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Psychiatry and Suicide - Contemporary Attitudes
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0 Introduction
1 Medicalization of suicide
1.1 A clinical approach to a moral issue
1.2 Suicide as a taboo
1.3 Linguistic Manipulation
1.4 Ambivalence and irrational approach to suicide
1.5 Psychiatry obstructive to open discussion
2 Reasons for Current Attitudes
2.1 Psychiatry shaped by society
2.2 Scientific conservatism.
2.3 Psychiatrists can be blamed for suicide
3 Consequences of Current Attitudes:
3.1 Alienation of the suicidal
3.2 Alienation encourages irrational decisions and ambivalence
3.3 Reinforcement of the taboo
3.4 Despair for patients whose treatment does not help
4 Alternative attitudes
5 Conclusion
If psychiatry accepted that human beings could freely and sanely decide to commit suicide, society would be obliged to rethink voluntary death as a moral problem. Most people in our time are unwilling to deal with the issue in any form, while society accordingly prefers the easy way of relegating it to pathology. The official medicalization of suicide parallels the informal, popular taboo surrounding suicide. Society is afraid of facing the blunt question: "Is it legitimate to choose a shorter lifespan than the biologically available one"? Far from providing or looking for an answer, psychiatry is mostly a tool used to quell such a question.
Psychiatry's attitude to suicide in our society is obviously too vast a subject to address in a short essay, without the risk of dangerous generalization. We do not claim to talk about all psychiatrists as individuals. Things may be very different from country to country or person to person. While some psychiatrists' thoughts about suicide may be deep and sensitive, we believe the official attitude of psychiatry concerning suicide relies on a few basic presuppositions. The primary sources in writing this article are the writer's own experience with psychiatric care and posts on the alt.suicide.holiday newsgroup. Psychiatric theories may be more elaborate than the beliefs of the average psychiatrist, although not necessarily based on more refined assumptions. The formal control exerted by psychiatry, as well as the informal control exerted by popular opinions in the name of psychiatry, are however more influential than psychiatric theories as such. It is also likely that ashers are or were confronted with psychiatry in the form of mental-health practitioners and of offhand attitudes about the social role of psychiatry (the "go for medical help!" type). Also, while it is undeniable that some, perhaps many, psychiatrists may be gentle and helpful as individuals, their professional attitude to suicide is highly questionable. Psychiatric help may be beneficial for someone lucky enough to find a good therapist; one should have, however, realistic expectations about the kind of help available.
1. MEDICALIZATION OF SUICIDE
For at least 200 years, suicide has commonly been attributed to the "medicine of the soul". This was a move in the general tendency of viewing unacceptable forms of behavior as medical disorders, rather than guilty conducts. (Melancholy itself, the old name of "depression", had been until the 18th century a vice and not a disease: an excessively sad person was guilty of losing faith in God's mercy and feelings of despair were allegedly sent by the Devil). [1]
With the advance of mental-health around 1800, more people would undergo treatment instead of being punished. The allotment of "mental disturbances" to medicine was viewed as a humanistic and enlightened measure, the "those who do the evil don't really know what they are doing" kind. [10] In respect to suicidal individuals, the supposition was that they were mentally ill and in need of treatment. Successful suiciders ceased to be referred to as a species of assassins, becoming a class of victims.
1.1. A clinical approach to a moral issue
Psychiatry hasn't necessarily promoted the view that suicide is immoral, and thus the medicalization of suicide has partly influenced society to question or even abandon some traditional anti-suicide cliches. The methods of psychiatric treatment changed drastically over the time, but the basic assumptions remained unchallenged to our day. Sane people's behavior is accounted in terms of purposes, ideals, preferences, choices; insane people have instead symptoms, tendencies, acute states and relapses. This is the pattern taken for granted to our day. It may be helpful for some people, harmful and offensive for others.
Ashers think suicide is not inherently either good or bad; it might be good in some cases and bad in other cases. Psychiatrists, however, generally maintain that the question of the morality of suicide is out of the point: their underlying assumption is that suicide is the outcome of mental disease and that it is not a result of choice but of a disturbed condition. The medicalization of suicide has replaced the theological condemnation of suicide with new cliches, which claim to be scientific discoveries, but largely express moral or philosophical bias in disguise. Psychiatry's assumption seems to be "It's not interesting to know if suicide can, in theory, be moral or rational, since people who actually (try to) commit suicide don't do it because of moral or rational reasons, but because they are sick".
When society classifies suicide as a mental-health problem, it obviously doesn't mean: "a person may be mentally ill and, contemplating his mental illness from a detached standpoint, decide to stop it by suicide rather than by therapy". Rather, it means that the desire to commit suicide is itself sick, is the sign that the mental illness is particularly critical. The assumption is that suicidal people's minds are clouded and the suicide attempter is particularly deranged when planning or even considering exiting. As it were, if a thing is done by mentally ill people, that thing is itself ill. To apply consistently this reasonning, it follows that art created by depressive people is a sick art.
1.2. Suicide as a taboo
Ascription of suicide to medicine is the scientific counterpart of the general mentalities, as both are expressed in the taboo on any discussion about the morality or rationality of voluntary death. Far from being morally neutral about suicide, psychiatry most often does take a stance, namely assuming suicide is a bad thing that must be prevented: well, it is not bad as murder is bad, but as earthquakes or heart diseases are bad. Suicide is viewed in psychiatry as a natural evil, not as a voluntary action [2]. This involves an ethical stance, which, though disguised, is in many cases a simplistic one. In this view, a suicidal person is no longer, or not directly, condemned, since he is deemed irresponsible: an object of pathology rather than a free agent able to choose.
A person who commits suicide, or even talks about it, is disturbing for social conformity, implicitly suggesting suicide is an open possibility to be considered by other people as well. Talk about suicide is not welcome in our society, which in turn needs a body of "experts", like psychiatrists, who will reassure public opinion that "no sane human commits suicide". The psychiatric stigma of suicide is a way of telling people "don't be troubled, you should not think about dying at a moment of your choosing, since you are not crazy". Suicide is too thought-provoking for those who are unwilling to think. When confronted with the subject, ordinary people feel a mental cramp: it is better to change the topic.
1.3. Linguistic Manipulation
Since suicide, officially, can be anything but an understandable and responsible decision, the fact that depressive patients have higher suicide rates than the general population leads to classification of depression as a "potentially lethal" disease, like cancer or stroke, and to cliches like "depression causes suicide", "depression kills by suicide" - as if a depressed person's free will simply vanished. Psychiatric discourse indeed assumes free will to be an organ, which can malfunction like the heart or the kidneys. Such metaphors might be questioned, however, by any intelligent being. The analogy between mental and physical diseases is, in this respect, a convenient moral expedient: when you assume an act (like suicide) to be wrong, but are not sure why and how to condemn it, it is easy to state that it "happens" without being chosen
1.4. Ambivalence and irrational approach to suicide
An argument often heard against a more permissive attitude to suicide
is the the ambivalence of the suicide-attempters. [3] Most attempters aren't fully decided to die. People who succeed in suicide are sometimes reviled, sometimes
admired, according to the perceived loftiness of their reasons, or
the embarrassment caused by their gesture. Manipulative suicide
attempts - sometimes successful in their desired intention, sometimes
not - can be viewed as a product of these ambiguous attitudes towards
suicide. We have no records of people simulating suicide gestures in
order to get attention in earlier times - although voluntary death
occurred in all ages, and official - religious and social - attitudes
varied from active encouragement to fierce condemnation. Suicide
attempts meant to draw attention (the "cry for help" type) are,
at least partly, a cultural phenomenon: attempting or even
talking about suicide is obviously shocking in a society in which
suicide is taboo. Contemporary psychiatry presents these phenomena as
if they were part of human nature, while it is much more plausible
that they are encouraged, if not created, precisely by the current
medicalization and resulting stigma of suicide.
1.5. Psychiatry obstructive to open discussion
By presenting suicidal ideation as a reason for alarm, [4] by encouraging a thought-police about the subject
("if someone tells you he is going to do it, call the paramedics!"),
psychiatry obstructs open debate and stimulates instead irrational
attitudes about suicide, only to complain hypocritically in turn that
suicide is irrational. This approach does not always make people
happier, and definitely doesn't make them wiser. (In Western
countries the media is nowadays obliged to present cases of suicide
in a negative manner; contrast this with 18th century Britain, where
reports of suicide were daily published in the newspapers and readers
were encouraged to express their opinions pro and against suicide[5]). The control, practised in the name of
mental-health, over the public perception of suicide is all the more
regrettable and harmful as most people nowadays think that doctors
are the experts in suicide, who discovered, using tools inaccessible
to the lay people, that suicide is a matter of disease - as if the whole
history of ideas about suicide and all philosophical or religious
arguments pro and against voluntary death were irrelevant, or as if
psychiatrists were particularly knowledgeable in them (they aren't,
and have no training in these fields).
2. REASONS OF CURRENT ATTITUDES
Psychiatry claims to explain, and is perceived as explaining,
people's behavior. While the mental patient is thought unable to
understand his own person, the psychiatrist is allegedly able to
understand both himself and the patient. Actually, psychiatrists'
behavior can be accounted for, once we analyze it from a larger,
social or historical, perspective.
2.1. Psychiatry and society condition each
other It is easy to realize that psychiatry is an institution
shaped by and shaping the prevalent social mentality. Many people
nowadays believe that everything that bears the stamp of "scientific
expertise" is itself good, losing sight of the fact that categories
of human science often change for rather un-scientific reasons.
Since psychiatry is not regarded simply a
branch of medicine, but as a source of verdicts concerning the limits of normality and
responsibility, its assumptions are socially
conditioned to a much higher extent than those of other
sciences. Psychiatry and society are two parrallel mirrors: one's
attitudes are reinforced by the other.
This is illustrated by the classification - supported by
statistic evidence - of suicidal ideation as a "symptom of mental
disease". One could notice, however, that many people who consider
divorce have infidel spouses. Using the same logic, this correlation
should lead to classifying divorce as a medical symptom of
adultery. If this is not the case, the reason seems to be that the
desire to divorce is socially accepted in our culture, while the
desire to die is not.
2.2. Scientific conservatism If
psychiatry wondered how facts would be like given a different social
mentality, its methods and assumptions would have to be
changed. Psychiatry's refusal to accept the legitimacy of suicide and
suicidal ideation can thus be viewed in part as an issue of
scientific conservatism: it is much easier to trim facts to fit your
framework than to change the framework itself. This is a well-known
phenomenon in the history of science. In the field of mental health,
this takes the form of classifying as symptoms and diseases problems
which society doesn't like or doesn't know to argue about. If the
current classification of psychic diseases cannot include all cases
of suicide, new diseases and new symptoms will have to be invented in
order to keep suicide within the domain of pathology. This secures
social conformity, but does not address the issues as such. The
problems are not solved, but silenced.
2.3. Psychiatrists can be blamed for
suicide In fairness to psychiatrists, we guess a reason of
their intolerance of suicide is their fear of being blamed for the
suicide of a patient. There were, indeed, cases of psychiatrists
sued by relatives of a suicider. [6] That's why,
when one considers the relation between our cultural bias against
suicide and psychiatrists' efforts to prevent it, one cannot tell,
without circularity, which is the cause and which the effect: these
attitudes actually condition each other. Society "knows" suicide is
wrong: Psychiatry reinforces this belief claiming it can and should
prevent it. This is sometimes a costly attitude. To prevent suicides,
psychiatrists may resort to repressive measures, such as
incarceration of potential suiciders - for which they are blamed less
than for a successful suicide. Such repressive measures can often
cause feelings of humiliation and actually trigger the patient's
suicide. In this respect, psychiatry is a social institution meant to
spare people of the effort of thinking.
3. CONSEQUENCES OF CURRENT ATTITUDES
It is perhaps important for us to understand the attitude of
psychiatry, as this is one of the causes, albeit an indirect one, of
our problems as ashers. Specifically, the mental health
establishment's stigmatization of suicide as a disease is partly
responsible for social intolerance of discussions about suicide.
3.1. Alienation of the suicidal
While a typical suicidal person attributes their wish to die to
personal factors, it is likely that inappropriate reactions to
expressions of suicidal feelings, unwillingness of surrounding people
to deal calmly with the issue, the general hysteria about suicide,
are consequences of the larger framework of beliefs of our age.
Central to this framework is the tacit assumption that a long life is
inherently preferable to a short one. It is not unlikely that
someone who questions this assumption will be unable to communicate
genuinely with other people, including mental health professionals.
This is not surprising, since psychiatry is a device of social
conformism playing a part in this process.
3.2. Alienation encourages ambivalence and
irrational decisions It is highly debatable whether most, or
many, suicides are committed following a period of genuine insanity;
it is probably false that most suicides are impulsive and
spontaneous. A triggering factor of such - arguably tragic and
desperate - suicides is society itself, which permits little if any
deliberation of the appropriateness of suicide. A person who
considers whether to continue living or not has no assistance in
making a decision. Moreover, keep in mind that suicide is not
easy. [7] Committing suicide requires courage and
determination that may be difficult to attain in a calm state of
mind. If suicide and discussions about suicide were socially
accepted, if non-traumatic methods were available, voluntary death
would be more likely to be accomplished or considered with
composure. Thus, the argument "suicide attempters are insane,
therefore suicide should not be permitted" does not work: if society
were more open and tolerant about suicide, one would not be under so
much stress and fear when contemplating killing oneself.
Ancient Rome was, for example, a society largely tolerant
of suicide: an ideal suicide was a public event, committed in the presence of friends and family, and prefaced by a speech intended for public consumption, containing an explanation of motive, words of comfort, and advice for the future. [11]
Can you imagine such a thing in our society ? How could the Romans have an ideal
of rational suicide, if - as we are told today - suicide is in 90% of cases the outcome of mental disease?
Were all Roman writers, who
praised suicide as a matter of personal freedom, so stupid that they didn't realize people who committed suicide were in fact crazy? Or did human nature change in the meanwhile,
so that we are no longer able of calmly choosing suicide? In 1996 a study surveyed the attitudes of American and Japanese psychiatrists about suicide and euthanasia. Asked if someone could reasonably commit suicide if unable to fulfill work duties or responsibilities towards family, more Japanese than American psychiatrists answered yes.[12]
This suggests that either cultural biases affect the psychiatric
diagnoses, or that the degree of social acceptance of suicide
influences the suicidal behaviour. This should make us all the more
suspicious about the assertion "suicidals are mentally ill", often
presented as a psychiatric discovery about human nature but actually
relevant to the framework of a particular (contemporary Western)
culture.
3.3. Reinforcement of the taboo
Not only do not psychiatrists provide counseling on choosing suicide,
but they typically reinforce the taboo, diverting the attention of
their patients from suicide. Contemplating suicide is little less
than a thought-crime. The assumption is that thinking seriously
about death and suicide is incompatible with an acceptable or normal
life. It would follow that talking and thinking freely about suicide
is a dangerous thing. Psychiatrists often speak about the stigma of
depression and suicide, simutaneously proposing repressive
solutions. For example, suicide prevention sites present signs to
identify persons suspected of contemplating suicide and recommend
attitudes such as "take the person to a hospital","don't argue
whether suicide is good or bad". Psychiatry precisely re-stigmatizes
suicide in the name of science, with much the same practices as
religion did in the name of God.
3.4. Despair for patients whose treatment is not helpful
Another regrettable consequence of the medicalization of suicide is
that suicidal persons whose therapy or hospitalization is not helpful
can tend to think that nothing can help any further in improving
their lives, feeling discouraged to look for non-medical
alternatives: which seems logical, since psychiatry is thought to be
the supreme authority in dealing with suicidal tendencies. People may
think: "Since even my doctor admitted that treatment didn't have much
effect on me and I am very ill mentally, my situation must be really
desperate". Actually, psychiatrists' ability to predict the future
evolution of symptoms (worsening or improvement) in mental disease is
very small, since here - unlike the bodily disease - there are no, or
very few, established laws medicine can use. Very little can be done
to know scientifically - except in a rough probabilistic way - if
one's mental state will get better or worse: a lot depends on one's
desire to improve their own situation. [8] This
might, obviously, be considered by anyone contemplating
suicide.
4. Alternative attitudes: acknowledgment of different outlooks
If ash proves anything, it is that some people feel better if they
are allowed to express freely their thoughts about suicide in a
non-judgmental environment. Without inciting to suicide, open
discussion about voluntary death can be beneficial to many persons.
There is no evidence that suicide rates were particularly high, or
that sadness and despair prevailed, in historic ages when the subject
of suicide was not taboo. [1]. The ancient wisdom of
"Live each day of yours as if it were the last one!" doesn't
impress, however, contemporary anti-suicide preachers.
Depression and suicidal ideation can be viewed not so much as a
clinical disease, as a particular world view: a depressed person has
a different way of looking at things, a different system of values,
from the prevalent optimistic attitude. Communication between people
with different world views - for example, between psychiatrist and
patient, or between shiny-happy and depressive people - faces serious
obstacles, since there are very few assumptions common to the
partners in the dialogue. In such failed dialogues, argumentation is
replaced by rhetoric, and words with deep emotional import, such as
"life", "hope", "understanding" become void of meaning, since each
side of the dialogue feels that the other side misses the point.
People are generally too strongly attached to their own biases,
becoming unable to examine them critically. (see [9] for an example). This is what often happens in
psychotherapy.
5. CONCLUSION
The reasons for diagnozing suicidal ideation as pathological are
doubtful at best, traceable to social habitudes rather than to
serious arguments. So many distinguished people committed suicide in
all times. Some of them shaped, by their work, the way we think:
Empedocles, Democritos,
Lucretius, Ernest Hemingway, Alan Turing. Some of them had a lifetime
preoccupation with suicide: Seneca, Henri de Montherlant, Virginia
Woolf. The list can be countless. Even more others contemplated
suicide. Can all these people be indiscriminately classified as sick
and mentally
compromised? How long will society refuse to
examine its taboo?
Ironically or not, barbarity and torture against criminals have been
abandoned in modern society. In countries, such as the United States,
where the death penalty is still in vigor, a convicted serial killer
is now granted the gentlest death that was available. For legally
innocent person who simply wishes to end their life, no possibility
of dying painlessly is allowed. The only methods readily available
are traumatic, agonizing and risky. A person fully and persistently
decided to commit suicide is worse treated than the most heinous
murderer. This is encouraged in the name of mental health and suicide
prevention.
This essay tried to interpret empirical evidence from
the standpoint of the history of ideas. Mentalities that govern
implicitly our beliefs and evaluations evolve, in a way often
independent of the intentions of their proponents, leading to
unpredicted consequences. They become clichés and dogmas whose
original justification is forgotten and whose validity in new
contexts is left unexamined. Suicide as a genuine moral problem is
not yet honestly analyzed, neither will it be as long as we tacitly
assume that living in any circumstance values more than being dead.
Given the strength of the anti-suicide biases, one could hardly
expect psychiatry accept that suicide and suicidal thoughts are not
themselves pathological, unless the general mentality changes. This
is proven by the slow progress of euthanasia movements, which want to
allow hastened death in terminal illnesses but generally do not
question the taboo of suicide outside medical context. We should not
realistically expect psychiatrists officially say suicide is not a
disease: if they did so, ordinary people wouldn't know what exactly
suicide is. They would remain with a mental vacuum - since society is
largely unprepared to address the possibility of suicide as a
responsible decision. It's perhaps the time to fill this
vacuum. [1] George Minois - A History of Suicide. Voluntary Death in the Western
World chapter.6
Assuming this is true, an explanation may be again the current
mentality, irrational and itself ambivalent, about suicide. People
who fail in suicide attempts are neither allowed to die nor
encouraged to take a calm decision about how long they want their
lives to be; they are neither praised nor legally condemned (apart
from being hospitalized for an indefinite period). The most one can
hope when talking about suicide with an understanding psychiatrist is
probably receiving a reaction like "if you consider doing it, we
won't talk about such an option; I can only provide you with help in
life".
Hopefully, the official dogmas of psychiatry do not represent the
beliefs of each individual psychiatrist.
References
http://www.press.jhu.edu/press/books/titles/sampler/minois.htm
[2] alt.support.depression FAQ:
http://www.faqs.org/faqs/alt-support-depression/faq/part1/
[3] Balch and Bannon: Why We Shouldn't Legalize Assisting Suicide
http://www.nrlc.org/euthanasia/asisuid1.html
[4] See any suicide prevention site
[5] Minois, chapter 8
[6] "Residents Advised on How to Prevent Malpractice Suits", in Psychiatric News - July 3, 1998 Volume XXXIII Number 13,
http://www.prmsva.com/risk_management/risk_prevent_malpractice.htm
[7]alt.suicide.holiday FAQ part 3 "Are you for Real?"
RU4real.html
[8] Lawrence Stevens - Does Mental Illness Exist?
http://www.antipsychiatry.org/exist.htm
[9] http://ash.xanthia.com/karladialogue.html
[10] Thomas Szasz-Mental illness: psychiatry's phlogiston
http://www.szasz.com/phlogiston.html
[11] Nick Kapur- Cato and his Heirs. Roman Ideals of Suicide
http://www.atuatuca.de/v2/quellenkritik/suicid.php
[12]
Berger, Fukunishi et al - A Comparison of Japanese and American Psychiatrists' Attitudes towards Patients wishing to Die in General Hospital, in Psychotherapy and Psychosomatics, 66:319-328;1997 http://www.japanpsychiatrist.com/Abstracts/SAINichibei1.html
