Suicide is an uncommon phenomenon. When you consider what people suffer because of medical illness, physical injury, the deprivations of old age, mental illness, personal failure and the betrayal by others, one wonders why more people don't choose to end their lives.
Many are deterred from suicide by religious dictates, the social stigma associated with giving up in the face of hardship and the reluctance to abandon others by making this kind of exit. Even without these proscriptions, and under the most trying circumstances, life is often obstinately embraced until the very end. People just don't want to die.
Many of us have thought about the possibility of taking our lives at some point, wondering what would happen if the steering wheel were turned just slightly to the left as an oncoming car approaches, or considering the consequences of jumping out of a window eight stories up. Most of us quickly reject the projected outcome of these actions. We don't want our lives to end in this way.
But some people do commit suicide, most of them during the course of a severe depression. This mental state is not just the feeling of loss or sadness that is familiar to all of us, or even the condition described as major depressive disorder in the "Diagnostic and Statistical Manual of Mental Disorders."
How do we understand the state of mind of a depressed person who is at serious risk for suicide? The view of depression that I subscribe to derives from the psychobiology of Adolf Meyer, psychiatrist-in-chief at Johns Hopkins Hospital from 1910 to 1941, and the ontology of Jean-Paul Sartre. Meyer believed that depression is an inadequate psychological response to a loss or other negative experience — an unwillingness or constitutional disinclination to move beyond the incident — which has biological correlates. His psychobiology is radically different from today's biological psychiatry, which views depression as a disease caused by a glitch in the brain's structure and/or function.
Sartre saw in Meyer's depressive reaction what he called a "de-differentiation" — an emotional, affective and cognitive flattening and emptying, a change in essence — of a person's formerly instrumental world of cause and effect. In this transformation, a good deal of what was once perceived and lived by the depressed person as interesting and important is now re-construed as empty and unappealing.
The invitation of the world to respond to its possibilities, formerly accepted, is rebuffed. The severely depressed person turns tail on the world of cause and effect, retreating to a lower state of being. In some instances, this regression may evolve into a strategy for regrouping and returning to a normal mood.
That structural transformation of a person's world occurs to different degrees, which is why depression varies in severity. This transformation can also be reversed, which is ultimately what it means to recover from depression.
In the kind of depression that becomes the ground for suicide, people find themselves isolated, alone and in despair. Guilt, shame, anger and other negative emotions dominate. Prior accomplishments and honors become remote, empty memories. Most suicides occur when a severely depressed person loses both hope and the capacity to imagine a future.
For someone in this extreme emotional state, religious and social constraints against suicide may be de-differentiated along with everything else, losing their prohibiting power. And the normally inhibiting realization that others would be badly hurt by one's suicide may be swallowed whole by overpowering negative emotions and an all-encompassing hopelessness.
Some who devolve into a state of despair and then commit suicide may appear to have had "everything." Those familiar with Robin Williams' work and the essential facts of his life — but not the contents of his heart and mind — would say that Williams was one of these fortunate people. Sometimes, having "everything" is not enough.
Carl Jung, R. D. Laing and others made the distinction between the real self and the persona, the mask a person presents to the world. All we ever saw of Robin Williams — from his stand-up routines, his appearances on late-night TV, his movies, his performances for charity — appeared as creations of his persona, the act that he so successfully put on for us.
While the persona is faring well, the real self "underneath" the mask may be out of touch, cut off, dying. No matter how successful our "act" may be, we are stuck with this "real" part of ourselves — unless, of course, we choose to end our lives. For some who make this choice — like Robin Williams — the creations of their persona live on.
René J. Muller is a clinical psychologist and the author, most recently, of "Doing Psychiatry Wrong." His email is firstname.lastname@example.org.
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