burden of understanding and exploring their own response to the thought of losing a patient in this way.  In twenty-five-plus years of practice I have never been faced with such an immediately dire situation.  However, I have had numerous people come to me who had either seriously considered killing themselves, were considering doing so presently, and/or had made serious, perhaps nearly successful past attempts.  If and when such patients tell me of their wish to die, or it becomes evident at some point that such an intent is “in the air”, I generally have told them some version of the following:

I respect your freedom in this matter.  Of course, you may know that I am legally obligated to take action to try to stop you, if such a thing seems about to occur and we can’t agree to keep talking about it.  But I’m no fool.  I know I can’t stop anyone from committing suicide, if they are determined to do so.  And, honestly, my respect for the value of human freedom extends to your wish to cause your own death, if at some time that is what you truly, deeply feel is your only good option.

So you have the final say here, which I think is as it should be.  But I’d at least like you and I to have an agreement that you’ll speak with me before you act on such a wish, since killing yourself is final, the end of all possibility in your life.  And you did come to see me, after all, which means that you have some hope that you may find life worth living.  If you choose to kill yourself, then so be it; but it seems that a period of serious thought should precede such an act. 

While the foregoing is a bit of a “canned” speech, I always mean it entirely honestly.  Its perhaps scripted nature is a result of the extensive thought that I have devoted to the nuanced and indeterminate nature of suicide, an expression of my concern to keep that which is quintessentially human clearly in view that I sense patients readily infer.  I have never had a patient decline this proposal.  And notably, quite a few have expressed relief at my ultimate support for their existential freedom to kill themselves, in the event that they became convinced that going on is futile.  For most, my position on this matter came as a complete surprise, coming as it does from someone they naturally assumed would display the standard “life at all costs” posture toward their suicidal thoughts that dominates the helping professions.  I cannot be sure, of course, but I suspect that this is why I have never had a patient commit suicide while in treatment with me (though I have heard of two who did so some years after they stopped seeing me).

Most of us know that forbidding something causes the desire to see it through build in intensity, while a reasonably permissive stance allows desire to seek its own, natural resolution; which, at day’s end, is the only way that a compelling desire is ever genuinely resolved.  Suicidal persons derive unconscious comfort from knowing that the option of killing themselves is available to them, though this can seem hard to believe, given that they generally present their suicidal wishes only as torments.  But the recourse to a self-inflicted death also provides perhaps the last element of self-determination that they feel is available to them.  (Winston Churchill, who struggled throughout life with severe depression, once quipped with typically British doggedness that it put him at ease to know that if he wished he could throw himself under the morning train to London.)  Hence, suicide must not be approached as a “pathogenic” factor in the personality but as one that supplies a real measure of dignity.  This means assiduously avoiding actions that may provoke the patient’s ego-protective wishes to rebel against what they perceive as an agenda to deprive them of this treasured possession, however responsible the therapist believes such a project to be.

Expressing a genuine stance of regard for someone’s right to make meaning of their life, up to and including its ultimate worth or worthlessness and what to do with their verdict about this, tells them that I am not in practice to control or coerce others; and that this would be true even if such godlike authority over their thoughts and acts were attainable, which of course it is not.  It perhaps goes without saying that verbalizing this attitude to someone in treatment is not properly (read honestly) applied as a sly and disingenuous exercise in reverse psychology.  It should be offered sincerely, with genuine acceptance of the fact that an outcome disagreeable or even abhorrent to one’s sensibilities may be the final result.  I think this vow, made without pretension, represents an abdication of grandiosity and its attendant selfishness, among other things.  Further, I consider that honestly informing the suicidal patient that I will obey the legal mandate to unilaterally intervene to prevent their death, should it come to this, introduces the reality of my own humanity into the interaction.  This is yet another aspect of surrendering the more grandiose aspects of therapeutic ambition.  Almost all patients are accepting of this legal caveat, perhaps partly because it says that I am not lacking in a self-preservative instinct: that is, I am willing to go the extra mile for them, but not at the loss of my livelihood.

Hence, I want to convey to the patient that, within broad limits, I am willing to be viewed as a professional – and very probably personal – failure if they act on their suicidal impulses; because, when all is said and done, I am convinced that it is their right of self-determination that must carry the day, whatever I or anyone else may think.  A prosaic but nonetheless modestly astute popular expression from the 1970s advises, “If you love someone, let them go”, which I think captures this idea well.  Of course, the moral for the psychotherapist in this is to be sure you know what you are asking for when you give a suicidal person assent to be the free being that they essentially are, as they may take you at your word.

To be clear, by citing the positive response of my patients to the foregoing I do not mean to suggest that I am an unusually talented therapist, or even above average in emotional stalwartness.  (As those who know me intimately will tell you, I can be sometimes be quite uninsightful about human nature and openly cowardly when facing certain of life’s difficulties).  It simply means that I have found a way to live out my fundamental moral and ethical sensibilities in dialogue with those in this most desperate of straits.  I think this is possible for most people to do this, though it requires both that one has actually thoughtfully examined these biases and is optimally – not completely, but fundamentally, in one’s emotional core – free from deep personal identification with “common sense”, taken-for-granted approaches to moral problems.

Does expressing to the patient this thoroughgoing esteem for their free will imply a laxidasical neglect of their distress, one that may invite them to act on their self-destructiveness?  Assuming that this position is motivated by genuine concern for the integrity of the patient’s humanity, I say not at all.  On the contrary, I think it keeps the patient’s distress front and center in the therapeutic encounter, which provide the best hope for actually enabling the patient to come to terms with its meaning(s) and ominous hold over their life.  Conversely, the patient’s psychic turmoil is neglected when it is displaced from its proper place as the main object of our concern, in the service of attempting to create and enforce unrealistic assurances that they remain physically alive.  It is the individual before us, in the totality of their being – only one expression of which is material – who must be at the center of our thoughts.  When a therapist veers from this stance into an attempt to unilaterally manage their suicidal wishes, the patient is no longer understood as “whole” being.  Instead, in such a circumstance they may well be viewed as someone contaminated with an alien, uncanny, and purpose-driven force that must be exorcised from their being.  In all this the patient’s humanity is not respected.  They become framed as a threatening “other”, in an interpersonal reflection of the same way that they have been unwittingly urged to see their self-destructiveness as an alien entity lodged within their being.

This view can and does result in the therapist eyeing them with suspicious apprehension, as someone possessed by an internal saboteur that may propel them into some dreaded action, one that should be headed off at the metaphoric pass, whatever the patient may happen to think about this.  Patients are exquisitely, if usually only preconsciously aware of how the therapist feels toward them.  Being framed as someone requiring “management” objectifies someone, and may conceivably impel them to commit the very dreaded action that the therapist so earnestly seeks to forestall, as noted earlier.  Hence, I suggest that it is essential that such an individual be understood and approached as someone whose self-destructiveness is comprehensible as a feature of our shared humanity.  In this way, their self-loathing, the very thing that they presume alienates them from the human community, can come to be seen as a bridge that actually connects them to it.   All this to say that we only obtain access to the patient’s soul by faithfully following the logic of their suffering or, to use a medicalized term, their “symptom”.  Attempting to skirt or isolate this fact means that we are addressing superficial manifestations of their dilemma, at best.

Inviting discussion of suicidal ideation is the best and, I am convinced, only existentially authentic, practically effective way of providing lasting relief from its torments.  This is so because putting words to a dark impulse deprives it of much of its power and allure, as it is concernfully coaxed toward a degree of integration with the synthesizing action of ego-consciousness.  Any aspect of the therapeutic situation that directly or indirectly promotes that a dimension of the patient’s subjectivity to be split off and banished to a separate interpersonal and/or intrapsychic realm, sets the stage for a dreadful resurfacing in awareness of this psychic dynamism, one unmodified by consciousness and so quite possibly one-sidedly affixed to realizing a terrible intention.

Facilitating a therapeutic environment that invites authentic, uncoerced contemplation about all dimensions of the patient’s wishes is fundamental to any effective treatment.  And this is no less the case with the phenomenon of suicidal ideation.  Now, it is well-known that individuals who consider suicide are also ambivalent about doing it.  That is, they harbor conflicting goals, wishing on the one hand to rid themselves of unbearable suffering, though uncertain that doing so by killing themselves is desirable, as they are aware, if mostly intellectually, that this solution also eradicates all that is good (or which may become good) about their lives.  Openly and honestly discussing these warring dimensions of mind provides such persons with a larger perspective on their being-in-the-world.  To do so they require an interpersonal situation optimally free from the threat of incarceration in a mental ward, or any other outcome that they experience as an actual or metaphoric punishment for having been forthright.

From a psychoanalytic perspective, the provision of a therapeutic relationship founded upon trust allows the gradual development of what Freud (1913) called the process of “free association” to unfold.  In this process the patient is invited to share and comment upon, in as unscripted and spontaneous a manner as possible, the relationships between ideas as these emerge naturally in awareness.  This is dipping into what we sometimes call the “stream of consciousness”.  It is an arduous and usually lengthy procedure, one that cannot be rushed, since in acquiescing to the invitation to speak freely the patient surrenders him or herself to the presumption of the therapist’s wisdom and empathy.  Further, he or she becomes vulnerable to the emergence in the ego of deeply disturbing unconscious conflicts and needs, including those fueling their self-destructive wishes.  These have been maintained apart from awareness because they clash, often violently, with conscious constructions of the self.  Following the thread of these unfolding thoughts leads to the reawakening of painful present and past dilemmas, threatening to evoke the profound guilt, despair, and “forbidden” desire that the patient imagines renders them morally deplorable.

In this treatment model, the therapist’s ability to sensitively interpret connections between emerging unconscious elements to their historical roots may provide the patient with a new, vital, and liberating sense of wholeness and intellectual understanding of his or her current situation.  Free association expresses the therapist’s existential devotion to the task of recovering the integrity of the patient’s being, through a gentle but determined resolve to call forth aspects of unconscious life that are acting as ruinous, disavowed objects in the patient’s psyche.  In terms of this essay’s thesis, this process is doomed to defensive foreclosure in any situation in which the guilt that the patient unconsciously harbors about these wishes is confirmed by a fearful, dismissive, or reproachful attitude, real or imagined, on the part of the therapist.  Of course, the consequences of the patient feeling that trust has been broken with the therapist on such grounds can be quite dramatic and dire, sometimes even leading to the patient angrily enacting their suicidal intentions.  And it is therapist responses to a patient’s expression of suicidal impulses, like the anxiety-fueled rush to herd them prematurely into a hospital ward, contact family members, or direct them forthwith to a psychiatrist to receive numbing medications, that such a patient often correctly infers to mean that they are seen as “too much”, “too bad”, or “too hopeless” for treatment to proceed normally.  To be clear, such interventions are called for in some cases, and can be reassuring expressions of therapist mindfulness to a despairing person.  However, they should be proffered from a therapeutic vantage point that embraces the ultimate indeterminacy of the impulse toward suicide, the sanctity of free will, and is realistically accepting of the final limits of therapy’s influence on the individual.

Summary

Simply because a law was passed by some official body that as much as says “it’s the will of the electorate that knows whether or not life is worth living” seems quite irrelevant to what is actually at stake, emotionally, spiritually, and philosophically in contemplating this topic.   I see this as being the case whether such a law comes down on the side of granting radical freedom of self-determination (as in some European countries) or assuming that someone’s will and foresight is impaired to the point that, in essence, it is asserted that “they know not what they do”.  I have argued here that public consensus and professional ethics do a lot of good things, but one of them is not answering the question of the meaning of our relationship to Being.  There do need to be laws surrounding suicide, as it is an act occurring within human communities, one that profoundly impacts the well-being of those involved with the suicidal person, and, on a larger scale, our collective sense of what American philosopher John Dewey (1934/1958) called the “spiritual culture” of the nation itself [1].  But I think that the fundamental questions about the nature and meaning of suicide itself exist in a quite different domain.

We can and should muster the courage to venture into this difficult existential realm, resolutely setting aside the rush to foreclose thought about the existential inevitability of death and our relationship to it.  Suicide is a vexing and dark topic.  But we will be compensated for the pain of feeling our way through the dark night of disillusionment about the human condition by what I think is the realistic hope that considering its strictures brings with it an unexpectedly radiant dawn; a daylight that comes from within consciousness itself, as it encounters Being’s “meaningful meaninglessness”.  It is this resolve, more radical even than the act of suicide, that led Camus (1942/1991) in “The Myth of Sisyphus” to finally assert the value of continuing with life.  As he wrote there, “The struggle itself toward the heights is enough to fill a man’s heart.  One must imagine Sisyphus happy”. (p. 24)

Footnote

[1]  Dewey’s term is not meant to be taken religiously, though it may be, if one is so disposed.  Rather, taken in the generic sense that Dewey intended, it means our experience of existential immersion or “embeddedness” in the network of personal, social, and historical realities that confront us daily, and from which we derive an inner awareness of the topography of what Heidegger deemed our total “Situation”.  This is our entwinement, as it were, in the totality of involvements making up what he called our Being-in-the-world, and what Dewey (1934/1958) referred to as “our sense of an extensive and underlying whole”.  (p. 194)

References

Becker, Ernst (1973).  The Denial of Death.  The Free Press: New York, New York.

Camus, Albert (1942/1991).  The Myth of Sisyphus and Other Essays.  Vintage Books: New York, New York.

Dewey, John (1934/1958).  Art as Experience.  Capricorn: New York, New York.

Freud, Sigmund (1913)  On Beginning the Treatment (Further Recommendations on the Technique of Psycho-Analysis I).  The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 121-144

Freud, Sigmund (1926). Beyond The Pleasure Principle.  Authorized translation from the Second German Edition, by C. J. M. Hubback. Published by, Boni and Liveright.  (P. 91)

Heidegger, Martin (1927/1962).  Being and Time.  (Trans. John Macquarrie and Edward Robinson.)  SCM Press, London.

Jung, C.G. (1961/1989).  Memories, Dreams, Reflections.  Vintage Books: New York, New York.

Stevens, Wallace (1923/2015).  Collected Works of Wallace Stevens: John Serio and Chris Breyers, Eds.  Vintage Books, New York, New York.

Sullivan, H. S. (1947).  Conceptions of Modern Psychiatry.  William A. White Psychiatric Foundation: Washington D.C

 

Featured Image: Edvard Munch (1894), The Death and the Young Girl

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